Dry Skin (Xerosis)

Xerosis (dry skin) is a very common condition in which the outermost skin layer, the stratum corneum, loses its ability to hold water. The stratum corneum works like a brick wall — skin cells are the bricks, and intercellular lipids are the mortar — and together they block water loss and keep out allergens, irritants, and infectious particles.^[1] Xerosis develops when this barrier breaks down: the skin's natural moisturizing factor (NMF, the water-binding end-product of profilaggrin breakdown) and its intercellular lipids (ceramides, cholesterol, and free fatty acids) are both reduced, so transepidermal water loss rises, the outer keratin layers dehydrate below the roughly 10-20% water content they need to stay flexible, and corneocytes curl upward — producing the rough, flaky, sometimes cracked surface that defines the condition.^[2]

Xerosis increases with age and is one of the most frequently reported dermatologic complaints in older adults, driven by genuinely reduced sebaceous and sweat gland activity and slower epidermal turnover — not simply "getting older" in a vague sense.^[1][3] It also has specific, mechanistically distinct causes that matter directly to this platform's audience: diabetes (impaired barrier function plus autonomic neuropathy reducing sweating), hypothyroidism (reduced glandular secretion and slowed epidermal turnover), chronic kidney disease and dialysis (glandular atrophy and altered skin lipid composition), and common medications including diuretics, statins, and retinoids.^[1][3][4][5]

General presentation

Xerosis presents as flaky, rough, and uneven skin, most often on the hands and lower legs, ranging from a fine sandpaper-like texture to deep fissures on the fingertips or shins; in severe cases the skin can bleed and become significantly itchy.^[1]

Asteatotic eczema (eczema craquelé) — the pattern to recognize

When xerosis becomes inflamed, it produces a distinctive "crazy-paving" appearance: diamond-shaped plates of dry skin separated by a network of red, fissured bands. The shins are the most common site, though the pattern can spread to the thighs, upper limbs, or trunk; it is most often seen in older adults, particularly after a change in season or a hospital admission with more frequent bathing.^[2] Pruritus can be significant and, particularly in dry, cold weather or in patients with a systemic contributor such as CKD, is often worse at night and can meaningfully disrupt sleep.^[5]

A close-up of dry, flaking skin with fine surface cracking — the texture change that, when it becomes inflamed and fissured in a "crazy-paving" distribution (most classically on the shins of an older adult), is termed asteatotic eczema or eczema craquelé. (Ser Amantio di Nicolao, CC BY-SA 4.0, Wikimedia Commons)

Dry, rough skin with visible cracking on the knuckles — hands and lower legs are the two sites patients most often bring to a pharmacist's attention. (Ser Amantio di Nicolao, CC BY-SA 3.0, Wikimedia Commons)

Diabetic foot presentation — distinct from ordinary xerosis

In a diabetic foot, xerosis characteristically begins as dry, rough skin with pronounced skin lines and progresses to superficial scaling, fissuring, and erythema; the mean number of superficial fissures found on cross-sectional assessment is markedly higher in diabetic than in non-diabetic patients.^[6] These fissures — not the dryness itself — are what create the infection risk described throughout this chapter.^[6][7]

• Aging — decreased sebaceous and sweat gland activity, slower epidermal cell turnover, and increased enzymatic breakdown of skin lipids; xerosis is one of the most common dermatologic complaints in older adults for this reason, not simply a nonspecific feature of getting older.^[1][3]
• Diabetes — impaired epidermal barrier function combined with autonomic neuropathy that reduces sweating, particularly affecting the feet; the resulting dryness progresses to fissuring far more often than in non-diabetic skin.^[6]
• Hypothyroidism — thyroid hormone normally supports sebaceous and eccrine gland secretion, epidermal barrier lipid formation, and cell turnover; xerosis cutis is reported in roughly 57% of hypothyroid patients, making it the single most common dermatologic manifestation of the condition.^[4]
• Chronic kidney disease, especially on dialysis — atrophy of sweat and sebaceous glands, thickening of the epidermal basal zone, and altered stratum corneum lipid composition; xerosis coexists with CKD-associated pruritus in roughly 50-80% of affected patients.^[5]
• Medications — diuretics, cholesterol-lowering agents (including statins), retinoids, and antiandrogens are all associated with a higher incidence of xerosis.^[1][3][2]
• Environmental factors — cold weather with low ambient humidity, indoor heating, air conditioning, and other artificial air treatment all strip moisture from the skin surface.^[1]
• Bathing habits and cleansers — hot water and long showers or baths remove surface oils and lipids more aggressively than lukewarm, brief ones; standard bar soap is formulated at pH 9-10, well above the skin's natural pH of roughly 5, and disrupts the barrier more than a fragrance-free syndet (pH 5-7) cleanser.^[1]
• Other systemic causes to keep in mind for a recent-onset or severe presentation — malnutrition (zinc or essential fatty acid deficiency), significant unintentional weight loss, and lymphoma.^[2]

A clinical diagnosis in most patients

Xerosis and asteatotic eczema are usually diagnosed on appearance and history alone — the crazy-paving, fissured pattern on the shins of an older adult, in the setting of cold weather, frequent hot bathing, or a recent hospital stay, rarely needs further workup.^[2]

When to investigate further

Check thyroid function (TSH) if other signs of hypothyroidism are present, and consider nutritional and hematologic investigation (looking for malnutrition, zinc or essential fatty acid deficiency, or lymphoma) when xerosis is of recent onset, unusually severe, or accompanied by excessive scaling, unintentional weight loss, fevers, or malaise.^[2][4]

The diabetic foot exam — build skin assessment in, don't bolt it on

Diabetes Canada's foot screening tool explicitly includes skin as one of its core inspection components, alongside nails, structure, sensation, vascular status, and footwear; the inspection specifically looks for blisters, calluses, fissures/cracks, and abnormal colour.^[7] A pharmacist reviewing a diabetic patient's feet — whether formally or opportunistically — should look specifically for dryness progressing to fissuring, not just note "dry skin" as a minor incidental finding.^[6][7]

• Restore stratum corneum barrier function and natural moisturizing factor/lipid content.
• Relieve pruritus, particularly nocturnal itch that disrupts sleep.
• Prevent skin breakdown and, in at-risk patients (diabetes, CKD, immunocompromise, older age), prevent secondary bacterial infection arising through a fissure.
• Identify and address a modifiable contributor (bathing habits, cleanser choice, a causative medication) rather than treating only the symptom.
• Screen for and address an underlying systemic driver (hypothyroidism, CKD, malnutrition) when the presentation or response to treatment suggests one.
• For diabetic patients specifically: make daily skin inspection and correct moisturizing technique a standing preventive habit, not a one-time instruction.

Bathing and cleansing come first, every time

Shower rather than bathe where possible, limit sessions to 5-10 minutes, use lukewarm (not hot) water, and pat the skin dry rather than rubbing.^[1][8] Replace a standard high-pH bar soap with a fragrance-free syndet or lipid-free cleanser formulated closer to the skin's own pH.^[1]

Choosing the right product: ointment, cream, or lotion

Preferred for genuinely dry, fissured, or thickened skin ointments and creams — they contain more occlusive lipid and less water than lotions, and hold moisture in the skin more effectively.^[8][1] Reasonable for mild dryness or larger body-surface areas a lotion may be more cosmetically acceptable and easier to apply, but is the least effective option for moderate-to-severe xerosis or fissured skin.^[1] Look for fragrance-free products containing ceramides, glycerin, hyaluronic acid, lanolin, mineral oil, petrolatum, dimethicone, or shea butter; choose items labelled "fragrance-free" rather than "unscented," since unscented products may still contain a masking fragrance that can irritate already-compromised skin.^[8][1]

Thickened or scaly skin: add a keratolytic

Preferred for thick, scaly, or hyperkeratotic areas a urea- or lactic-acid-containing moisturizer. Urea disrupts keratin structure to help shed excess stratum corneum while also drawing in and holding moisture; 5-10% concentrations are generally well tolerated, and lactic acid provides a milder complementary keratolytic and hydrating effect. Start with a lower concentration on fissured or diabetic foot skin, since stinging is more likely on broken skin.

Inflamed, fissured skin (eczema craquelé)

Preferred for the inflamed, itchy, fissured component a short course (typically 1-2 weeks) of a low-potency topical corticosteroid such as hydrocortisone applied to the affected areas only, continuing the emollient underneath and after the course.^[2] If a low-potency agent does not adequately control inflammation, current comparative evidence shows medium-potency corticosteroids meaningfully outperform low-potency ones (number needed to treat of 6 for one additional treatment success), while high-potency agents add little further benefit over medium-potency — so stepping up to a medium-potency product is a reasonable next step rather than simply extending a low-potency course indefinitely.^[9]

Severe nocturnal pruritus

Alternative for pruritus significantly disrupting sleep a sedating (first-generation) antihistamine such as hydroxyzine or diphenhydramine at bedtime can help, but is not first-line and is not a substitute for correcting the underlying dryness. Use caution in older adults both are flagged in the American Geriatrics Society Beers Criteria for anticholinergic and sedative risk (confusion, constipation, urinary retention, next-day grogginess); start at the lowest effective dose, and reassess ongoing need rather than continuing indefinitely.^[10] Non-sedating agents (cetirizine, loratadine) are better tolerated for daytime use but have limited evidence for xerosis-related itch specifically, which is often not primarily histamine-mediated.

• Apply a fragrance-free emollient within a few minutes of every bath, shower, or handwash, while skin is still damp — this is the single highest-yield counseling point in this chapter.^[8][1]
• Shower rather than bathe, keep sessions to 5-10 minutes, and use lukewarm rather than hot water.^[1][8]
• Use a fragrance-free syndet or lipid-free cleanser instead of a standard high-pH bar soap.^[1]
• Pat skin dry rather than rubbing with a towel.^[1][8]
• Run a humidifier, particularly in the bedroom overnight during cold, dry weather, and clean it regularly to prevent mould growth.^[1][8]
• Wear loose-fitting, breathable natural-fibre clothing (cotton, silk); a cotton liner under rougher fabrics such as wool reduces mechanical irritation.^[1][8]
• Wear gloves (latex-free, with a cotton liner if performing wet work) for dishwashing, gardening, or prolonged water exposure, and re-moisturize hands after each washing.^[1]
• Avoid products containing alcohol, added fragrance, or retinoids on already-dry skin, as each can worsen dryness and itching.^[8]
• Diabetic patients specifically: moisturize the feet daily, but never between the toes — trapped moisture there favours fungal and bacterial growth rather than helping the skin.^[7] Pair this with daily visual foot inspection so a developing fissure is caught before it becomes a wound.^[7][6]

Older adults

Xerosis is among the most common dermatologic complaints in older adults, driven by a genuine, multifactorial decline in sebaceous and sweat gland activity, slower epidermal turnover, and increased enzymatic breakdown of skin lipids, often compounded by medications (diuretics, statins) and comorbid hypothyroidism.^[1][3] Review the medication list for a modifiable contributor whenever xerosis is new or worsening, and favour non-pharmacologic measures and topical treatment over a sedating oral antihistamine for pruritus wherever possible; when a sedating antihistamine is genuinely needed, use it at the lowest effective dose and reassess regularly rather than continuing indefinitely, given the Beers Criteria anticholinergic/sedation caution.^[10]

Patients with diabetes — the priority counseling population for this chapter

Diabetes affects the skin through two compounding mechanisms: impaired epidermal barrier function, and autonomic neuropathy that reduces sweating, particularly on the feet.^[6] The result is skin that becomes dry and fissures far more readily than in a non-diabetic patient — the mean fissure count on cross-sectional assessment is markedly higher in diabetic feet.^[6] Combined with peripheral neuropathy (the patient may not feel a fissure developing) and impaired circulation and wound healing, a simple dry-skin crack becomes a genuine portal of entry for infection.^[6][7] Core counseling daily moisturizing (ointment or cream, never between the toes) plus daily visual foot inspection, integrated into the same routine as the rest of diabetic foot self-care.^[7] Diabetes Canada's own foot screening framework treats skin assessment as a standing component of every foot exam, at least annually and more often in higher-risk patients — reinforce this rather than treating dry feet as a separate, lower-priority concern.^[7]

Chronic kidney disease and dialysis

CKD-associated pruritus affects a large proportion of patients with end-stage kidney disease — reported rates run from roughly 22% to 84% among hemodialysis patients — and coexists with xerosis in about 50-80% of cases; the xerosis itself reflects atrophy of sweat and sebaceous glands, thickening of the epidermal basal zone, and altered stratum corneum lipid composition rather than simple environmental dryness.^[5] Itch in this population is often worse at night, meaningfully disrupts sleep, and has a real, documented impact on quality of life and mood.^[5] Good topical skin care — the same bathing and emollient measures used throughout this chapter — is a reasonable first step and is genuinely helpful even though it will not resolve pruritus driven by the systemic microinflammatory process underlying CKD-associated pruritus; persistent, severe itch despite optimized topical care warrants nephrology/dermatology involvement rather than escalating over-the-counter antihistamines indefinitely.^[5]

Hypothyroidism

Xerosis cutis is reported in roughly 57% of patients with hypothyroidism, making it the most common dermatologic manifestation of the condition; proposed mechanisms include reduced eccrine and sebaceous gland secretion, disrupted epidermal barrier lipid formation, and slowed keratinocyte turnover.^[4] Consider checking TSH in a patient with new, unexplained, or treatment-resistant xerosis, particularly alongside other hypothyroid features (fatigue, cold intolerance, hair thinning).^[4][2]

Pregnancy and breastfeeding

Plain fragrance-free emollients (petrolatum, mineral oil, glycerin, urea- or lactic-acid-based moisturizers) are generally considered compatible with pregnancy and breastfeeding. A short course of a low-potency topical corticosteroid such as hydrocortisone for a genuinely inflamed area is generally considered compatible as well; favour non-pharmacologic measures first, and use a sedating antihistamine only if needed and after weighing alternatives, confirming specifics against each product's own Drug Database entry.

Reassess skin integrity and pruritus severity at follow-up, and specifically confirm the patient is applying moisturizer within the damp window after bathing — not just "when they remember" — since technique affects outcome as much as product choice.^[8][1]

• In diabetic patients, fold skin/fissure inspection into the standard periodic diabetic foot examination already recommended by Diabetes Canada (at least annually, more often in higher-risk patients) rather than treating xerosis as a separate, lower-priority issue.^[7]
• In CKD/dialysis patients with persistent pruritus, coordinate with nephrology if itch remains a significant quality-of-life or sleep problem despite optimized topical skin care, since further management (addressing dialysis adequacy, phototherapy, or systemic agents) sits outside routine topical/OTC management.^[5]
• Periodically reassess the ongoing need for any sedating antihistamine prescribed for nocturnal pruritus in an older adult, rather than continuing it indefinitely once started.^[10]
• If a corticosteroid course was used for eczema craquelé, confirm it was stopped or stepped down as planned once inflammation resolves, with the emollient regimen continuing afterward.^[2]

1. No improvement after several weeks of genuinely adherent bathing and moisturizing measures: reconsider a secondary or systemic cause — hypothyroidism, CKD, malnutrition, or an irritant/allergic contact dermatitis overlay — rather than simply continuing the same regimen.^[2][4][5]
2. Eczema craquelé not responding to a low-potency topical corticosteroid: step up to a medium-potency agent, which current comparative evidence shows meaningfully outperforms low-potency treatment, or reconsider the diagnosis and refer to dermatology if the pattern is atypical.^[9]
3. A diabetic foot fissure not healing despite consistent moisturizer and keratolytic use: refer to podiatry or a wound-care service rather than continuing self-care alone — this is exactly the situation the diabetic-foot safety emphasis in this chapter is meant to prevent from being missed.^[6][7]
4. CKD/dialysis-associated pruritus persisting despite optimized topical skin care: involve nephrology and/or dermatology for the broader CKD-associated pruritus workup and management options, rather than escalating antihistamine doses on their own.^[5]
5. An older adult on a sedating antihistamine developing next-day grogginess, confusion, constipation, or urinary retention: stop the antihistamine and reassess — do not simply continue it for itch control.^[10]

• Long, hot showers or baths and a standard high-pH bar soap — both strip the surface lipids xerosis treatment is trying to restore.^[1]
• Applying moisturizer only once skin already feels dry, rather than proactively and within minutes of bathing while still damp.^[8][1]
• Reaching for a lotion when an ointment or cream is what genuinely dry, thickened, or fissured skin needs — lotions contain more water and less occlusive lipid.^[8][1]
• Applying moisturizer between a diabetic patient's toes, which traps moisture and favours fungal or bacterial growth instead of helping the skin.^[7]
• Treating dry, cracked skin on a diabetic patient's feet as a purely cosmetic complaint rather than a genuine infection-entry risk that belongs in the same conversation as the rest of diabetic foot care.^[6][7]
• Reflexively reaching for a sedating first-generation antihistamine in an older adult for nighttime itch without weighing the Beers Criteria anticholinergic and sedation risk, or without a plan to reassess ongoing need.^[10]
• Labelling every case of itching without an obvious rash as "just dry skin," rather than screening for an underlying systemic cause when the presentation is severe, of recent onset, or accompanied by systemic symptoms.^[2]
• Missing hypothyroidism, CKD, or another systemic driver in a patient whose xerosis genuinely does not respond to good topical care.^[4][5]
• Continuing a topical corticosteroid course indefinitely rather than stepping potency up (if truly needed) or down once inflammation resolves.^[2][9]

How to use this table: Doses are adult doses and require patient-specific confirmation (renal/hepatic function, weight, allergy history). Pediatric dosing is weight-based per the current product monograph unless stated. Drug pricing is intentionally omitted. Select any drug name to open its complete Pharmasist Drug Database page.

Emollients and Moisturizers — First-Line for Every Patient

None of these plain emollient ingredients has its own Drug Database monograph; select a fragrance-free ointment or cream (not a lotion) for genuinely dry, thick, or fissured skin, and apply within minutes of bathing while skin is still damp.

Keratolytic Moisturizers — Thickened, Scaly, or Fissured Skin

Added when plain emollients are not enough for thick, scaly, or fissured areas such as shins, heels, palms, or soles.

Low-Potency Topical Corticosteroids — Inflamed/Fissured Skin (Eczema Craquelé) Only

Reserved for the inflamed, itchy, fissured component of xerosis, not plain dry skin without inflammation. Continue the emollient underneath and after the course; a short course (typically 1-2 weeks) is standard.

Oral Antihistamines — Severe Pruritus Only, Not a Substitute for Treating the Dryness

Reserve for pruritus not controlled by emollients, keratolytics, and (where indicated) a topical corticosteroid. Sedating agents carry a specific caution in older adults.