Practice Points
Xerosis in Older Adults
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Lizanne Dalgleish, PhD, RN, GCertClinEpid and Jill Campbell, PhD, RN, BHealth SC(Nursing), Grad Dip(Wound Care)
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erosis, also referred to as dry skin, affects 30% to
X 99.1% of people older than 60 years.1,2 Xerosis is
usually caused by a lack of epidermal lipids and
is the most common cause of pruritus in the
older adult.2,3 Pruritus can result in excessive scratching,
skin injury, skin tears, wounds, secondary infection, dis-
comfort, and pain and can have a considerable impact
on quality of life.3 Although all areas of the body may
be generally affected, sites with fewer sebaceous glands,
such as the lower legs, forearms, hands, and feet, are
more frequently affected.2
Xerosis predominantly affects the outermost layer of
the epidermis, the stratum corneum (SC), which serves
as a barrier to the external environment, providing pro-
tection against water loss.3 The SC is composed of
corneocytes, which are terminally differentiated kerati-
nocytes that contain natural moisturizing factors
(NMFs), such as urea, lactic acid derivatives, pyrrolidine
carboxylic acid, amino acids, ammonia, uric acid, and in-
organic salts and sugars. These NMFs act as humectants
(they attract and bind water to the skin), promoting skin
plasticity, optimum skin barrier function, and healthy
shedding of skin cells (desquamation).4 Corneocytes
are embedded in a lipid matrix consisting of ceramides,
fatty acids, and cholesterol. The lipid matrix prevents
water evaporation and is responsible for the chemical
barrier of the skin.2 The SC needs a minimum water
content of 10% to remain pliable and avoid fissures.4
Risk Factors
In the older adult, xerosis results from a complex interplay
of age, health, environmental, and lifestyle factors (Table).
As the body ages, epidermal cell renewal and sebum pro-
duction decline, levels of filaggrin (a protein that derives
NMF components) decreases, and transepidermal water
loss (TEWL) increases.2,3 These changes in aging skin,
combined with environment and lifestyle factors, produce
structural and functional disturbances causing xerosis.3
Symptoms
Visual signs of xerosis include dry, scaly, rough, and
grayish skin.2 In addition, the skin is characterized by
decreased elasticity, coarse texture, wrinkling, erythema,
Lizanne Dalgleish, PhD, RN, GCertClinEpid, is Clinical Nurse Consultant and Skin Integrity Improvement Facilitator, Northern Sydney Local Health District, NSW Health, Sydney, Australia. Jill Campbell, PhD, RN,
BHealth SC(Nursing), Grad Dip(Wound Care), is Senior Research Fellow, National Health and Medical Research Council Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute
Queensland, Griffith University, Gold Coast Campus, Queensland, Australia.
ADVANCES IN SKIN & WOUND CARE • JANUARY 2022
and fissures (Figure).2 An individual may feel skin tight-
ness and itching, which can be perceived as pain or a
burning sensation.2
Prevention and Management
The overall goal of xerosis management is to restore nor-
mal skin barrier function, soothe affected skin, and reduce
itch and scratching to prevent further damage.3 Patients
should (1) avoid aggravating factors, (2) promote epider-
mal hydration, and (3) repair barrier function. The follow-
ing practical strategies may support these aims:
• Bathing in lukewarm water for 10 to 15 minutes,
followed by immediate application of moisturizer to
the skin (within 3 minutes).
• Replace harsh skin cleansers with gentle substitutes
(soap-free, fragrance-free cleanser or bath oil)
• Avoid friction from washcloths, rough clothing, and
abrasives
• Ensure adequate nutrition and hydration
• Use a humidifier to ensure a relative humidity setting
of 45% to 60%
• Use hypoallergenic products and avoid fragrances and
common allergens, such as lanolin and nut oil products
• Refer to healthcare professionals where appropriate2,3,6
Topical Treatment
The use of leave-on skin care products is the mainstay
treatment for xerosis. The aim of skin care products is
to restore the structure and function of the epidermis,
improve skin barrier functioning, decrease TEWL, reduce
inflammation, and decrease itch.3
Various leave-on skin care product formulations are
available. These products can be categorized into three
classes: (1) emollients, which soften and smooth the skin
with ingredients, such as naturally occurring oils, fats,
and waxes; (2) occlusives, which create a film on the skin
surface and reduce TEWL and include petrolatum jelly,
liquid paraffin, and wax or silicone-derived products,
such as dimethicone; and (3) humectants, which bind
and hold water in the SC, and include urea, glycerine,
lactic or glycolic acid, and hyaluronic acid. An ideal
leave-on skin care product should, as much as possible,
mimic the components of the skin barrier and SC.2
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 Practice Points

Table. FACTORS CONTRIBUTING TO XEROSIS IN THE OLDER ADULT1–3,5,6

Age-related factors Age-related factors

• Skin atrophy (reduction in epidermal and dermal thickness, regression of the sebaceous • Genetic factors
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glands, subcutaneous fat loss, and muscle atrophy) • Concomitant skin conditions such as atopic dermatitis, psoriasis, eczema
• Thickening of collagen fibers • Comorbidities such as thyroid disease, renal disease, diabetes
• Limited capacity to retain moisture • Systemic disease that results in ichthyosis (persistently dry, thickened, “fish
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• Decreased thermoregulation, vascularity, cutaneous senses, cell turnover scale” skin)

• Decreased key stratum corneum metabolites, eg, components of natural moisturizing factor • Polypharmacy and medication interactions
• Weakened immune system response • Infection
• Hormonal changes such as menopause
• Excessive sweating
• Dehydration
Environmental factors Lifestyle factors
• Low-humidity climate • Frequent immersion in water, eg, long showers/baths
• Cold, dry air • Swimming in chlorinated pools
• Direct heat such as central heating or fireplaces • Excessive handwashing
• Air conditioning • Overcleaning of the skin
• Chronic sun exposure and sun damage • Vigorous drying of the skin with a towel
• Harsh soaps or detergents, eg, fragranced or alkaline content (pH >7)
• Irritation from synthetic clothing fibers

Figure. CLINICAL EXAMPLES OF XEROSIS

A, Xerosis with typical fine scaling and coarse skin texture. B, Older adult xerosis with wrinkling, mild erythema, and scaling. C, Xerosis with coarse scaling and fissures.

However, based on current evidence, it is unclear if one
product or ingredient is superior to another; rather, it is
the regular application of a leave-on skin care product
that likely improves xerosis.1
If the skin is erythematous or if there is pruritus, addi-
tional ingredients with antipruritic properties should be
recommended.2 Plant-based additives, such as oat ex-
tract, have been shown to reduce pruritus intensity.2 Fur-
ther, bases with a higher water content and refrigerated
products can help soothe intense pruritus.2
Leave-on skin care products should be routinely and
liberally applied to the affected areas of the body by gen-
tle rubbing into the skin. Using leave-on skin care prod-
ucts, particularly after bathing, will help trap moisture in
the skin.5 Importantly, clinicians should make patients
aware of the increased risk of falls with product application
to hands and feet because of reduced grip, and prevention
strategies should be considered to ensure safety.5 •
REFERENCES
1. Lichterfeld-Kottner A, El Genedy M, Lahmann N, Blume-Peytavi U, Büscher A, Kottner J. Maintaining
skin integrity in the aged: a systematic review. Int J Nurs Stud 2020;103:103509.
2. Augustin M, Wilsmann-Theis D, Körber A, et al. Diagnosis and treatment of xerosis cutis—a position
paper. J Dtsch Dermatol Ges 2019;17:3-33.
3. Ritter CG. Xerosis. In: Dermatology in Public Health Environments. Bonamigo R, Dornelles S, eds.
Springer; 2018.
4. Fowler J. Understanding the role of natural moisturizing factor in skin hydration. Pract Dermatol 2012;
36-40.
5. Lacy F, Ziemer C. Xerosis Cutis in the aging population: an approach to diagnosis and treatment. Curr
Geriatr Rep 2020;1-4.
6. Cowdell F, Jadotte YT, Ersser SJ, et al. Hygiene and emollient interventions for maintaining skin integrity in
older people in hospital and residential care settings. Cochrane Database Syst Rev 2020;1(1):CD011377.

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