Review

Critical assessment of diabetic

xerosis
Gerald E Pierard, Claudine Pierard-Franchimont & Andre Scheen

1. Introduction University Hospital of Lie`ge, Department of Dermatopathology, Laboratory of Skin Bioengineering
and Imaging (LABIC), Lie`ge, Belgium
2. Structure and function of the
stratum corneum Introduction: Diabetes mellitus is commonly responsible for skin changes
3. Xerosis severity grading including discrete to mild xerosis.
Expert Opin. Med. Diagn. Downloaded from informahealthcare.com by Karolinska Institutet University Library on 04/14/15

4. Corneodynamics Areas covered: This review focuses on some selected relevant bioinstrumental
methods assessing diabetes xerosis. Peer-reviewed articles on objective non-
5. Global electrometric
invasive methods were scrutinized. The reviewed methods address i) the xero-
assessment and skin
sis severity grading scale, ii) corneodynamics referring to the desquamation
capacitance mapping
rate, iii) electrometric assessment of skin hydration including skin capacitance
6. Imperceptible perspiration
mapping and iv) implication of the imperceptible perspiration. The subjective
7. Emollient effects clinical assessment often fails to disclose diabetic xerosis with confidence and
8. Conclusion precision. By contrast, a multipronged biometrological approach identifies a
9. Expert opinion cluster of diabetic patients who experience alterations in the structural and
functional maturation of the stratum corneum.
Expert opinion: A multipronged biometrological approach helps identifying
the changes in the stratum corneum of diabetic xerosis. There is a continuum
between the dry skin feeling, xerosis and ichthyosiform presentations,
For personal use only.

particularly on the shins and feet of diabetic patients.

Keywords: dermoscosmetics, diabetes, neuropathy, skin, stratum corneum, xerosis

Expert Opin. Med. Diagn. (2013) 7(2):201-207

1. Introduction

It has been reported that a majority of diabetic patients presented with skin changes
at some periods in their life [1,2]. A cluster of the diabetes-associated skin conditions
results from the direct metabolic dysfunctions. Accumulation of advanced glycation
end products, as well as progressive damages to the vascular, neural and immune
systems contribute to other skin disorders [3]. One of the most common diabetes-
related condition corresponds to a discrete dry skin feeling potentially evolving
to more severe xerosis, ichthyosiform conditions and callus formation [1,4,5], which
in turn is at the origin of diabetic foot ulceration.
The keratinization, more properly called cornification process, exerts a key role in
the hydration physiology of the stratum corneum (SC). This process covers both
morphological and molecular events taking place in the living keratinocytes ahead
of the formation of dead anucleated corneocytes of the SC. On most body parts,
the SC typically consists of 12 -- 20 layers of flattened corneocytes. Each of these
cells is about 1 m thick and covers an area averaging approximately 1000 m2.
However, the average corneocyte surface area is commonly influenced by age,
anatomical site and any change altering the epidermal renewal. When the average
corneocyte size increases such as with aging [6], it is assumed that the corneocyte
transit time is prolonged in the SC.
This review focuses on selected non-invasive methods applicable to diabetic
xerosis. They explore its physiopathology and the corrections brought by some
dermocosmetic products.

10.1517/17530059.2013.728585 2013 Informa UK, Ltd. ISSN 1753-0059, e-ISSN 1753-0067 201
All rights reserved: reproduction in whole or in part not permitted
 G. E. Pierard et al.
Article highlights.
. Xerosis corresponding to a structural alteration of the
stratum corneum is a common ailment in diabetic patients.
. Current clinical grading systems of diabetic xerosis lack
specificity and objectivity.
.
A series of non-invasive or minimally invasive
biometrological methods provide accurate information
about xerosis severity, the rate of desquamation, the
hydration level of the stratum corneum and the
imperceptible perspiration.
. The effects of emollients and keratolytic-enriched
Expert Opin. Med. Diagn. Downloaded from informahealthcare.com by Karolinska Institutet University Library on 04/14/15
formulations are better appreciated using dermometrology.
. The strategy directed to diabetic xerosis should help
preventing and treating some ailments including the
dry skin feeling and pruritus. They contribute to reduce
the risk of the diabetic foot syndrome.
This box summarizes key points contained in the article.
2. Structure and function of the stratum
corneum
The primary function of the SC is to act as a physicochemical
semi-permeable barrier against both the environment and the
transepidermal water loss (TEWL) from the body. In addi-
For personal use only.
tion, the water-holding capacity of the SC is crucial for the
control of the global epidermal homeostasis and differentia-
tion. The water-holding capacity governs the SC plasticity
and prevents physiological harsh/dry skin conditions [7,8].
The turnover and assembly of corneocytes are important fac-
tors controlling the water flux and retention inside the SC,
thus governing the overall level of SC moisturization. At the
molecular level, the SC is a selective lipidic barrier. Its perme-
ability largely depends on the nature, integrity and assembly
of the intercorneocyte lipid layers.
Each corneocyte contains a water-insoluble protein scaffold
made predominantly of a highly organized keratin microfi-
brillar matrix. This meshwork is encapsulated in a protein-
and lipid-enriched shell showing variable maturation among
corneocytes. Two distinct types of cornified cell envelopes
were contrasted as fragile and rigid, also called immature
and mature [9]. Each corneocyte is further embedded in a
hydrophobic domain formed by lipid bilayers. The global
structure guarantees the SC water-holding capacity, and limits
the trans-SC water flux, thus preventing dessication of the
living epidermis. Both the SC structure and TEWL result
from dynamic processes that are possibly altered in diabetes
mellitus. Accordingly, the SC homeostasis and hydration are
commonly altered in this disease.
Any xerotic process is a combination of SC thickening, tidy
corneocyte assembly with lowered flexibility, harsh surface and
lowered hydration of the uppermost SC layers [10]. Weathering
xeroses (related to surfactants, cold, dry, windy environment,
friction, pressure, etc.) and metabolic xeroses (related to diabetes
neuropathy and peripheral vascular disease, atopy, ichthyosiform
conditions, aging, etc.) are conveniently distinguished.
202 Expert Opin. Med. Diagn. (2013) 7(2)
3. Xerosis severity grading
Xerosis grading is important for a proper clinical management
because emollients, urea-based formulations, salicylic acid prep-
arations, chitin-glucan-enriched creams are indicated and active
in only a part of the whole spectrum of diabetic xeroses.
Clinical assessments of the SC aspect commonly rely on
ordinal grading scales [11]. Most of them suffer from vague
and overlapping definitions. Indeed, subjective clinical assess-
ments referring to visual and tactile scoring show variability
due to inconsistencies from grade to grade, and from limita-
tions in reproducibility. Variations in the environmental con-
ditions commonly jeopardize such grading systems because
hydration swells the outer SC and often camouflages
low-grade dryness/roughness, xerosis and scaling.
One of the ancillary method designed to study the outer SC
layers relied on tape stripping. The use of casual sticky tapes
often proved to be unreliable for quantitative assessments
because considerable variation prevailed in the adhesion of
different batches to the SC. During the past decades, investi-
gators strived relentless to provide more precise evaluation
tools for xerosis rating. In this field, bioinstrumentation
reduced grading uncertainties and interobserver inconsisten-
cies. It yielded better distinction between xerotic conditions
by increasing the accuracy, sensitivity, specificity and repro-
ducibility of data. Bioinstrumentation typically provided
increased positive predictive value. Hence, the power of the
majority of these methods appears superior to subjective
scoring and regular clinical grading. Currently, the standard
operating procedures in many laboratories rely on two mini-
mally invasive sampling methods, namely the cyanoacrylate
skin surface strippings (CSSS) and strippings with adhesive
coated discs (SACD) under controlled pressure. In vivo con-
trolled optical visualization of the skin surface is further
used with camera recordings and image analysis.
3.1 Cyanoacrylate skin surface stripping
CSSS sampling consists of harvesting a uniform continuous
sheet of SC using a cyanoacrylate bond with a transparent
plastic strip. After a 15 -- 30 s polymerization time, the sample
is lifted off. It is stained by a variety of microscopical stains
and examined under a low-power magnification.
Several grades of diabetes-related orthokeratotic hyperkera-
tosis are possibly distinguished using CSSS [12]. Grade 0 corre-
sponds to the absence of hyperkeratosis, except for some
discrete focal accumulations of corneocytes in the primary
order lines of the skin. Grade 1 corresponds to a continuous
linear hyperkeratosis confined to the primary lines or to spotty
hyperkeratosis predominating at adnexal openings, either at
hair follicles or acrosyringia. Grade 2 corresponds to focal
hyperkeratosis of the skin surface plateaus covering less than
30% of the sampling surface. Grade 3 is similar to grade 2,
but with a xerotic area extending over 30% of the CSSS. Grade
4 is defined by an homogeneous and diffuse hyperkeratosis
with persistence of the primary order lines. Grade 5 resembles

grade 4, but hyperkeratosis is uneven with loss of the pattern of
the primary lines. The excessive SC thickening results from a
multilayered stacking of corneocytes.
3.2 Ultraviolet light-enhanced visualization
Similar aspects are provided in vivo using a CCD camera
equipped with an internal UV-emitting unit (VisioScan
VC98, C+K electronic, Cologne, Germany). The video sensor
chip is closely applied to the skin surface in order to avoid
shadows. The uniform lighting of the SC brings out a sharp
Expert Opin. Med. Diagn. Downloaded from informahealthcare.com by Karolinska Institutet University Library on 04/14/15
picture of a 6*8 mm skin area. The high resolution of the
equipment allows close assessments of the SC. The digitaliza-
tion unit configures the image in 256-gray-level pixels, where
0 is black and 256 is white. This procedure leads to the so-
called UV-light enhanced visualization (ULEV) method [13,14].
The ULEV pictures conveniently reveal any hyperkeratotic and
scaly aspect of the skin surface. The lesions look whitish,
contrasting with the gray aspect of the normal-looking skin [13].
3.3 Surface evaluation of living skin
The SELS (surface evaluation of living skin) method is an
additional way, allowing direct and non-invasive measure-
ment of the skin topography using the VisioScan camera.
The actual skin picture can be presented with false colors
For personal use only.
and viewed either two-dimensionally or tridimensionally.
Different parameters are displayed in the evaluation of the
skin surface. For instance, the scaliness parameter (SEsc)
aims at representing the xerosis grade [14].
3.4 Strippings with adhesive coated discs
Groundbreaking work using the SACD method has reached
recognition for fundamental research, clinical experimenta-
tion and applied dermocosmetology [6,8,15]. The SACD
sampling device is a crystal-clear pressure-sensitive
adhesive-coated disc (D-squame, Cuderm Corp., Dallas,
TX; Corneofix, C+K Electronic). Such specific sampling
material exhibits adequate rigidity and adhesion to uni-
formly harvest loose corneocytes from a fixed area of the
SC. The disc is applied to the skin surface using a gauge
spring dynamometer to ensure a calibrated pressure usually
in the range 100 -- 250 g/cm2. Both the pressure and the
time of application of the disc influence the amount of SC
removed. A short-time (5 s) SACD application harvests less
corneocytes from the stratum disjunctum than a longer
time (1 h) application. Such difference is due to the occlu-
sion time modifying the SC hydration and cohesion between
corneocytes. Seasonal and other environmental variations
alter the amount of harvested SC [10].
A wealth of applications have benefited from a 1-min
staining procedure using toluidine blue and basic fuchsin in
30% ethanol at pH 3.4. Such samples are suitable for both
microscopic examination and reflectance colorimetry. This
latter assessment was coined squamometry [15]. For that pur-
pose, the color of each specimen is measured using reflectance
colorimetry. The most convenient colorimetric parameter was
Expert Opin. Med. Diagn. (2013) 7(2)
Critical assessment of diabetic xerosis
called the squamometry index (SQMI), which refers to the
Chroma C* corresponding to (a*2 + b*2).
Squamometry is currently used for several purposes.
Accordingly, different names were coined and defined,
including squamometry X, which specifically refers to the
assessment of xerosis [15]. A linear correlation exists between
the amount of harvested corneocytes and SQMI. Data are
influenced by the presence of parakeratotic cells.
4. Corneodynamics
The SC is subject to constant self-renewal. Diabetes com-
monly slows down the turnover time of the SC, and alters
the evenness of this process [4,7]. CSSS are conveniently used
for objectively assessing the rate of SC renewal. For the pur-
pose of corneodynamics assessment, the SC has to be stained
down to its deeper layers. After a lag period lasting about
10 days, a CSSS is collected to be examined under light or
fluorescence microscopy according to the staining compound.
Dansyl chloride is a time-honored fluorescent compound
for the SC. For years, the test relied on daily assessments of
the decline in the clinical fluorescence [16]. The rate of SC
renewal was determined by the duration of the fluorescence
persistence. However, this clinical test was difficult to inter-
pret because it was uneasy to accurately determine the time
point when fluorescence was lost. This was in part due to
the uneven fade out of fluorescence at the skin surface. The
CSSS procedure is a variant method performed at a fixed
time after dansyl chloride application. The fluorescence pat-
tern is quantified using image analysis under the fluorescence
microscope [17].
A number of topical products extract dansyl chloride from
the SC [18]. Hence, for testing the product efficacy on xerosis
while avoiding any dansyl chloride extraction, the in vivo test
should begin with the application of the test product for a
dozen of days. In a second step, dansyl chloride should be
applied without any further application of the test product.
A risk of contact allergy and systemic resorption of dansyl
chloride was reported [19]. Hence, there is some limitation
for its use, particularly in subjects involved in a series of
similar tests. Dihydroxyacetone was offered as a surrogate
SC marker [20].
5.Global electrometric assessment and skin
capacitance mapping
Skin electrical properties are influenced by i) the surface
texture and microrelief together with ii) the water and electro-
lyte content inside the SC and iii) the sweat production.
Measuring electrical capacitance is a convenient although
indirect way to appreciate any changes in these physiological
parameters [21-23]. The capacitance method is rooted on the
permittivity of water (" = 81), which is higher than for most
other molecules. Thus, the dielectric characteristics of the
SC mainly depend on its water content. According to the
203
 G. E. Pierard et al.
location of the measurement site, sources of error and varia-
tion in the data are encountered, including sweat production,
occlusion of the sweat ducts and density in vellus hairs, as well
as the electrolyte content of the SC and some artifacts from
topically applied xenobiotics. Regular devices devoted to skin
capacitance measurements provide average electrometric values
for the global skin area covered by the sensor probe. Hence,
there is no information about the possible heterogeneity in
the measured physical parameter over the test area.
Over the past few years, a new advance was made, with the
Expert Opin. Med. Diagn. Downloaded from informahealthcare.com by Karolinska Institutet University Library on 04/14/15
skin capacitance mapping/imaging (SCM) method, represent-
ing a unique type of non-optical skin surface imaging [24,25].
This method relies on fine-tuned electrometric measurements
of the skin surface properties. It represents a physiological and
medical application of the silicon image sensor technology
initially designed for identifying fingerprints in security pro-
cedures. The same electrometric assessments of the upper
layers of the SC represent a convenient non-invasive way
assessing the SC hydration. Such properties are closely related
to a series of specific SC structures and functions.
The SCM method currently relies on the unique
SkinChip device (ST microelectronics, Geneva, Switzerland
and LOreal, Paris, France). This specific sensor is dedicated
for computer recordings of both the skin surface hydration
For personal use only.
and microrelief. It contains a network of 92,160 microcapaci-
tors orderly dispersed on a 18*12.8 mm plate protected by a
thin silicon oxide layer. The probe must be closely applied
to the skin surface for approximately 5 s in order to collect
relevant information without interfering with both the water
flux through and water collection inside the SC.
In practice, the real-time SCM images are acquired and
displayed on the computer screen. They provide simultaneous
SC capacitance measurements every 50 m over the test area.
Capacitance values of the superficial SC appear as pixels in a
range of 256 gray levels. The darker pixels correspond to high
capacitance (hydrated) spots, whereas the clear ones represent
the lower capacitance (dry) values. In addition, other specific
skin parameters are characterized. On a flat skin surface, the
mean gray level of the image represents the average SC hydra-
tion. The SC commonly exhibits an heterogeneous pattern of
corneocyte hydration, particularly during aging [26,27] and in
diabetic xerosis of mild-to-moderate intensity as well [28].
6. Imperceptible perspiration
Eccrine sweating is under the control of the cholinergic sympa-
thetic innervation. It plays an essential role in regulating body
temperature in physiological and pathological conditions [29].
This function is altered by some systemic diseases including
diabetic neuropathy, which commonly involves the distal sen-
sorimotor innervation [30,31]. The resulting peripheral sweating
deficit is responsible for unequivocal abnormalities of length-
dependent thermoregulatory sweating. Other sweating changes
in diabetes include segmental hypohidrosis and more rarely a
set of dermatome involvement [31]. Some patients suffer from
204 Expert Opin. Med. Diagn. (2013) 7(2)
a combination of two or more patterns of sweating abnor-
malities and even from global anhidrosis. The extent in body
surface anhidrosis was reported to be correlated with the seve-
rity of clinical dysautosomia [30,31]. Fine-tuning the objective
assessments of discrete sweat gland dysfunction in diabetes
has not received much attention so far using recent sensitive
biometrological methods [28].
At rest, water evaporation from each sweat pore at the
skin surface is added to the regular TEWL for creating the
so-called insensible perspiration corresponding to the global
skin surface water loss (SSWL) [32]. This latter parameter is
not perceptible at the clinical observation. The literature is
occasionally quite confusing regarding the clear-cut distinc-
tion between TEWL and SSWL. The imperceptible perspira-
tion is conveniently observed using SCM. Tiny black dots
mark the discretely active sweat gland openings and the SC
appears dull. This aspect has little influence on the casual
TEWL determinations. When sweating is more active, SCM
black dots become larger and some merge to form irregular
dark puddles. Because sweat appears as black dots, it is possi-
ble to measure its contribution to the SCM-derived mean
gray level by thresholding the values.
At rest, diabetic subjects exhibit symmetrical sweating with-
out any significant difference between both forearms and legs.
No significant differences were found in both the Corneome-
ter average capacitance (CMAC) value and TEWL between
the upper and lower limbs. By contrast, the mean SCM was
significantly lower on the legs compared with the forearms.
In addition, the mean SCM on the forearms was significantly
higher in diabetic patients than in healthy subjects [28].
Diabetic neuropathy predominantly affects the distal por-
tions of the sensory motor innervation [30,31]. As a result,
eccrine hypohidrosis develops in time on the legs, and a reac-
tional hyperhidrosis is expected to occur on the upper body
regions [28]. Such conditions become obvious in severe cases
of diabetic neuropathy and during psychological stress or
increased body temperature such as after intense physical exer-
cise. Globally, after discrete physical exercise, SSWL, CMAC
and the mean SCM remain positively correlated [28,29].
7. Emollient effects
Many consumers believe that emollients, moisturizers and
hydrating creams actively increase the water content in the
SC. By contrast, a number of physicians perceive moisturizers
as emollients softening the SC and removing its uppermost
layers [4,33,34]. Indeed, the term moisturizer does not imply
that water is being added to the SC [35]. Traditionally, SC
moisturization is expected to follow reduction in TEWL by
occlusion. However, such claim is rarely supported by exper-
imental evidence in clinical settings. In fact, moisturizers are
used to fill in some tiny cracks at the skin surface and to
provide the SC surface with a soothing protective film. The
products help the process of corneodesmolysis while keeping
it in the physiological range [35-40]. Indeed, some moisturizers

improve the appearance and tactile properties of the skin,
including diabetic xerosis [4]. As an inert epicutaneous layer,
they are thought to redistribute water in the superficial layers
of the SC and to reduce skin friction. Of note, emollients
probably represent a first approach to prevent the callus for-
mation in the diabetic foot syndrome [37,41].
8. Conclusion
Most dedicated dermometrology assessments of diabetic xerosis
are valuable because their sensitivity and objectivity often appear
Expert Opin. Med. Diagn. Downloaded from informahealthcare.com by Karolinska Institutet University Library on 04/14/15
undisputable. However, their respective specificity is much
weaker and should not dismiss the global evaluations best
obtained by the non-instrumental expertise. The global three-
pronged approach using instruments, trained assessors and
self-assessments provides a good opportunity to evaluate the
xerotic status and increases the confidence of the evaluations.
Data gained by instruments add quantification to the sub-
jective perception by the patient and/or the physician. Non-
invasive measurements reveal changes in the functional prop-
erties of the skin, which are not readily accessible at the visual
and tactile examinations. This situation represents an advance
in knowledge when it describes a relevant clinical aspect.
Unfortunately, it may represent hype in some instances.
For personal use only.
Any significant difference yielded by instrumental methods
between two conditions, but lacking clinical relevance sug-
gests discrepancies between the two assessments regarding
their sensitivity and specificity.
In some instances, surrogate parameters are used to assess
the efficacy of therapies. This approach does not represent a
direct measure of the benefit of treatment. However, carefully
chosen and validated surrogate parameters provide insights to
queries that would typically require much complicated trials if
the specific targeted end point had to be assessed. One exam-
ple of such a surrogate parameter is the determination of skin
electric properties as a measure of the SC hydration.
Some diabetic patients suffer from xerosis similar to senile
xerosis. The skin condition ranges from a dry/rough skin feeling
to obvious xerosis and even to an ichthyosiform presentation.
When severe, it participates to the diabetic foot syndrome [36,37].
Due to its high prevalence and potential severity, this contin-
uum of disorders is not trivial and should be properly managed.
Bioinstrumentation is useful, particularly in the assessment
of the shins and feet of diabetic patients suffering from
microangiopathy and peripheral neuropathy.
Grading the xerosis severity is important both for defining
the skin changes and assessing the effects of treatment or pre-
vention. Objective comparisons of the emollient effects
become possible. Corneodynamics is a method bringing a
dynamic information about the renewal rate of the SC. Any
boosting effect of medications on this parameter would prob-
ably be welcome in diabetic xerosis. Among the electrometric
assessments of the SC moisture, SCM appears to be the most
promising tool in diabetic patients prone to xerosis. The
impairment in autonomic innervation of sweat glands alters
Expert Opin. Med. Diagn. (2013) 7(2)
Critical assessment of diabetic xerosis
the imperceptible perspiration. This function in unstimulated
conditions is clearly observed using SCM. Any correlation
with other consequences of diabetes complications merits to
be investigated.
Emollients represent the current preventive and therapeutic
management of diabetic xerosis.
9. Expert opinion
During the past decades, much progress has been made in the
design of dermometrological methods allowing objective and
accurate measurements of skin changes. Some of the methods
are useful in the management of related conditions encompass-
ing the dry/rough skin feeling, xerosis, ichthyosiform presenta-
tion and the diabetic foot syndrome. In addition, they help the
preventive and therapeutic managements of these conditions.
The cluster of xerotic presentations appears to be particu-
larly related to the microangiopathy and neuropathy affecting
diabetic patients. Possible correlations between xerotic mani-
festations, the duration of diabetes and the poor glycemic con-
trol have not been searched so far. Similarly, any association
with nephropathy and retinopathy remains unsettled. Some
studies could be initiated introducing xerosis biometrology
in the assessment procedures.
An extensive arsenal of emollients is available. Emollients
still have a pivotal role to fulfill in this field of pathology
because the biological origins of diabetic xerosis are out of
access for any current drug. Moisturizers basically act on the
water concentration gradient in the SC in two ways: i) by
restoring, retaining or increasing moisture in the SC allowing
the addition of water from the dermis and stratum Malpighi
or conversely from the applied product and ii) by occluding
the skin surface, impeding TEWL and causing a buildup of
moisture in the SC. These modes of action are commonly
combined in the same product. There are, however, excep-
tions, such as petrolatum or floating (spreading) bath oils
that are considered to work only by forming a semi-
occlusive layer on the SC. Some of the formulations are
designed for a general use in the population irrespective of
the diabetic status or not. Other products claim to be specifi-
cally targeting diabetic xerosis. Ongoing research and deve-
lopment activities should be focusing on novel types of
formulations. In addition, it would be worth to evaluate the
effects of age and environmental conditions on diabetic
xerosis in order to design adequately preventive measures.
Acknowledgments
The authors appreciate the excellent secretarial assistance of
I Leclercq and M Pugliese.
Declaration of interest
The authors state no conflict of interest and have received no
payment in preparation of this manuscript.
205
 G. E. Pierard et al.

Bibliography
Papers of special note have been highlighted as
either of interest () or of considerable interest
() to the readers.
1. Romano G, Moretti G, Di Benedetto A,
et al. Skin lesions in diabetes mellitus:
prevalence and clinical correlations.
Diabetes Res Clin Pract 1998;30:101-6
.. A comprehensive survey of skin
disorders prevalent in diabetic patients.
2. Yosipovitch G, Hodak E, Vardi P, et al.
Expert Opin. Med. Diagn. Downloaded from informahealthcare.com by Karolinska Institutet University Library on 04/14/15
11. Serup J. EEMCO guidance for the
assessment of dry skin (xerosis) and
ichthyosis: clinical scoring systems.
Skin Res Technol 1995;1:109-14
12. Pierard GE. EEMCO guidance for the
assessment of dry skin (xerosis) and
ichthyosis: evaluation by stratum
corneum strippings. Skin Res Technol
1996;2:3-11
13. Pierard-Franchimont C, Petit L,
designs. Skin Pharmacol Appl
Skin Physiol 2001;14:183-95
23. Lee CM, Maibach HI. Bioengeneering
analysis of water hydration: an overview.
Exogenous Dermatol 2002;1:269-75
24. Leveque JL, Xhauflaire-Uhoda E,
Pieard GE. Skin capacitance imaging, a
new technique for investigating skin
surface properties. Eur J Dermatol
2006;16:500-6

The prevalence of cutaneous
manifestations in IDDM patients and
their association with diabetes risk factors
and microvascular complications.
Diabetes Care 1998;21:506-9
3. Gerrits EG, Lutgers HL, Kleefstra N,
et al. Skin autofluorescence: a tool to
identify type 2 diabetic patients at risk
for developing microvascular
complications. Diabetes Care
2008;31:517-21
4. Uhoda E, Debatisse B, Paquet P, et al.
The so-called dry skin of the diabetic
patient. Rev Med Liege 2005;60:560-3
For personal use only.
Pierard GE. Skin surface patterns of
xerotic legs: the flexural and accretive
types. Int J Cosmet Sci 2001;23:121-6
14. Quatresooz P, Pierard GE. The
visioscan-driven ULEV and SELS
methods. In: Barel AO, Paye M,
Maibach HI, editors. Handbook of
cosmetic science and technology. 3rd
edition. Publ. Informa Healthcare; New
York, USA; 2009. p. 283-90
15. Pierard-Franchimont C, Henry F,
Pierard GE. The SACD method and the
XLRS squamometry tests revisited. Int J
Cosmet Sci 2000;22:437-46
25. Xhauflaire-Uhoda E, Pierard GE,
Quatresooz P. The skin landscape
following nonoptical capacitance
imaging. Am J Clin Dermatol
2010;11:89-94
26. Bazin R, Laquieze S, Rosillo A,
Leveque JL. Photoaging of the chest
analyzed by capacitance imaging.
Skin Res Technol 2008;14:23-9
27. German GK, Engl WC, Pashkovski E,
et al. Heterogeneous drying stresses in
stratum corneum. Biophys J
2012;102:2424-32
28. Xhauflaire-Uhoda E, Mayeux G,

5. Seite S, Khemis A, Rougier A,
Ortonne JP. Importance of treatment of
skin xerosis in diabetes. J Eur Acad
Dermatol Venereol 2011;25:607-9
6. Leveque JL, Francois G, Sojic N,
Giron F. A new technique to in vivo
study the corenocyte features at the
surface of the skin. Skin Res Technol
2008;14:468-71
7. Yoon HS, Baik SH, Oh CH.
Quantitative measurement of
desquamation and skin elasticity in
diabetic patients. Skin Res Technol
2002;8:250-4
8. Sakai S, Kikuchi K, Satoh J, et al.
Functional properties of the stratum
corneum in patients with diabetes
mellitus: similarities to senile xerosis.
Br J Dermatol 2005;153:319-23
.. A well-designed consideration of
xerosis in diabetes and aging.
9. Hirao T, Denda M, Takahashi M.
Identification of immature cornified
envelopes in the barrier-impaired
epidermis by characterization of their
hydrophobicity and antigenicities of the
components. Exp Dermatol
2001;10:35-44
10. Pierard-Franchimont C, Pierard GE.
Beyond a glimpse at seasonal dry skin:
a review. Exogenous Dermatol
2002;1:3-6
16. Takahashi M, Black D, Hughes B,
Marks R. Exploration of a quantitative
dansyl chloride technique for
measurement of the rate of
desquamation. Clin Exp Dermatol
1986;12:246-9
29.
17. Pierard-Franchimont C, Pierard GE.
Cyanoacrylate skin surface strippings for
visualising the stratum corneum structure
and dynamics. In: Agache P, Humbert P,
30.
editors. Measuring the skin. Non invasive
investigations, physiology, normal
constants. Springer-Verlag, Berlin; 2004
18. Paye M, Simion A, Pierard GE. Dansyl
chloride labelling of stratum corneum: its
31.
rapid extraction from skin predict skin
irritation due to surfactants and cleansing
products. Contact Dermat 1994;30:91-6
19. Gumowski-Sunek D, Saurat JH.
32.
Systemic reaction during a dansyl
chloride test. Dermatology 1992;185:73
20. Uhoda E, Pierard-Franchimont C,
Debatisse B, et al. Repair kinetics of
stratum corneum under repeated insults.
33.
Exogenous Dermatol 2004;3:7-11
21. Berardesca E. EEMCO guidance for the
assessment of stratum corneum
hydration: electrical methods.
Skin Res Technol 1997;3:126-32
22. Fischer TW, Wigger-Alberti W,
Elsner P. Assessment of dry skin:
current bioengineering methods and tests
Quatresooz P, et al. Facing up to the
imperceptible perspiration. Modulation
influences by diabetic neuropathy,
physical exercise and antiperspirant.
Skin Res Technol 2011;17:487-93
Noel F, Pierard-Franchimont C,
Pierard GE, Quatresooz P. Sweaty skin,
background and assessments.
Int J Dermatol 2012;51:647-55
Petrofsky JS, Lee S, Patterson C, et al.
Sweat production during global heating
and during isometric exercise in people
with diabetes. Med Sci Monit
2005;11:CR515-21
Provitera V, Nolano M, Caporaso G,
et al. Evaluation of sudomotor function
in diabetes using the dynamic sweat test.
Neurology 2010;74:50-6
Pierard GE; the EEMCO group.
EEMCO guidance for the efficacy
assessment of antiperspirants and
deodorants. Skin Pharmacol Appl
Skin Physiol 2003;16:324-42
Draelos ZD, Yatskayer M, Raab S,
Oresajo C. An evaluation of the effect of
a topical product containing C-xyloside
and blueberry extract on the appearance
of type II diabetic skin.
J Cosmet Dermatol 2009;8:147-51

206 Expert Opin. Med. Diagn. (2013) 7(2)


34. Loden M. The clinical benefit of
moisturizers. J Eur Acad
Dermatol Venereol 2005;19:672-88
35. Shi VY, Tran K, Lio PA. A comparison
of physicochemical properties of a
selection of modern moisturizers:
hydrophilic index and pH.
J Drugs Dermatol 2012;11:633-6
36. Pham HT, Exelbert L, Segal-Owens A,
et al. A prospective, randomized,
controlled double-blind study of a
Expert Opin. Med. Diagn. Downloaded from informahealthcare.com by Karolinska Institutet University Library on 04/14/15
moisturizer for xerosis of the feet in
patients with diabetes.
Ost Wound Manag 2002;48:30-6
37. Pavicic T, Korting HC. Xerosis and
callus formation as a key to the diabetic
foot syndrome: dermatologic view of the
problem and its management. J Dtsch
Dermatol Ges 2006;4:935-41
38. Quatresooz P, Pierard-Franchimont C,
Szepetiuk G, et al. Fungal chitin-glucan
scaffold for managing diabetic xerosis of
For personal use only.
the feet in menopausal women.
Expert Opin Pharmacother
2009;10:2221-9
. Original work alluding to the
beneficial effectors of topical
chitin-glucan applications on
xerotic skin.
39. Seite S, Khemis A, Rougier A, et al.
Importance of treatment of skin xerosis
in diabetes. J Eur Acad
Dermatol Venereol 2011;25:607-9
40. Pierard GE, Seite S, Hermanns-Le T,
et al. The skin landscape in diabetes
mellitus. Focus on dermocosmetic
management. Dermatol Ther; In press
41. Garrigue E, Martini J, Cousty-Pech F,
et al. Evaluation of the moisturizer
Pedimed in the foot care of diabetic
patients. Diabetes Metab 2011;37:330-5
Expert Opin. Med. Diagn. (2013) 7(2)
Critical assessment of diabetic xerosis
Affiliation
Gerald E Pierard1,3 MD PhD,
Claudine Pierard-Franchimont1 &
Andre Scheen2
Author for correspondence
1
Professor,
Laboratory of Skin Bioengineering
and Imaging (LABIC),
Lie`ge, Belgium
2
University of Lie`ge,
Department of Diabetology,
Nutrition and Metabolic Diseases,
and Clinical Pharmacology Unit,
Lie`ge, Belgium
3
University Hospital of Lie`ge,
Department of Dermatopathology,
Laboratory of Skin Bioengineering
and Imaging (LABIC),
BE-4000 Lie`ge, Belgium
Tel: +32 4 3662408;
Fax: +32 4 3662976;
E-mail: gerald.pierard@ulg.ac.be
207