Author:

Editor(s):

Updated:

ULY CLINIC

18 Septemba 2025, 12:12:44

Scaly skin

Scaly skin results when the cells of the stratum corneum desiccate and shed excessively, causing accumulation of loosely adherent flakes of normal or abnormal keratin. Normally, skin cell turnover is imperceptible, but the appearance of scale indicates increased cell proliferation or abnormal keratinization.

Scales vary in texture (fine, branlike, coarse, or stratified), color (white, gray, yellow, brown, or silvery), and appearance (dry, brittle, shiny, greasy, or dull). While often benign, scaly skin may reflect underlying infections, inflammatory disorders, autoimmune disease, malignancy, or drug reactions.

Pathophysiology

Abnormal keratinization: Accelerated proliferation or impaired desquamation leads to visible scaling.
Inflammation: Dermal or epidermal inflammation increases turnover of keratinocytes.
Infection: Fungal, bacterial, or viral pathogens damage skin and induce hyperproliferation.
Immune-mediated damage: Disorders like lupus or lymphoma disrupt epidermal integrity.
Drug-induced: Certain medications alter keratinocyte turnover or trigger hypersensitivity reactions.

History and Physical Examination

History

Onset, duration, and pattern of scaling.
Previous episodes, precipitating factors, and seasonal variation.
Recent febrile illness, sunburn, burns, or joint pain.
Use of new topical products, soaps, cosmetics, or hair preparations.
Work-related chemical exposure or systemic medications.
Family history of skin disorders.
Presence of pruritus, pain, or exudate.

Physical Examination

Assess skin texture (dry, greasy, moist, or oily).
Observe distribution: localized vs generalized; extensor vs flexor surfaces.
Inspect color, shape, size, and thickness of scales.
Evaluate associated lesions on mucous membranes, hair, nails, and scalp.
Check for systemic signs: lymphadenopathy, hepatosplenomegaly, or signs of infection.

Medical causes

Cause	Onset	Key Features	Associated Signs	Pathophysiology	Management
Bowen’s disease	Chronic	Painless erythematous plaques, thick hyperkeratotic scale, possible ulceration	Rare ulceration	Intraepidermal carcinoma	Biopsy, excision or topical therapy
Exfoliative dermatitis	Rapid	Generalized erythema and fine/large scales	Fever, chills, malaise, lymphadenopathy, gynecomastia, hypothermia	Widespread epidermal inflammation	Hospitalization, supportive care, treat underlying cause
Nummular dermatitis	Subacute	Round, pustular lesions, crusted and scaly	Severe pruritus, oozing exudate	Eczematous inflammation	Topical corticosteroids, emollients, antihistamines
Seborrheic dermatitis	Chronic	Erythematous papules → greasy yellow scales	Pruritus; scalp, face, chest involvement	Malassezia yeast, sebaceous gland activity	Antifungal creams/shampoos, topical corticosteroids
Dermatophytosis	Variable	Tinea capitis: red scaly plaques with central clearing; Tinea pedis: intertriginous scaling/blisters; Tinea corporis: ring-shaped lesions	Alopecia (capitis), pruritus	Fungal infection of keratinized tissues	Topical/oral antifungals
Lymphoma	Chronic	Hodgkin’s: pruritic scaling dermatitis; Non-Hodgkin’s: patches → nodules, ulcers	Fever, weight loss, lymphadenopathy, hepatosplenomegaly	Malignant infiltration of skin	Oncology referral, chemotherapy, supportive care
Parapsoriasis	Chronic	Small/medium erythematous maculopapular eruptions with thin adherent scale	Trunk, hands, feet	Idiopathic inflammatory disorder, possibly early cutaneous T-cell lymphoma	Topical corticosteroids, phototherapy
Pityriasis rosea	Acute	Herald patch → multiple oval, scaly patches	Pruritus, trunk, proximal limbs	Unknown (possibly viral)	Self-limiting, symptomatic treatment
Pityriasis rubra pilaris	Chronic	Seborrheic scaling → thick, hyperkeratotic scaly patches on palms, soles, trunk	Painful fissures, pruritus	Keratinization disorder	Retinoids, corticosteroids, phototherapy
Psoriasis	Chronic	Silvery, micaceous scales over erythematous plaques	Nail pitting, arthritis	Immune-mediated hyperproliferation	Topical/systemic therapy, biologics
SLE	Chronic	Butterfly rash with scaling; other skin surfaces involved	Photosensitivity, joint pain, vasculitis, alopecia	Autoimmune inflammation	Immunosuppressants, antimalarials
Tinea versicolor	Chronic	Hypo-/hyperpigmented macular patches, slightly scaly	Upper trunk, arms, lower abdomen	Malassezia infection	Topical/oral antifungals

Other causes

Drug-induced scaling: Penicillins, sulfonamides, barbiturates, quinidine, diazepam, phenytoin, isoniazid.
Corticosteroid withdrawal: Abrupt cessation may trigger scaling.

Special considerations

Confirm the diagnosis with Wood’s lamp examination, KOH prep, skin scraping, or biopsy as needed.
Manage underlying cause rather than only treating the scales.
Educate about proper skin care: gentle cleansing, moisturization, and avoidance of irritants.

Patient counseling

Explain that scaling is usually a manifestation of an underlying disorder.
Teach early recognition of flares (e.g., new lesions, infection, systemic symptoms).
Advise consistent use of prescribed topical or systemic treatments.
Encourage avoiding excessive bathing, harsh soaps, or irritants.

Pediatric pointers

Common causes: infantile eczema, cradle cap, pityriasis rosea, epidermolytic hyperkeratosis, ichthyosis, viral exanthems, atopic dermatitis.
Post-febrile desquamation may be observed.
Evaluate for systemic illness if generalized or persistent scaling occurs.

References

Berkowitz CD. Berkowitz’s Pediatrics: A Primary Care Approach. 4th ed. American Academy of Pediatrics; 2012.
Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. Mosby Elsevier; 2008.
Lehne RA. Pharmacology for Nursing Care. 7th ed. Saunders Elsevier; 2010.
McCance KL, Huether SE, Brashers VL, Rote NS. Pathophysiology: The Biologic Basis for Disease in Adults and Children. Mosby Elsevier; 2010.
Sommers MS, Brunner LS. Pocket Diseases. F.A. Davis; 2012.
Wolff K, Johnson RA. Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology. 6th ed. McGraw Hill Medical; 2009.
Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 7th ed. Elsevier; 2021.
James WD, Elston DM, Treat JR, et al. Andrews’ Diseases of the Skin: Clinical Dermatology. 13th ed. Elsevier; 2020.
Bolognia JL, Schaffer JV, Cerroni L. Dermatology. 5th ed. Elsevier; 2018.
Rook A, Burns T, Breathnach S, Cox N, Griffiths C, eds. Rook’s Textbook of Dermatology. 9th ed. Wiley-Blackwell; 2016.
Goldsmith LA, Katz SI, Gilchrest BA, et al., eds. Fitzpatrick’s Dermatology in General Medicine. 9th ed. McGraw-Hill; 2019.
Habif TP. Skin Disease in Children and Adolescents. 2nd ed. Elsevier; 2019.