Sandbox:Shalinder

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shalinder Singh, M.B.B.S.[2]

Overview

The majority of patients with [disease name] are asymptomatic.

OR

The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. Common symptoms of [disease] include [symptom 1], [symptom 2], and [symptom 3]. Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].

History and Symptoms

History

Patients with atopic dermatitis may have a positive history of:

• cutaneous hyper-reactivity to diverse environmental stimuli:
  • exposure to food and inhalant allergens
  • changes in physical environment (including humidity, pollution etc)
  • irritants
  • microbial infection
  • stress
• personal or family history of type I hypersensitivity
• asthma
• allergic rhinitis

Common Symptoms

Common symptoms of atopic dermatitis include:

• Pruritus
• Chronic or relapsing dermatitis
• Distribution of rash on:
  • Facial and extensor surfaces in infants and young children
  • Flexure lichenification in older children and adults
• Personal or family history of atopy (asthma, allergic rhinitis, atopic dermatitis)

Less Common Symptoms

Less common symptoms of atopic dermatitis include:

• Facial pallor/facial erythema
• Xerosis (especially in winter)
• Nonspecific dermatitis of the hands and feet
• Food intolerance
• Itch when sweating

Overview

Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].

OR

Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

The presence of [finding(s)] on physical examination is diagnostic of [disease name].

OR

The presence of [finding(s)] on physical examination is highly suggestive of [disease name].

Physical Examination

The clinical presentation of atopic dermatitis is highly variable, depending upon the patient's age and disease activity.

Appearance of the Patient

• Patients with [disease name] usually appear [general appearance].

Vital Signs

• High-grade / low-grade fever
• Hypothermia / hyperthermia may be present
• Tachycardia with regular pulse or (ir)regularly irregular pulse
• Bradycardia with regular pulse or (ir)regularly irregular pulse
• Tachypnea / bradypnea
• Kussmal respirations may be present in _____ (advanced disease state)
• Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
• High/low blood pressure with normal pulse pressure / wide pulse pressure / narrow pulse pressure

Skin

• Primary findings:
  • Severe pruritus- cardinal feature of atopic dermatitis
  • Eczematous lesions- location of lesions has age-specific patterns
  • Xerosis (especially during winters)
  • Lichenification
  • An acute eczematoid eruption (with erythematous papules) appears after patients scratch their skin
• Eczema:
  • Acute atopic dermatitis:
    • The skin is erythematous with papules and vesicles, and can usually get infected with Staphylococcus aureus
    • Lesions presents as intense pruritic erythematous papules and vesicles with exudation and crusting
  • Subacute or chronic atopic dermatitis:
    • The skin is dry, infiltrated and usually lichenified with scales and fissures. In severe cases the disease can lead to erythroderma
    • Lesions are dry, scaly, or excoriated erythematous papules
    • Lichenification (chronic scratching may result in skin thickening) and fissuring may develop over time
  • Age-specific patterns:

Infants and young children(zero to two years)
Earliest lesions: Presents with erythema and exudation of the creases(antecubital and popliteal fossae) Over the following few weeks: highly pruritic, red, scaly and crusted lesions, usually localized to the cheeks, the forehead and scalp, and the extensors of the lower legs Lesions are ill-defined, erythematous, scaly, and crusted (eczematous) patches and plaques. The most commonly involved areas: Scalp, cheeks and extensor side of the extremities. Flexural areas, especially the neck fold, may be involved Midline of the face and the tip of the nose is spared (Yamamoto’s sign) Diaper area is generally spared Lichenification is uncommon in infancy
Older children and adolescents (2 to 16 years)
Lichenification is characteristic of childhood AD Areas involved: Flexural areas, particularly the antecubital and popliteal fossae, and buttock-thigh creases Volar aspect of the wrists and ankles may be involved "Atopic dirty neck" - neck and sides of the neck may show a reticulate pigmentation Thickened plaques show lichenification and excoriation Xerosis is generalized Dennie-Morgan folds (i.e. increased folds below the eye) along with erythema and scaling around the eyes is often seen Centrofacial pallor is common Dry skin and fissuring behind the ears or on the earlobe (infra-auricular and retroauricular fissuring) In African-American children, follicular papular lesions are prominent and striking and hypopigmentation and hyperpigmentation
Adults (from puberty onward)
Lesions are more localized and lichenified. Areas involved: Facial involvement is common, especially the forehead and periorbital regions. Lichenification occurs in skin flexures such as wrists, hands, ankles, feet, fingers, and toes A brown macular ring around the neck may be present (localized deposition of amyloid)- "Atopic dirty neck" Xerosis is prominent

• Associated symptoms with atopic dermatitis:

Atopic stigmata (associated cutaneous findings seen in atopic dermatitis patients)
Atypical vascular responses Centrofacial pallor delayed blanch response Skin Keratosis pilaris Palmar hyperlinearity Pityriasis alba ichthyosis Ocular/periorbital Periorbital darkening and Dennie-Morgan infraorbital folds Hertoghe's sign- thinning or absence of the lateral portion of the eyebrows Other Infra-auricular and retro-auricular fissuring Nipple eczema White dermographism Perifollicular accentuation

• Clinical phenotypes of atopic dermatitis:
  • Localized and morphological variants of atopic dermatitis are present in both children and adults.
  • These variants can present as only clinical feature of atopic dermatitis or can present in association with age related manifestations.

• Localized variants:
  • Atopic hand eczema:
    • Atopic hand eczema typically affects volar wrists and dorsum of the hands.
    • one-third of patients with atopic hand eczema, also reports foot eczema.
    • Common in adults with past medical history of history of atopic dermatitis, and currently do not have dermatitis in typical areas (i.e. flexural)
    • Most common in adults exposed to wet environments
  • Eyelid eczema :
    • Some patients of atopic dermatitis, may present with eyelid eczema alone
    • associated with lichenification and presence of Dennie-Morgan lines
  • Atopic cheilitis:
    • Also known as lip eczema or cheilitis sicca
    • Presents as dryness, peeling, and fissuring of the lips

Different phenotypes of atopic dermatitis
Acute vs chronic eczema Intrinsic vs extrinsic atopic eczema Early onset vs late onset Mild vs severe eczema Increased IgE vs non-atopic S. aureus infection/colonization, disseminated viral or fungal infections e.g. EH, molluscum contagiosum, Malassezia Associated with ichthyosis, keratosis pilaris, palmar hyperlinearity, early onset, severe and persistent eczema (FLG null genotype)
Localized variants	Morphological variants
Hand eczema Juvenile palmar and plantar dermatitis Eyelid dermatitis Atopic cheilitis Periorificial dermatitis Nipple dermatitis	Nummular eczema Atopic prurigo Lichen planus-like Pityriasis alba

• HEENT examination of patients with [disease name] is usually normal.

OR

• Abnormalities of the head/hair may include ___
• Evidence of trauma
• Icteric sclera
• Nystagmus
• Extra-ocular movements may be abnormal
• Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
• Ophthalmoscopic exam may be abnormal with findings of ___
• Hearing acuity may be reduced
• Weber test may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
• Rinne test may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
• Exudate from the ear canal
• Tenderness upon palpation of the ear pinnae/tragus (anterior to ear canal)
• Inflamed nares / congested nares
• Purulent exudate from the nares
• Facial tenderness
• Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae

Neck

• Neck examination of patients with [disease name] is usually normal.

OR

• Jugular venous distension
• Carotid bruits may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
• Lymphadenopathy (describe location, size, tenderness, mobility, and symmetry)
• Thyromegaly / thyroid nodules
• Hepatojugular reflux

Lungs

• Pulmonary examination of patients with [disease name] is usually normal.

OR

• Asymmetric chest expansion OR decreased chest expansion
• Lungs are hyporesonant OR hyperresonant
• Fine/coarse crackles upon auscultation of the lung bases/apices unilaterally/bilaterally
• Rhonchi
• Vesicular breath sounds OR distant breath sounds
• Expiratory wheezing OR inspiratory wheezing with normal OR delayed expiratory phase
• Wheezing may be present
• Egophony present/absent
• Bronchophony present/absent
• Normal/reduced tactile fremitus

Heart

• Cardiovascular examination of patients with [disease name] is usually normal.

OR

• Chest tenderness upon palpation
• PMI within 2 cm of the sternum (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
• Heave / thrill
• Friction rub
• S1
• S2
• S3
• S4
• Gallops
• A high/low grade early/late systolic murmur / diastolic murmur best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the stethoscope

Abdomen

• Abdominal examination of patients with [disease name] is usually normal.

OR

• Abdominal distention
• Abdominal tenderness in the right/left upper/lower abdominal quadrant
• Rebound tenderness (positive Blumberg sign)
• A palpable abdominal mass in the right/left upper/lower abdominal quadrant
• Guarding may be present
• Hepatomegaly / splenomegaly / hepatosplenomegaly
• Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test

Back

• Back examination of patients with [disease name] is usually normal.

OR

• Point tenderness over __ vertebrae (e.g. L3-L4)
• Sacral edema
• Costovertebral angle tenderness bilaterally/unilaterally
• Buffalo hump

Genitourinary

• Genitourinary examination of patients with [disease name] is usually normal.

OR

• A pelvic/adnexal mass may be palpated
• Inflamed mucosa
• Clear/(color), foul-smelling/odorless penile/vaginal discharge

Neuromuscular

• Neuromuscular examination of patients with [disease name] is usually normal.

OR

• Patient is usually oriented to persons, place, and time
• Altered mental status
• Glasgow coma scale is ___ / 15
• Clonus may be present
• Hyperreflexia / hyporeflexia / areflexia
• Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
• Muscle rigidity
• Proximal/distal muscle weakness unilaterally/bilaterally
• ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
• Unilateral/bilateral upper/lower extremity weakness
• Unilateral/bilateral sensory loss in the upper/lower extremity
• Positive straight leg raise test
• Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
• Positive/negative Trendelenburg sign
• Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
• Normal finger-to-nose test / Dysmetria
• Absent/present dysdiadochokinesia (palm tapping test)

Extremities

• Extremities examination of patients with [disease name] is usually normal.

OR

• Clubbing
• Cyanosis
• Pitting/non-pitting edema of the upper/lower extremities
• Muscle atrophy
• Fasciculations in the upper/lower extremity