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 most common symptoms of atopic dermatitis include pruritus, distribution of rash on age- specific patters and dry skin. Patients often have personal or family history of asthma or allergic rhinitis.

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
• Atopic march: development of clinical signs during childhood from atopic dermatitis to asthma to allergic rhinitis
  • clinical features of atopic dermatitis usually occur earlier in life
  • asthma and allergic rhinitis occur later on in life.

Common Symptoms

Common symptoms of atopic dermatitis include:

• Severe pruritus - can cause sleep disturbances in children
• Chronic or relapsing skin lesions
• Distribution of rash on:
  • Facial and extensor surfaces in infants and young children
  • Flexural lichenification in older children and adults

Less Common Symptoms

Less common symptoms of atopic dermatitis include:

• Facial pallor
• Dry skin especially in winter)
• Nonspecific dermatitis of the hands and feet
• Food intolerance
• Itch when sweating

Overview

Atopic dermatitis is a chronic or relapsing hypersensitive manifestation of the skin. Common physical examination findings of atopic dermatitis include pruritus, eczematous lesions, xerosis and lichenification. The lesions are usually age specific and can be in various stages of development. The lesions can involve any area of body in severe cases, but usually it is uncommon to find lesions in the axillary, gluteal, or groin area.

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 atopic dermatitis usually appear normal.

Vital Signs

• Vitals signs in atopic dermatitis patients are usually within normal limits.

Skin

• Primary findings:
  • Atopic Itch: Severe pruritus- cardinal feature of atopic dermatitis (must be present)
  • Atopic dry skin: xerosis (especially during winters)
  • Atopic eczema: location of lesions has age-specific patterns
  • Stigmata of AD
• Constant scratching may lead to lichenification.
• An acute eczematoid eruption (with erythematous papules) appears after patients scratch their skin
• Most severe form of atopic dermatitis can include erythroderma
• Typical morphology and distribution:
  • Eczematous dermatitis: Symmetrical lesions

Acute atopic dermatitis	Subacute or chronic atopic dermatitis:
Erythema, exudates, papules, vesicles, scales and crusts Can usually get infected with Staphylococcus aureus Lesions are intensely pruritic	Infiltrated erythema, prurigo, scales and crusts Lesions are dry 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 atopic dermatitis 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.

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

• 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
  • Juvenile papular dermatitis:
    • Primarily occurs in the spring and summer - associated with pollinosis
    • localized mainly to the elbows and knees
  • Juvenile palmar and plantar dermatitis
    • painful variant of atopic dermatitis
    • Localized on the anterior part of the sole
• Morphological variants:
  • Nummular (discoid eczema):
    • Sharply demarcated patches and plaques with inflammation of skin
    • Secondarily infection with Staphylococcus aureus common
    • Commonly affected areas- extremities and buttocks
    • Very difficult to treat

HEENT

• HEENT examination of patients with atopic dermatitis is usually normal.

• Eczematous lesions can be present depending on the age of the patients.

Neck

• Neck examination of patients with atopic dermatitis is usually normal.
• Eczematous lesions can be present depending on the age of the patients.

Lungs

• Pulmonary examination of patients with atopic dermatitis is usually normal.

Heart

• Cardiovascular examination of patients with atopic dermatitis is usually normal.

Abdomen

• Abdominal examination of patients with atopic dermatitis is usually normal.

Back

• Back examination of patients with atopic dermatitis is usually normal.
• Eczematous lesions can be present depending on the age of the patients.

Genitourinary

• Genitourinary examination of patients with atopic dermatitis is usually normal.

Neuromuscular

• Neuromuscular examination of patients with atopic dermatitis is usually normal.

Extremities

• Extremities examination of patients with atopic dermatitis is usually normal.
• Eczematous lesions can be present depending on the age of the patients.