• Diagnosis is based on patient's history, cutaneous findings (atopic stigmata), and physical exam
• Investigate exacerbating factors
  • Eg Aeroallergens, foods, irritating chemicals, emotional stress, extreme temperature
  • Not very useful clinically
• Identify and eliminate trigger factors
  • Identify potential allergens by careful history and selective allergy tests
    • Skin prick tests and serum tests for allergen-specific IgE are only useful if there is a suspected allergen
    • Negative results are useful for ruling out suspected allergens
    • In vitro allergy tests or positive skin prick tests do not always correlate with clinical symptoms (especially foods) and controlled food challenges, atopy patch tests or elimination diets may be needed
    • Limited food allergy testing may be considered in children <5 years with moderate-severe or refractory disease and/or a history of an allergic reaction after a particular food exposure 
      • Most children will outgrow food hypersensitivity within the first few years of life
  • Avoid foods identified as allergens in controlled food challenges

Criteria for Diagnosis (Based on criteria developed by Hanifin 1991)

Major Features (must have ≥3)

• Pruritus
• Typical morphology and distribution
• Facial and extensor involvement in infants and children
• Flexural lichenification and linearity in adults
• Dermatitis - chronic or chronically relapsing
• Personal or family history of atopy - asthma, allergic rhinitis, atopic dermatitis

Minor/Less Specific Features

• Cheilitis
• Hand/foot dermatitis
• Scalp (cradle cap) dermatitis
• Ichthyosis, hyperlinearity, keratosis pilaris
• IgE reactivity (increased serum IgE, radioallergosorbent, or prick test reactivity)
• Periauricular fissures
• Eczema - perifollicular accentuation
• Cutaneous infections (Staphylococcus aureus, Herpes simplex)
• Xerosis
• Recurrent conjunctivitis
• Keratoconus
• Anterior subcapsular cataract
• Ptyriasis alba
• White dermographism

Disease Severity

• Severity is assessed using different scoring methods [eg SCORing Atopic Dermatitis (SCORAD), Eczema Area and Severity Index (EASI), Patient Oriented Eczema Measure (POEM), Three Items Severity Score (TISS)] 
• SCORAD is the scoring method developed by the European Task Force of Atopic Dermatitis (ETFAD), which uses area/extent affected, intensity & subjective symptoms to score the severity of patient’s atopic dermatitis
  • Mild disease: <25
  • Moderate disease: 25-50
  • Severe disease: >50
• TISS is a simplified scoring system based on 3 symptoms of the disease: Erythema, edema/papulation, & excoriation
• POEM measures severity by depending on the patient’s answers to 7 questions based on symptoms & its frequency
• Other scoring systems based on the impact on the quality of life are also used [eg Children’s Dermatology Life Quality Index (CDLQI), the Dermatitis Family Impact (DFI), the Dermatology Life Quality Index (DLQI), & the Infant’s Dermatology Life Quality Index (IDQOL)]
• Ocular or infectious complications may also be present in severe atopic dermatitis
• May require hospitalization for severe eczema or skin infections