atopic%20dermatitis
ATOPIC DERMATITIS
Atopic dermatitis or atopic eczema is a chronic, relapsing, familial, symmetric and pruritic inflammatory skin disease that commonly presents during early infancy and childhood, but can persist or start in adulthood.
It is commonly associated with elevated serum immunoglobulin E levels and a personal or family history of allergies, allergic rhinitis and asthma.
It is one of the most common skin diseases afflicting both children and adults.

Diagnosis

  • 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

Evaluation

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

Assessment

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 and 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, and excoriation
  • POEM measures severity by depending on the patient’s answers to 7 questions based on symptoms and 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), and 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

Differential Diagnosis

  • Other conditions can mimic atopic dermatitis and thus have to be ruled out: Contact dermatitis, dermatomyositis, ichthyosis, lymphoma, mycosis fungoides, primary immunodeficiency, psoriasis, scabies, seborrheic dermatitis
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