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ESSENTIALS OF DIAGNOSIS

  • Pruritic, xerotic, exudative, or lichenified eruption on face, neck, upper trunk, wrists, and hands and in the antecubital and popliteal folds.

  • Personal or family history of atopy (eg, asthma, allergic rhinitis, atopic dermatitis).

  • Tendency to recur.

  • Onset in childhood in most patients. Onset after age 30 is very uncommon.

GENERAL CONSIDERATIONS

Atopic dermatitis (also known as eczema) has distinct presentations in people of different ages and races. Diagnostic criteria for atopic dermatitis must include pruritus, typical morphology and distribution (flexural lichenification, hand eczema, nipple eczema, and eyelid eczema in adults), onset in childhood, and chronicity. Also helpful are (1) a personal or family history of atopy (asthma, allergic rhinitis, atopic dermatitis), (2) xerosis-ichthyosis, (3) facial pallor with infraorbital darkening, (4) elevated serum IgE, and (5) repeated skin infections.

CLINICAL FINDINGS

A. Symptoms and Signs

Itching is a key clinical feature and may be severe and prolonged. Ill-defined, scaly, red plaques (eFigure 6–9) affect the face, neck, and upper trunk. The flexural surfaces of elbows and knees are often involved. In chronic cases, the skin is dry and lichenified. In dark-skinned patients with severe disease, pigmentation may be lost in lichenified areas. During acute flares, widespread redness with weeping, either diffusely or in discrete plaques, is common. Since virtually all patients with atopic dermatitis have skin disease before age 5, a new diagnosis of atopic dermatitis in an adult over age 30 should be made only after consultation with a dermatologist.

eFigure 6–9.

Atopic dermatitis on flexural surface of elbows. (Used, with permission, from Lindy Fox, MD.)

B. Laboratory Findings

Food allergy is an uncommon cause of flares of atopic dermatitis in adults. Eosinophilia and increased serum IgE levels may be present.

DIFFERENTIAL DIAGNOSIS

Atopic dermatitis must be distinguished from seborrheic dermatitis (less pruritic, frequent scalp and central face involvement, greasy and scaly lesions, and quick response to therapy). Psoriasis is marked by sharply demarcated thickly scaled plaques on elbows, knees, scalp, and intergluteal cleft. Secondary staphylococcal or herpetic infections may exacerbate atopic dermatitis and should be considered during hyperacute, weeping flares of atopic dermatitis. An infra-auricular fissure is a cardinal sign of secondary infection.

TREATMENT

Patient education regarding gentle skin care and exactly how to use medications is critical to successful management of atopic dermatitis.

A. General Measures

Atopic patients have hyperirritable skin. Anything that dries or irritates the skin will potentially trigger dermatitis. Atopic individuals are sensitive to low humidity and often flare in the winter. Adults with atopic disorders should not bathe more than once daily. Soap should be confined to the armpits, groin, scalp, and feet. Washcloths and ...

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