Atopic dermatitis presents in three overlapping stages: infantile, childhood, and adult. Infantile begins after 2 months of age and is symmetrically distributed on the cheeks, scalp, neck, forehead, and extensor surfaces of the extremities. The lesions begin as erythema or papules, but with persistent itching and rubbing, they become thin plaques, exudative, and crusted. Childhood atopic dermatitis presents with flexural involvement. Other areas frequently involved are the face, neck, and trunk. The scratching induces plaque lichenification and potential for secondary infection. Adult atopic dermatitis is less specific but can present with a childhood-like distribution, papular lesions that coalesce into plaques, and chronic hand dermatitis. Uncontrolled atopic dermatitis can become a generalized exfoliative erythroderma. Differential diagnoses include seborrheic dermatitis, psoriasis, irritant or allergic contact dermatitis, nummular eczema, and scabies.
Management and Disposition
If a severe flare, suprainfection, punched-out lesions (eczema herpeticum), or a generalized exfoliative erythroderma is present, an ED dermatologic consultation is indicated. Mild cases can be sent home with referral. Patients (caregivers) should avoid soaps, detergents, or any personal products with fragrances. After bathing, pat dry the skin and smear a thin film of petrolatum or mild corticosteroid over the affected areas. A short course of systemic steroids may be indicated. Ensure follow-up with dermatologist.
Atopic dermatitis is often called the “itch that rashes” since pruritus precedes clinical disease.
If dispensing corticosteroids, use appropriate classes for the affected site and patient age.
Frequent relapses are common and require an astute clinician to differentiate associated complications (eg, HSV infection or developing cellulitis).
Atopic Dermatitis. A typical localization in children is the region around the mouth, with lichenification, fissuring, and crusting. (Used with permission from Wolff K, Johnson RA, Saavedra AP. Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology. 7th ed. New York, NY: McGraw Hill; 2013: Fig. 2-14.)
Atopic Dermatitis. (A) One of the hallmarks is lichenification in the flexural regions. Note the thickening of the skin with exaggerated skin lines and erosions. (B) Atopic dermatitis in black child. Pruritic follicular papules on posterior leg. Follicular eczema pattern is more common in African and Asian children. (Used with permission from Wolff K, Johnson RA, Saavedra AP. Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology. 7th ed. New York, NY: McGraw Hill; 2013: Fig. 2-15 A and B.)
Adult Atopic Dermatitis. Lichenified plaques, erosions, and fissures are characteristic. (Photo contributor: James J. Nordlund, MD.)