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Atopic dermatitis

Last updated: October 26, 2020

Summary

Atopic dermatitis (AD) is an inflammatory skin disease that typically manifests for the first time in early childhood. Although it often improves during adolescence, it may also become a chronic condition that extends into adulthood. Atopic dermatitis is often associated with other atopic diseases, such as asthma or allergic rhinitis. Although the underlying etiology is not completely understood, genetic components, as well as exogenous and endogenous triggers, are believed to play a role. The main symptoms of atopic dermatitis include severe pruritus and dry skin. Primary treatment involves managing the pruritus and moisturizing the skin. Topical steroids and calcineurin inhibitors may be added if treatment with moisturizers is insufficient. In severe cases, systemic therapy with steroids is required. The main complication of atopic dermatitis is the development of secondary infections.

Epidemiology

  • Prevalence: About 8–12% of children and 6–9% of adults are affected. [1][2]
  • Age [3]
    • Onset of symptoms usually occurs between 3–6 months of age.
    • Disease often improves with age.

Epidemiological data refers to the US, unless otherwise specified.

Etiology

The etiology of atopic dermatitis is not completely understood. However, genetic factors (polygenic inheritance), as well as exogenous and endogenous triggers, may play a role.

Clinical features

  • Main symptoms: intense pruritus and dry skin
  • Infantile AD (age < 2 years) [7]
    • Eczema: over the face, head, and extensor surfaces of the extremities that usually spares the diaper area
    • May begin as cradle cap [8]
    • Dennie-Morgan fold: increased folds below the eye
    • Occasionally, lesions appear on the trunk.
  • Childhood AD (age 2 to 12 years)
  • Adult/adolescent AD (age > 12 years) [7]
  • Associated findings [9][10]
    • Atopic triad: triad of asthma, allergic rhinitis, and atopic dermatitis that is linked to allergen-triggered IgE-mast cell activation
    • Food allergies
    • Xerosis
    • White dermographism: a physical finding of transiently blanched skin after skin stroking
      • Caused by cutaneous vasoconstriction
      • Normal variant, but more common in patients with atopic dermatitis
    • Dermatographism: formation of urticaria after minor pressure is applied to the skin, likely mediated by local histamine release
    • Hertoghe sign: thinning or loss of the outer third of the eyebrows
    • Keratosis pilaris: keratinized hair follicles ("rough bumps") typically distributed over extensor arms and thighs

The symptoms of atopic dermatitis are variable and often change in the course of a lifetime. Itching and dry skin are usually the main symptoms.

Diagnostics

The diagnosis of atopic dermatitis is usually based on patient history and clinical appearance. The American Academy of Dermatology suggests the use of several clinical criteria that need to be fulfilled in order to establish the diagnosis.

Clinical criteria [11]

Histopathology [12]

Severity assessment [11]

  • Scoring system (SCORAD = scoring atopic dermatitis)

Differential diagnoses

The differential diagnoses listed here are not exhaustive.

Treatment

General measures [11]

  • Avoid triggers:
    • Allergic trigger factors (pets, dust mites, pollen, certain foods)
    • Irritants (clothing, chemicals)
    • Heat
  • Keep the skin moist
  • Manage/eliminate stress
  • Breastfeeding recommended during infancy

Management of AD based on disease severity [15][16]

Treatment of atopic dermatitis
Mild AD Moderate AD Severe AD

Complications

We list the most important complications. The selection is not exhaustive.

Prognosis

The symptoms of atopic dermatitis usually improve with age and often resolve completely after puberty. [3]

References

  1. Chiesa Fuxench ZC, Block JK, Boguniewicz M, et al. Atopic Dermatitis in America Study: A Cross-Sectional Study Examining the Prevalence and Disease Burden of Atopic Dermatitis in the US Adult Population. J Invest Dermatol. 2019; 139 (3): p.583-590. doi: 10.1016/j.jid.2018.08.028 . | Open in Read by QxMD
  2. Eczema Stats. https://www.ajmc.com/view/overview-of-atopic-dermatitis-article. . Accessed: October 25, 2020.
  3. Bieber T. Atopic Dermatitis. N Engl J Med. 2008; 358 (14): p.1483-1494. doi: 10.1056/nejmra074081 . | Open in Read by QxMD
  4. Osawa R, Akiyama M, Shimizu H. Filaggrin Gene Defects and the Risk of Developing Allergic Disorders. Allergology International. 2011; 60 (1): p.1-9. doi: 10.2332/allergolint.10-rai-0270 . | Open in Read by QxMD
  5. Eichenfield LF, Tom WL, Chamlin SL, et al. Guidelines of care for the management of atopic dermatitis. J Am Acad Dermatol. 2014; 70 (2): p.338-351. doi: 10.1016/j.jaad.2013.10.010 . | Open in Read by QxMD
  6. Kowalska-Olędzka E, Czarnecka M, Baran A. Epidemiology of atopic dermatitis in Europe. Journal of Drug Assessment. 2019; 8 (1): p.126-128. doi: 10.1080/21556660.2019.1619570 . | Open in Read by QxMD
  7. Eczema Types: Atopic Dermatitis Symptoms. https://www.aad.org/public/diseases/eczema/types/atopic-dermatitis/symptoms. . Accessed: October 25, 2020.
  8. Cradle Cap. http://www.dermnetnz.org/topics/cradle-cap/. Updated: January 1, 2002. Accessed: May 15, 2017.
  9. Bolognia J, Jorizzo J, Schaffer J. Dermatology: 2-Volume Set. Elsevier ; 2012
  10. Marks JG Jr, Miller JJ . Lookingbill and Marks' Principles of Dermatology. Saunders Elsevier ; 2013
  11. Guidelines of care for the management of atopic dermatitis. http://www.jaad.org/article/S0190-9622(13)01095-5/fulltext. Updated: December 1, 2013. Accessed: May 15, 2017.
  12. Eczema pathology: codes and concepts. https://dermnetnz.org/topics/eczema-pathology/. Updated: January 1, 2013. Accessed: July 28, 2020.
  13. Wedi B, Kapp A. Differential Diagnosis of Atopic Eczema. Springer-Verlag ; 2020 : p. 100-107
  14. Seborrhoeic Dermatitis. http://www.dermnetnz.org/topics/seborrhoeic-dermatitis/. Updated: July 1, 2014. Accessed: May 15, 2017.
  15. Atopic eczema in children: Management of atopic eczema in children from birth up to the age of 12 years. https://www.ncbi.nlm.nih.gov/books/NBK49358/. Updated: January 1, 2007. Accessed: May 15, 2017.
  16. Guideline on the treatment of atopic eczema (atopic dermatitis) .
  17. Abeck D, Mempel M. Staphylococcus aureus colonization in atopic dermatitis and its therapeutic implications. Br J Dermatol. 1998; 139 : p.13-16.
  18. Liaw FY, Huang CF, Hsueh JT, Chiang CP. Eczema herpeticum: a medical emergency.. Can Fam Physician. 2012; 58 (12): p.1358-61.
  19. Weston WL Howe W. Atopic Dermatitis (Eczema): Pathogenesis, Clinical Manifestations, and Diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/pathogenesis-clinical-manifestations-and-diagnosis-of-atopic-dermatitis-eczema.Last updated: March 20, 2017. Accessed: May 15, 2017.
  20. Complications of Atopic Dermatitis. http://www.dermnetnz.org/topics/complications-of-atopic-dermatitis/. Updated: February 1, 2004. Accessed: May 15, 2017.
  21. Causes of Atopic Dermatitis. https://www.dermnetnz.org/topics/causes-of-atopic-dermatitis/. Updated: February 1, 2004. Accessed: September 3, 2017.