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{{Atopic dermatitis}}
{{Atopic dermatitis}}


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{{CMG}};{{AE}}{{S.S}}


{{CMG}}
==Overview==
Atopic dermatitis is a chronic or relapsing [[hypersensitive]] manifestation of the [[skin]]. Common physical examination findings of atopic dermatitis include [[pruritus]], [[Eczema|eczematous]] lesions, [[xerosis]] and [[lichenification]]. The lesions are usually age-specific and can be at various stages of development. The lesions can involve any area of the body in severe cases, but usually, it is uncommon to find lesions in the [[axillary]], [[gluteal]], or [[groin]] area.


==Physical Examination==
==Physical Examination==
The clinical presentation of atopic dermatitis is highly variable, depending upon the patient's age and disease activity.<ref name="StänderRopper2021">{{cite journal|last1=Ständer|first1=Sonja|last2=Ropper|first2=Allan H.|title=Atopic Dermatitis|journal=New England Journal of Medicine|volume=384|issue=12|year=2021|pages=1136–1143|issn=0028-4793|doi=10.1056/NEJMra2023911}}</ref>
===Appearance of the Patient===
*Patients with atopic dermatitis usually appear normal.
===Vital Signs===
*Vitals signs in atopic dermatitis patients are usually within normal limits.
===Skin===
'''Primary findings''':
* Primary findings are present in all cases of atopic dermaitis.<ref name="Thestrup-Pedersen2000">{{cite journal|last1=Thestrup-Pedersen|first1=K.|title=Clinical aspects of atopic dermatitis|journal=Clinical and Experimental Dermatology|volume=25|issue=7|year=2000|pages=535–543|issn=0307-6938|doi=10.1046/j.1365-2230.2000.00696.x}}</ref>
** Atopic [[Itch]]: Severe pruritus- cardinal feature of atopic dermatitis (must be present)
** Atopic [[xerosis]]: Dry skin, especially during winters
** Atopic [[eczema]]: Location of lesions has age-specific patterns
** Stigmata of AD
'''Other findings''':
* Symmetrical [[lesions]]
* Constant scratching may lead to [[lichenification]]
* An acute eczematoid eruption (with erythematous [[papules]]) appears after patients scratch their skin.
* Most severe form of atopic dermatitis can include [[erythroderma]]
'''Typical morphology and distribution''':
* [[Eczema|Eczematous]] dermatitis:<ref>{{cite journal|title=Japanese Dermatological Association Criteria for the diagnosis of atopic dermatitis|journal=The Journal of Dermatology|volume=29|issue=6|year=2002|pages=398–398|issn=03852407|doi=10.1111/j.1346-8138.2002.tb00292.x}}</ref>erythema is more frequently violaceous or even invisible in Black patients. The
lesions are characterized by papules, papulovesicles, edema, crusting, and scaling
{| class="wikitable"
|+
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |'''Acute atopic dermatitis'''
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |'''Subacute or chronic atopic dermatitis'''
|-
|
* [[Erythema]], [[Exudate|exudates]], [[papules]], [[vesicles]], scales and crusts
* Can usually get  infected with ''[[Staphylococcus aureus]]''
* Lesions are intensely pruritic
|
* Infiltrated [[erythema]], [[prurigo]], scales and crusts
* Lesions are dry or excoriated [[erythematous]] [[papules]]
* [[Lichenification]] and fissuring may develop over time
|}
'''Age-specific patterns''':
{| class="wikitable"
|+
! colspan="3" style="background: #4479BA; color: #FFFFFF; text-align: center;" |'''Infants and young children(zero to two years)'''
|-
|
* Earliest lesions:<ref name="pmid97349034">{{cite journal |vauthors=Rudikoff D, Lebwohl M |title=Atopic dermatitis |journal=Lancet |volume=351 |issue=9117 |pages=1715–21 |date=June 1998 |pmid=9734903 |doi=10.1016/S0140-6736(97)12082-7 |url=}}</ref><ref name="StänderRopper2021">{{cite journal|last1=Ständer|first1=Sonja|last2=Ropper|first2=Allan H.|title=Atopic Dermatitis|journal=New England Journal of Medicine|volume=384|issue=12|year=2021|pages=1136–1143|issn=0028-4793|doi=10.1056/NEJMra2023911}}</ref>
** Presents with [[erythema]] and exudation of the creases([[Antecubital fossa|antecubital]] and [[Popliteal fossa|popliteal fossae]])
* Over the following few weeks:
** Highly pruritic, red, scaly and crusted lesions, usually localized to the cheeks, the forehead and scalp, and the [[extensors]] of the lower legs
* Lesions are ill-defined, [[erythematous]], scaly, and crusted (eczematous) patches and [[plaques]].
* Most commonly involved areas:
** Scalp, cheeks and [[extensor]] side of the extremities.
** Flexural areas, especially the neck fold
* Midline of the face and the tip of the nose is spared (Yamamoto’s sign)
* Diaper area is generally spared
* [[Lichenification]] is uncommon in infancy
|-
! colspan="3" style="background: #4479BA; color: #FFFFFF; text-align: center;" |'''Older children and adolescents (2 to 16 years)'''
|-
|
* [[Lichenification]] is characteristic of childhood atopic dermatitis
* Areas involved:
** Flexural areas, particularly the [[Antecubital fossa|antecubital]] and [[Popliteal fossa|popliteal fossae]], and buttock-thigh creases
** [[Volar|Volar aspect]] of the wrists and ankles
** "Atopic dirty neck" - neck and sides of the neck may show a reticulate pigmentation
* Thickened plaques show [[lichenification]] and [[excoriation]]
* [[Xerosis]] is generalized
* Dennie-Morgan folds (i.e. increased folds below the eye) along with [[erythema]] and scaling around the eyes
* Centrofacial pallor
* Dry skin and fissuring behind the ears or on the earlobe (infra-auricular and retro-auricular fissuring)
* In African-American patients, papulonodular lesions are prominent with post-inflammatory [[hyperpigmentation]]
|-
! colspan="3" style="background: #4479BA; color: #FFFFFF; text-align: center;" |'''Adults (from puberty onward)'''
|-
|
* Lesions are more localized and lichenified<ref name="pmid18402293">{{cite journal |vauthors=Kulthanan K, Samutrapong P, Jiamton S, Tuchinda P |title=Adult-onset atopic dermatitis: a cross-sectional study of natural history and clinical manifestation |journal=Asian Pac. J. Allergy Immunol. |volume=25 |issue=4 |pages=207–14 |date=December 2007 |pmid=18402293 |doi= |url=}}</ref><ref name="StänderRopper2021">{{cite journal|last1=Ständer|first1=Sonja|last2=Ropper|first2=Allan H.|title=Atopic Dermatitis|journal=New England Journal of Medicine|volume=384|issue=12|year=2021|pages=1136–1143|issn=0028-4793|doi=10.1056/NEJMra2023911}}</ref>
* Areas involved:
** Facial involvement is common, especially in the forehead and periorbital regions.
** [[Lichenification]] occurs in skin flexures such as wrists, hands, ankles, feet, fingers, and toes
* Atopic dirty neck: A brown macular ring around the neck may be present (localized deposition of [[amyloid]])
* [[Xerosis]] is prominent
|}
'''Associated symptoms with atopic dermatitis''':<ref name="RotheGrant-Kels19963">{{cite journal|last1=Rothe|first1=Marti Jill|last2=Grant-Kels|first2=Jane M|title=Diagnostic criteria for atopic dermatitis|journal=The Lancet|volume=348|issue=9030|year=1996|pages=769–770|issn=01406736|doi=10.1016/S0140-6736(05)65206-3}}</ref><ref name="StänderRopper2021">{{cite journal|last1=Ständer|first1=Sonja|last2=Ropper|first2=Allan H.|title=Atopic Dermatitis|journal=New England Journal of Medicine|volume=384|issue=12|year=2021|pages=1136–1143|issn=0028-4793|doi=10.1056/NEJMra2023911}}</ref>
{| class="wikitable"
|+
! colspan="3" style="background: #4479BA; color: #FFFFFF; text-align: center;" |'''Atopic stigmata'''
(associated cutaneous findings seen in atopic dermatitis patients)
|-
|
* Atypical vascular responses
** Centrofacial pallor
** Delayed blanch response
* Skin
** [[Keratosis pilaris]]
** Palmar hyperlinearity
** [[Pityriasis alba]]
** [[Ichthyosis]]
* [[Ocular]]/periorbital
** Periorbital darkening and Dennie-Morgan infraorbital folds
** Hertoghe's sign- thinning or absence of the lateral portion of the eyebrows
* Other
** Infra-auricular and retro-auricular fissuring
** Nipple [[eczema]]
** White dermographism
** Perifollicular accentuation
|}
'''Clinical phenotypes of atopic dermatitis:'''
* Localized and morphological variants of atopic dermatitis are present in both children and adults.
* These variants can present as only clinical features of atopic dermatitis or can present in association with age-related manifestations.
{| class="wikitable"
|+
! colspan="2" style="background: #4479BA; color: #FFFFFF; text-align: center;" |Different phenotypes of atopic dermatitis<ref name="pmid21054785">{{cite journal |vauthors=Pugliarello S, Cozzi A, Gisondi P, Girolomoni G |title=Phenotypes of atopic dermatitis |journal=J Dtsch Dermatol Ges |volume=9 |issue=1 |pages=12–20 |date=January 2011 |pmid=21054785 |doi=10.1111/j.1610-0387.2010.07508.x |url=}}</ref>
|-
| colspan="2" |
* Acute vs chronic eczema
* Intrinsic vs extrinsic atopic eczema
* Early onset vs late-onset
* Mild vs severe eczema
* Increased [[IgE]] vs non-atopic
* [[Staphylococcus aureus|''Staphylococcus aureus'']] infection/colonization, disseminated viral or fungal infections e.g. [[Molluscum contagiosum|''Molluscum contagiosum'']], [[Malassezia furfur|''Malassezia'']]
* Associated with [[ichthyosis]], [[keratosis pilaris]], palmar hyperlinearity, early-onset, severe and persistent eczema (FLG null genotype)
|-
! style="background: #7d7d7d; color: #FFFFFF; text-align: center;" |Localized variants
! style="background: #7d7d7d; color: #FFFFFF; text-align: center;" |Morphological variants
|-
|
* Hand eczema
* Juvenile [[palmar]] and [[plantar]] dermatitis
* Eyelid dermatitis
* Atopic [[cheilitis]]
* Periorificial dermatitis
* Nipple dermatitis
|
* Nummular eczema
* [[Prurigo|Atopic prurigo]]
* [[Lichen planus]]-like
* [[Pityriasis alba|Pit]]<span class="_ _1 current-selection"></span>[[Pityriasis alba|yriasis alba]]<span class="_ _1 current-selection"></span>
|}
* '''Localized variants''':<ref name="pmid21054785" />
** Atopic hand eczema:<ref name="pmid16956463">{{cite journal |vauthors=Simpson EL, Thompson MM, Hanifin JM |title=Prevalence and morphology of hand eczema in patients with atopic dermatitis |journal=Dermatitis |volume=17 |issue=3 |pages=123–7 |date=September 2006 |pmid=16956463 |doi= |url=}}</ref><ref name="StänderRopper2021">{{cite journal|last1=Ständer|first1=Sonja|last2=Ropper|first2=Allan H.|title=Atopic Dermatitis|journal=New England Journal of Medicine|volume=384|issue=12|year=2021|pages=1136–1143|issn=0028-4793|doi=10.1056/NEJMra2023911}}</ref>
*** Atopic hand eczema typically affects [[volar]] wrists and [[dorsum]] of the hands<ref name="StänderRopper2021">{{cite journal|last1=Ständer|first1=Sonja|last2=Ropper|first2=Allan H.|title=Atopic Dermatitis|journal=New England Journal of Medicine|volume=384|issue=12|year=2021|pages=1136–1143|issn=0028-4793|doi=10.1056/NEJMra2023911}}</ref>
*** One-third of patients with atopic hand eczema, also reports foot eczema<ref name="pmid25716740">{{cite journal |vauthors=Brans R, Hübner A, Gediga G, John SM |title=Prevalence of foot eczema and associated occupational and non-occupational factors in patients with hand eczema |journal=Contact Derm. |volume=73 |issue=2 |pages=100–7 |date=August 2015 |pmid=25716740 |doi=10.1111/cod.12370 |url=}}</ref>
*** Common in adults with past medical history of history of atopic dermatitis, and currently do not have dermatitis in typical areas (i.e. flexural)
*** Most common in adults exposed to wet environments
** Eyelid eczema:<ref name="pmid24314387">{{cite journal |vauthors=Wolf R, Orion E, Tüzün Y |title=Periorbital (eyelid) dermatides |journal=Clin. Dermatol. |volume=32 |issue=1 |pages=131–40 |date=2014 |pmid=24314387 |doi=10.1016/j.clindermatol.2013.05.035 |url=}}</ref>
*** Some patients of atopic dermatitis, may present with eyelid eczema alone
*** Associated with [[lichenification]] and presence of Dennie-Morgan lines
** Atopic cheilitis:
*** Also known as lip eczema or cheilitis sicca
*** Presents as dryness, peeling, and fissuring of the lips
** Juvenile papular dermatitis:<ref name="pmid83084">{{cite journal |vauthors=Rasmussen JE |title=Sutton's summer prurigo of the elbows |journal=Acta Derm. Venereol. |volume=58 |issue=6 |pages=547–9 |date=1978 |pmid=83084 |doi= |url=}}</ref>
*** Primarily occurs in the spring and summer - associated with [[pollinosis]] 
*** Localized mainly to the elbows and knees 
** Juvenile [[palmar]] and [[plantar]] dermatitis
*** Painful variant of atopic dermatitis
*** Localized on the anterior part of the sole
* '''Morphological variants''':<ref name="pmid21054785" />
** [[Nummular dermatitis|Nummular]] (discoid eczema):
*** Sharply demarcated patches and plaques with inflammation of skin
*** Secondarily infection with [[Staphylococcus aureus|''Staphylococcus aureus'']] common
*** Commonly affected areas- extremities and buttocks
*** Very difficult to treat
=== HEENT ===
* In patients with atopic dermatitis, eczematous lesions can be present on the face, depending on the age of the patients.
<gallery>
Image:Atopic Dermatitis01.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis05.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis06.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis11.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis12.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis13.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis16.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis17.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis18.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis19.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis32.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis20.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis21.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis22.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis23.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis24.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis27.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis28.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis29.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis31.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis01.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis05.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis06.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis11.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis12.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis13.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis16.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis17.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis18.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis19.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis20.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis01.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis05.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis06.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis11.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis12.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis13.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis16.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis17.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis18.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis19.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Skin atopic dermatitis2.jpg|Atopic dermatitis
</gallery>
===Neck===
* Neck examination of patients with atopic dermatitis is usually normal.
* Eczematous lesions can be present depending on the age of the patients.
===Lungs===
* Pulmonary examination of patients with atopic dermatitis is usually normal.
===Heart===
* Cardiovascular examination of patients with atopic dermatitis is usually normal.
===Abdomen===
* Abdominal examination of patients with atopic dermatitis is usually normal.
===Back===
* In patients with atopic dermatitis, eczematous lesions can be present on the trunk, depending on the age of the patients.
<gallery>
Image:Atopic Dermatitis07.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis08.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis09.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis10.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis14.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
</gallery>
===Genitourinary===
* Genitourinary examination of patients with atopic dermatitis is usually normal.
===Neuromuscular===
* Neuromuscular examination of patients with atopic dermatitis is usually normal.
===Extremities===
* In patients with atopic dermatitis, eczematous lesions can be present on extremities, depending on the age of the patients.
<gallery>
Image:Atopic Dermatitis02.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis03.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis04.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis15.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis25.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis26.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis33.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis34.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Atopic Dermatitis36.jpg|Atopic Dermatitis. ''[http://www.atlasdermatologico.com.br/  Adapted from Dermatology Atlas.]''
Image:Skin atopic dermatitis.jpg|Atopic dermatitis
</gallery>


(Images courtesy of Charlie Goldberg, M.D.)
(Images courtesy of Charlie Goldberg, M.D.)
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Image:Skin atopic dermatitis.jpg|Atopic dermatitis
 
Image:Skin atopic dermatitis2.jpg|Atopic dermatitis
</gallery>
</gallery>
</div>
</div>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


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Latest revision as of 20:12, 8 June 2021

Atopic dermatitis Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Shalinder Singh, M.B.B.S.[2]

Overview

Atopic dermatitis is a chronic or relapsing hypersensitive manifestation of the skin. Common physical examination findings of atopic dermatitis include pruritus, eczematous lesions, xerosis and lichenification. The lesions are usually age-specific and can be at various stages of development. The lesions can involve any area of the body in severe cases, but usually, it is uncommon to find lesions in the axillary, gluteal, or groin area.

Physical Examination

The clinical presentation of atopic dermatitis is highly variable, depending upon the patient's age and disease activity.[1]

Appearance of the Patient

  • Patients with atopic dermatitis usually appear normal.

Vital Signs

  • Vitals signs in atopic dermatitis patients are usually within normal limits.

Skin

Primary findings:

  • Primary findings are present in all cases of atopic dermaitis.[2]
    • Atopic Itch: Severe pruritus- cardinal feature of atopic dermatitis (must be present)
    • Atopic xerosis: Dry skin, especially during winters
    • Atopic eczema: Location of lesions has age-specific patterns
    • Stigmata of AD

Other findings:

  • An acute eczematoid eruption (with erythematous papules) appears after patients scratch their skin.
  • Most severe form of atopic dermatitis can include erythroderma

Typical morphology and distribution:

  • Eczematous dermatitis:[3]erythema is more frequently violaceous or even invisible in Black patients. The

lesions are characterized by papules, papulovesicles, edema, crusting, and scaling

Acute atopic dermatitis Subacute or chronic atopic dermatitis

Age-specific patterns:

Infants and young children(zero to two years)
  • Over the following few weeks:
    • Highly pruritic, red, scaly and crusted lesions, usually localized to the cheeks, the forehead and scalp, and the extensors of the lower legs
  • Lesions are ill-defined, erythematous, scaly, and crusted (eczematous) patches and plaques.
  • Most commonly involved areas:
    • Scalp, cheeks and extensor side of the extremities.
    • Flexural areas, especially the neck fold
  • Midline of the face and the tip of the nose is spared (Yamamoto’s sign)
  • Diaper area is generally spared
  • Lichenification is uncommon in infancy
Older children and adolescents (2 to 16 years)
  • Areas involved:
    • Flexural areas, particularly the antecubital and popliteal fossae, and buttock-thigh creases
    • Volar aspect of the wrists and ankles
    • "Atopic dirty neck" - neck and sides of the neck may show a reticulate pigmentation
  • Thickened plaques show lichenification and excoriation
  • Xerosis is generalized
  • Dennie-Morgan folds (i.e. increased folds below the eye) along with erythema and scaling around the eyes
  • Centrofacial pallor
  • Dry skin and fissuring behind the ears or on the earlobe (infra-auricular and retro-auricular fissuring)
  • In African-American patients, papulonodular lesions are prominent with post-inflammatory hyperpigmentation
Adults (from puberty onward)
  • Lesions are more localized and lichenified[5][1]
  • Areas involved:
    • Facial involvement is common, especially in the forehead and periorbital regions.
    • Lichenification occurs in skin flexures such as wrists, hands, ankles, feet, fingers, and toes
  • Atopic dirty neck: A brown macular ring around the neck may be present (localized deposition of amyloid)
  • Xerosis is prominent

Associated symptoms with atopic dermatitis:[6][1]

Atopic stigmata

(associated cutaneous findings seen in atopic dermatitis patients)

  • Atypical vascular responses
    • Centrofacial pallor
    • Delayed blanch response
  • Skin
  • Ocular/periorbital
    • Periorbital darkening and Dennie-Morgan infraorbital folds
    • Hertoghe's sign- thinning or absence of the lateral portion of the eyebrows
  • Other
    • Infra-auricular and retro-auricular fissuring
    • Nipple eczema
    • White dermographism
    • Perifollicular accentuation

Clinical phenotypes of atopic dermatitis:

  • Localized and morphological variants of atopic dermatitis are present in both children and adults.
  • These variants can present as only clinical features of atopic dermatitis or can present in association with age-related manifestations.
Different phenotypes of atopic dermatitis[7]
Localized variants Morphological variants
  • Hand eczema
  • Juvenile palmar and plantar dermatitis
  • Eyelid dermatitis
  • Atopic cheilitis
  • Periorificial dermatitis
  • Nipple dermatitis
  • Nummular eczema
  • Localized variants:[7]
    • Atopic hand eczema:[8][1]
      • Atopic hand eczema typically affects volar wrists and dorsum of the hands[1]
      • One-third of patients with atopic hand eczema, also reports foot eczema[9]
      • Common in adults with past medical history of history of atopic dermatitis, and currently do not have dermatitis in typical areas (i.e. flexural)
      • Most common in adults exposed to wet environments
    • Eyelid eczema:[10]
      • Some patients of atopic dermatitis, may present with eyelid eczema alone
      • Associated with lichenification and presence of Dennie-Morgan lines
    • Atopic cheilitis:
      • Also known as lip eczema or cheilitis sicca
      • Presents as dryness, peeling, and fissuring of the lips
    • Juvenile papular dermatitis:[11]
      • Primarily occurs in the spring and summer - associated with pollinosis
      • Localized mainly to the elbows and knees
    • Juvenile palmar and plantar dermatitis
      • Painful variant of atopic dermatitis
      • Localized on the anterior part of the sole
  • Morphological variants:[7]
    • Nummular (discoid eczema):
      • Sharply demarcated patches and plaques with inflammation of skin
      • Secondarily infection with Staphylococcus aureus common
      • Commonly affected areas- extremities and buttocks
      • Very difficult to treat

HEENT

  • In patients with atopic dermatitis, eczematous lesions can be present on the face, depending on the age of the patients.

Neck

  • Neck examination of patients with atopic dermatitis is usually normal.
  • Eczematous lesions can be present depending on the age of the patients.

Lungs

  • Pulmonary examination of patients with atopic dermatitis is usually normal.

Heart

  • Cardiovascular examination of patients with atopic dermatitis is usually normal.

Abdomen

  • Abdominal examination of patients with atopic dermatitis is usually normal.

Back

  • In patients with atopic dermatitis, eczematous lesions can be present on the trunk, depending on the age of the patients.

Genitourinary

  • Genitourinary examination of patients with atopic dermatitis is usually normal.

Neuromuscular

  • Neuromuscular examination of patients with atopic dermatitis is usually normal.

Extremities

  • In patients with atopic dermatitis, eczematous lesions can be present on extremities, depending on the age of the patients.

(Images courtesy of Charlie Goldberg, M.D.)

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Ständer, Sonja; Ropper, Allan H. (2021). "Atopic Dermatitis". New England Journal of Medicine. 384 (12): 1136–1143. doi:10.1056/NEJMra2023911. ISSN 0028-4793.
  2. ↑ Thestrup-Pedersen, K. (2000). "Clinical aspects of atopic dermatitis". Clinical and Experimental Dermatology. 25 (7): 535–543. doi:10.1046/j.1365-2230.2000.00696.x. ISSN 0307-6938.
  3. ↑ "Japanese Dermatological Association Criteria for the diagnosis of atopic dermatitis". The Journal of Dermatology. 29 (6): 398–398. 2002. doi:10.1111/j.1346-8138.2002.tb00292.x. ISSN 0385-2407.
  4. ↑ Rudikoff D, Lebwohl M (June 1998). "Atopic dermatitis". Lancet. 351 (9117): 1715–21. doi:10.1016/S0140-6736(97)12082-7. PMID 9734903.
  5. ↑ Kulthanan K, Samutrapong P, Jiamton S, Tuchinda P (December 2007). "Adult-onset atopic dermatitis: a cross-sectional study of natural history and clinical manifestation". Asian Pac. J. Allergy Immunol. 25 (4): 207–14. PMID 18402293.
  6. ↑ Rothe, Marti Jill; Grant-Kels, Jane M (1996). "Diagnostic criteria for atopic dermatitis". The Lancet. 348 (9030): 769–770. doi:10.1016/S0140-6736(05)65206-3. ISSN 0140-6736.
  7. ↑ 7.0 7.1 7.2 Pugliarello S, Cozzi A, Gisondi P, Girolomoni G (January 2011). "Phenotypes of atopic dermatitis". J Dtsch Dermatol Ges. 9 (1): 12–20. doi:10.1111/j.1610-0387.2010.07508.x. PMID 21054785.
  8. ↑ Simpson EL, Thompson MM, Hanifin JM (September 2006). "Prevalence and morphology of hand eczema in patients with atopic dermatitis". Dermatitis. 17 (3): 123–7. PMID 16956463.
  9. ↑ Brans R, Hübner A, Gediga G, John SM (August 2015). "Prevalence of foot eczema and associated occupational and non-occupational factors in patients with hand eczema". Contact Derm. 73 (2): 100–7. doi:10.1111/cod.12370. PMID 25716740.
  10. ↑ Wolf R, Orion E, Tüzün Y (2014). "Periorbital (eyelid) dermatides". Clin. Dermatol. 32 (1): 131–40. doi:10.1016/j.clindermatol.2013.05.035. PMID 24314387.
  11. ↑ Rasmussen JE (1978). "Sutton's summer prurigo of the elbows". Acta Derm. Venereol. 58 (6): 547–9. PMID 83084.
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