Atopic dermatitis physical examination: Difference between revisions

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* Earliest lesions:
* Earliest lesions:
** Presents with erythema and exudation of the creases(antecubital and popliteal fossae)
** Presents with [[erythema]] and exudation of the creases([[Antecubital fossa|antecubital]] and [[Popliteal fossa|popliteal fossae]])


* Over the following few weeks:
* 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
** 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.
* Lesions are ill-defined, [[erythematous]], scaly, and crusted (eczematous) patches and [[plaques]].
* Most commonly involved areas:
* Most commonly involved areas:
** Scalp, cheeks and extensor side of the extremities.
** Scalp, cheeks and extensor side of the extremities.
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* Midline of the face and the tip of the nose is spared (Yamamoto’s sign)
* Midline of the face and the tip of the nose is spared (Yamamoto’s sign)
* Diaper area is generally spared
* Diaper area is generally spared
* Lichenification is uncommon in infancy
* [[Lichenification]] is uncommon in infancy
|-
|-
!'''Older children and adolescents (2 to 16 years)'''
!'''Older children and adolescents (2 to 16 years)'''
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* Areas involved:  
* Areas involved:  
** Flexural areas, particularly the antecubital and popliteal fossae, and buttock-thigh creases
** Flexural areas, particularly the [[Antecubital fossa|antecubital]] and [[Popliteal fossa|popliteal fossae]], and buttock-thigh creases
** Volar aspect of the wrists and ankles
** [[Volar|Volar aspect]] of the wrists and ankles
** "Atopic dirty neck" - neck and sides of the neck may show a reticulate pigmentation
** "Atopic dirty neck" - neck and sides of the neck may show a reticulate pigmentation
* Thickened plaques show lichenification and excoriation
* Thickened plaques show lichenification and excoriation
* Xerosis is generalized
* [[Xerosis]] is generalized
* Dennie-Morgan folds (i.e. increased folds below the eye) along with erythema and scaling around the eyes
* Dennie-Morgan folds (i.e. increased folds below the eye) along with erythema and scaling around the eyes
* Centrofacial pallor
* Centrofacial pallor
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* Atypical vascular responses
* Atypical vascular responses
** Centrofacial pallor
** Centrofacial pallor
** delayed blanch response
** Delayed blanch response
* Skin
* Skin
** Keratosis pilaris
** [[Keratosis pilaris]]
** Palmar hyperlinearity
** Palmar hyperlinearity
** Pityriasis alba
** [[Pityriasis alba]]
** Ichthyosis
** [[Ichthyosis]]
* Ocular/periorbital
* Ocular/periorbital
** Periorbital darkening and Dennie-Morgan infraorbital folds
** Periorbital darkening and Dennie-Morgan infraorbital folds
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* Early onset vs late onset
* Early onset vs late onset
* Mild vs severe eczema
* Mild vs severe eczema
* Increased IgE vs non-atopic
* Increased [[IgE]] vs non-atopic
* S. aureus infection/colonization, disseminated viral or fungal infections e.g. EH, molluscum contagiosum, Malassezia
* [[Staphylococcus aureus|Staphylococcus. aureus]] infection/colonization, disseminated viral or fungal infections e.g. [[Molluscum contagiosum]], [[Malassezia furfur|Malassezia]]
* Associated with ichthyosis, keratosis pilaris, palmar hyperlinearity, early onset, severe and persistent eczema (FLG null genotype)
* Associated with [[ichthyosis]], [[keratosis pilaris]], palmar hyperlinearity, early onset, severe and persistent eczema (FLG null genotype)
|-
|-
!Localized variants
!Localized variants
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* Juvenile palmar and plantar dermatitis
* Juvenile palmar and plantar dermatitis
* Eyelid dermatitis
* Eyelid dermatitis
* Atopic cheilitis  
* Atopic [[cheilitis]]
* Periorificial dermatitis
* Periorificial dermatitis
* Nipple dermatitis
* Nipple dermatitis
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* Nummular eczema
* Nummular eczema


* Atopic prurigo
* [[Prurigo|Atopic prurigo]]


* Lichen planus-like  
* [[Lichen planus]]-like  


* Pit<span class="_ _1 current-selection"></span>yriasis alba<span class="_ _1 current-selection"></span>
* [[Pityriasis alba|Pit]]<span class="_ _1 current-selection"></span>[[Pityriasis alba|yriasis alba]]<span class="_ _1 current-selection"></span>
|}
|}
* '''Localized variants''':<ref name="pmid21054785" />
* '''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>
** 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>
*** Atopic hand eczema typically affects volar wrists and dorsum of the hands.
*** Atopic hand eczema typically affects [[volar]] wrists and [[dorsum]] of the hands.
*** 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>
*** 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)
*** 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  
*** 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>
** 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
*** Some patients of atopic dermatitis, may present with eyelid eczema alone
*** associated with lichenification and presence of Dennie-Morgan lines
*** Associated with [[lichenification]] and presence of Dennie-Morgan lines
** Atopic cheilitis:
** Atopic cheilitis:
*** Also known as lip eczema or cheilitis sicca
*** Also known as lip eczema or cheilitis sicca
*** Presents as dryness, peeling, and fissuring of the lips  
*** 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>
** 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   
*** Primarily occurs in the spring and summer - associated with [[pollinosis]]  
*** localized mainly to the elbows and knees   
*** Localized mainly to the elbows and knees   
** Juvenile palmar and plantar dermatitis
** Juvenile palmar and plantar dermatitis
*** painful variant of atopic dermatitis  
*** Painful variant of atopic dermatitis  
*** Localized on the anterior part of the sole  
*** Localized on the anterior part of the sole  
* '''Morphological variants''':<ref name="pmid21054785" />
* '''Morphological variants''':<ref name="pmid21054785" />
** Nummular (discoid eczema):
** [[Nummular dermatitis|Nummular]] (discoid eczema):
*** Sharply demarcated patches and plaques with inflammation of skin  
*** Sharply demarcated patches and plaques with inflammation of skin  
*** Secondarily infection with Staphylococcus aureus common  
*** Secondarily infection with [[Staphylococcus aureus]] common  
*** Commonly affected areas- extremities and buttocks
*** Commonly affected areas- extremities and buttocks
*** Very difficult to treat
*** Very difficult to treat

Revision as of 15:38, 16 October 2018

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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 in various stages of development. The lesions can involve any area of 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.

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:[1]

  • 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:[2]

  • Eczematous dermatitis:
Acute atopic dermatitis Subacute or chronic atopic dermatitis:

Age-specific patterns:[3]

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)
  • Lichenification is characteristic of childhood atopic dermatitis
  • 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)[4]
  • Lesions are more localized and lichenified.
  • Areas involved:
    • Facial involvement is common, especially the forehead and periorbital regions.
    • Lichenification occurs in skin flexures such as wrists, hands, ankles, feet, fingers, and toes
  • A brown macular ring around the neck may be present (localized deposition of amyloid)- "Atopic dirty neck"
  • Xerosis is prominent

Associated symptoms with atopic dermatitis:[5]

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 feature of atopic dermatitis or can present in association with age related manifestations.
Different phenotypes of atopic dermatitis[6]
Localized variants Morphological variants
  • Hand eczema
  • Juvenile palmar and plantar dermatitis
  • Eyelid dermatitis
  • Atopic cheilitis
  • Periorificial dermatitis
  • Nipple dermatitis
  • Nummular eczema
  • Localized variants:[6]
    • Atopic hand eczema:[7]
      • Atopic hand eczema typically affects volar wrists and dorsum of the hands.
      • One-third of patients with atopic hand eczema, also reports foot eczema.[8]
      • 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:[9]
      • 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:[10]
      • 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:[6]
    • 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.)

  • Atopic dermatitis

    Atopic dermatitis

  • Atopic dermatitis

    Atopic dermatitis


References

  1. ↑ 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.
  2. ↑ "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.
  3. ↑ Rudikoff D, Lebwohl M (June 1998). "Atopic dermatitis". Lancet. 351 (9117): 1715–21. doi:10.1016/S0140-6736(97)12082-7. PMID 9734903.
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ 6.0 6.1 6.2 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.
  7. ↑ 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.
  8. ↑ 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.
  9. ↑ 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.
  10. ↑ Rasmussen JE (1978). "Sutton's summer prurigo of the elbows". Acta Derm. Venereol. 58 (6): 547–9. PMID 83084.

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