Atopic dermatitis differential diagnosis

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

Differentiating Atopic Dermatitis from other Diseases

Category	Diseases	Etiology	Inherited	Acquired	Clinical manifestations													Para-clinical findings									Gold standard	Additional findings
					Demography	History	Symptoms						Physical examination
																		Lab Findings							Imaging	Histopathology
							Appearance				Itching	Bleeding	Fever	BP	Tenderness	Nail pitting	Other	CBC			ESR/CRP	Electrolytes	BUN/Cr	LFT
							Single/ Multiple	Rash	Involved areas	Pustule								WBC	Hb	Plt
Skin disorders	Atopic dermatitis																											Hayfever Asthma
	Allergic contact dermatitis	Delayed-type hypersensitivity response Skin inflammation mediated by hapten-specific T cells	–	+	Any	Contact with allergens in the past 1-2 days Positive family history	May be multiple after 1-2 days of exposure	Erythematous well-demarcated papules	Surrounding the area in contact with the offending agent	–	+	–	–	Nl	+	–	Stinging and burning Localized swelling Lichenified pruritic plaques	Nl to ↑ (Eosinophilia)	Nl	Nl	Nl	Nl	Nl	Nl	NA	NA	Clinical manifestation + patch test	Prevention by avoidance
	Irritant contact dermatitis	Activation of the innate immune system by the pro-inflammatory properties of chemicals	–	+	Any, more occupational exposure	Cumulative exposure to irritants	Usually single immediately after the exposure	Well-demarcated red patch with a glazed surface	Any area in contact with the irritant	–	+	–	–	Nl	+	–	Swelling, blistering and scaling of the damaged area Dryness Thicker skin	Nl	Nl	Nl	Nl	Nl	Nl	Nl	NA	Spongiosis Intraepidermal vesicles or bullae Necrosis of keratinocytes	Clinical manifestation + patch test	Negative hypersensitivity tests
	Seborrheic dermatitis	Unknown	–	+	Any, onset during the 1st days or weeks of life	Stress Cold, dry weather		Greasy scaling on a yellow-red base	Scalp, axilla, and diaper area		–
	Psoriasis	Keratinocyte hyperproliferation Dysregulation of the immune system	+	+	Any, 2 peaks of onset 30-39 years and 50-59 years	Smoking Skin trauma Alcohol abuse Stress Cold weather Vitamin D deficiency Drugs	Multiple	Well-circumscribed, pink papules and symmetrically distributed cutaneous plaques with silvery scales	Scalp Trunk Gluteal cleft Extensor surface of elbows and knees	+	+	+ Auspitz sign (pinpoint bleeding)	_	Nl	+	+
	Lichen simplex chronicus	Lichenified plaques and excoriations of lichen simplex chronicus develop secondary to extensive pruritus due to other conditions such as atopic dermatitis, neuropathic pruritus, etc	–	+	Any, peak at 30-50 years of age	Emotional stress Sleep disturbances Dry weather Sweating Excessive dryness	Multiple	Lichenified and erythematous, pruritic exudative plaque, and excoriations	Scalp, head, neck, hands, arms, and genitals areas	–	+	–	–	Nl	–	–	Color of plaque varies fro, yellow to reddish brown Plaque size can vary between 3X6 cm 6X10 cm areas.	Nl	Nl	Nl	Nl	Nl	Nl	Nl	Nl	Markedly hyperplastic epidermis Irregular hyperkeratosis and parakeratosis Thick granular zone Acanthosis	Clinical manifestation	Sexual dysfunction Sleep disturbances Depression Dissociative disturbances
	Ichthyosis vulgaris	Loss of function mutations in the filaggrin gene (FLG) Autosomal dominant inheritance with incomplete penetrance	+	+	Usually in infancy	Dry and cold weather Increased risk of atopic diseases including asthma, alllergic rhinitis and atopic dermatitis	Multiple	Xerosis and gray scaling Palmar hyperlinearity Keratosis pilaris	Extensor surfaces of the extremities Scalp Trunk	–	–	–	–	Nl	–	–	Scales can vary from mild scaling to large, plate (armor)-like scales and thickening of the skin.	Nl	Nl	Nl	Nl	Nl	Nl	Nl	Nl	Reduced keratohyalin granules Perinuclear keratin retractions in granular cells Thick stratum corneum Basket-weave pattern of stratum corneum	Clinical manifestation	Increased risk for atopy, including asthma, allergies, and atopic dermatitis
	Nummular dermatitis (discoid eczema)	Unknown	–	+	Any, two peaks, 6th-7th decade of life in males and 2nd-3rd decade of life in females	Temperature changes (particularly winter) Emotional stress Dry skin Environmental irritants Recent surgery Medications like topical antibiotic creams and isotretinoin	Multiple	Acute phase: Highly pruritic, round Coin-shaped patches of erythematous-to-violaceous papules or vesicles Chronic phase: Dry and scaly plaques Violaceous and crusty plaques	Upper extremities Lower extremities Lower trunk	–	+	–	–	Nl	–	–	Chronically lesions result into central clearing leading to annular lesions.	Nl	Nl	Nl	Nl	Nl	Nl	Nl	Nl	Spongiosis Perivascular lymphocytic infiltrates, with eosinophils and occasional neutrophils	Clinical manifestation	Superinfection with staphylococcus aureus
	Netherton's syndrome
	Dubowitz syndrome
	Erythrokeratodermia variabilis
	Diseases	Etiology	Inherited	Acquired	Demography	History	Single/ Multiple	Rash	Involved areas	Pustule	Itching	Bleeding	Fever	BP	Tenderness	Nail pitting	Other	WBC	Hb	Plt	ESR/CRP	Electrolytes	BUN/Cr	LFT	Imaging	Histopathology	Gold standard	Additional findings
Infection	Dermatophytes
	Candida
	Herpes simplex
	Staphylococcus aureus
	Molluscum contagiosum
	Scabies					Positive family history	Multiple	Erythematous papular lesions	Flexor wrists, finger webs and genitalia		+++
	HIV
	Diseases	Etiology	Inherited	Acquired	Demography	History	Single/ Multiple	Rash	Involved areas	Pustule	Itching	Bleeding	Fever	BP	Tenderness	Nail pitting	Other	WBC	Hb	Plt	ESR/CRP	Electrolytes	BUN/Cr	LFT	Imaging	Histopathology	Gold standard	Additional findings
Immunologic disorders	Dermatitis herpetiformis
	Pemphigus foliaceus
	Graft-versus-host disease
	Dermatomyositis
Immune deficiency	Wiskott-Aldrich syndrome
	Hyper-IgE syndrome
	DiGeorge syndrome
	Severe combined immunodeficiency (SCID)
	Ataxia telangiectasia
	Diseases	Etiology	Inherited	Acquired	Demography	History	Single/ Multiple	Rash	Involved areas	Pustule	Itching	Bleeding	Fever	BP	Tenderness	Nail pitting	Other	WBC	Hb	Plt	ESR/CRP	Electrolytes	BUN/Cr	LFT	Imaging	Histopathology	Gold standard	Additional findings
Metabolic Diseases	Phenylketonuria
	Tyrosinemia
	Histidinemia
	Multiple carboxylase deficiency
Nutritional deficiencies	Zinc deficiency
	Niacin (B3) deficiency
	Pyridoxine (B6) deficiency
	Biotin (B7) deficiency
Malignancy	Mycosis fungoides
	Histiocytosis X
Medications	Infliximab
Category	Diseases	Etiology	Inherited	Acquired	Demography	History	Single/ Multiple	Rash	Involved areas	Pustule	Itching	Bleeding	Fever	BP	Tenderness	Nail pitting	Other	WBC	Hb	Plt	ESR/CRP	Electrolytes	BUN/Cr	LFT	Imaging	Histopathology	Gold standard	Additional findings

References

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