Atopic dermatitis diagnostic study of choice

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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], Ogechukwu Hannah Nnabude, MD

Overview

Due to the variable morphology, distribution of skin lesions, and intermittent clinical features, it is very challenging to define the diagnosis of atopic dermatitis. Atopic dermatitis is primarily diagnosed based on the clinical presentation. Currently, the most commonly used criteria worldwide is published by the United Kingdom Working Group and is based on history, morphology, and distribution of eczematous lesions, and clinical features of atopic dermatitis.

Diagnostic Study of Choice

• There is no single diagnostic study of choice for routine diagnosis of atopic dermatitis, but in selected patients, to rule out other skin conditions, histologic examination of a skin biopsy and other laboratory tests (eg, serum immunoglobulin E, potassium hydroxide preparation, patch testing, genetic testing) may be considered.

Diagnostic Criteria:

• Atopic dermatitis is primarily diagnosed based on clinical presentation. There are several established criteria for the diagnosis of atopic dermatitis, the earliest and most accepted diagnostic criteria being the 1980 Hanifin and Rajka criteria that was previously used.
• Currently, the most commonly used criteria worldwide is published by United Kingdom Working Group and is based on history, morphology and distribution of eczematous lesions, and clinical features of atopic dermatitis.
• The United Kingdom Working Group's criteria includes one mandatory criteria and 3 or more from the 5 major criteria.

Atopic dermatitis diagnostic criteria
Mandatory criteria: Evidence of pruritus or report of scratching or rubbing by the parent 3 or more of the major criteria: History of skin creases involvement including areas around neck and eyes, front of ankles, front of elbows, and back of knees. History of asthma or hay fever (if children <4 years of age - history of atopic disease in a first-degree relative) History of the presence of generally dry skin in the past year. The onset of symptoms in child <2 years of age. This criterion is not recommended if a child <4 years old. Visible dermatitis including flexor surfaces. In children <4 years of age, the criterion can involve dermatitis affecting the cheeks or forehead and outer aspects of the extremities.
Adapted from U.K. Working Party's Diagnostic Criteria

• The basis for making decisions about treatment depends on:
  • Presence or absence of sleep disturbance
  • Number and location of involved sites
  • Clinical course of the disease

The American Academy of Dermatology Diagnostic Criteria for Atopic Dermatitis

Clinical features and description Essential Features and Description Eczema - May be chronic or relapsing with characteristic, age-specific patterns and morphologic features. Stages - Acute, subacute, or chronic Severity - Mild, moderate, or severe Immunoendo cell type - Th2 cells are seen in white and black people, Th2 and Th17 cells are seen in Asians Pruritus Important features and description Age at onset typically early, between 2 and 6 months of age Personal and/or family history of atopy, secondary to IgE reactivity seen in up to 80% of patients. Xerosis Associated features and description Atypical vascular responses - white dermographism or facial pallor. Perifollicular lesions - Keratosis pilaris and perifollicular accentuation. Ocular or periorbital lesions -Hertoghe’s sign Regional findings - ichthyosis, Perioral changes, pityriasis alba, periauricular lesions, hyper linear palms. Lesions related to chronic scratching - prurigo lesions and lesions Lichenification. Associated conditions Impetigo Skin abscesses Eczema herpeticum Molluscum contagiosum infection Dermatophytosis Candidiasis Asthma Rhinitis Rhinoconjunctivitis Food allergy Inflammatory bowel disease Rheumatoid arthritis Cardiovascular disease Sleep disturbance Anxiety Depression Suicidality