Atopic dermatitis differential diagnosis

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

Overview

Differentiating Atopic Dermatitis from other Diseases

Category Diseases Etiology Inherited Acquired Clinical manifestations Para-clinical findings Additional findings
Demography Associated factors Symptoms Physical examination
Lab Findings Histopathology
Appearance Itching Bleeding Fever BP Tenderness Other CBC ESR/CRP
Single/

Multiple

Rash Involved areas Pustule WBC Platelets
Skin disorders Atopic dermatitis
  • Epidermal barrier dysfunction
  • Immune dysregulation
+ +
  • Incidence is highest during infancy and early childhood.
Multiple
  • Young children -Scalp, cheeks amd extensor surface
  • Adolescents -flexural areas and buttock-thigh creases
  • Adults - facial involvement and skin flexures
+ NA
  • Infra-auricular and retro-auricular fissuring
  • Nipple eczema
  • White dermographism
  • Perifollicular accentuation
Nl to ↑

(Eosinophilia)

Nl Nl
  • Epidermal psoriasiform hyperplasia
  • Marked intercellular edema with spongiotic vesiculation
  • Hayfever
  • Asthma
Allergic contact dermatitis[1]
  • 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 NA
  • Prevention by avoidance
Irritant contact dermatitis[2]
  • 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
  • Spongiosis
  • Intraepidermal vesicles or bullae
  • Necrosis of keratinocytes
  • 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 [3]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
  • Markedly hyperplastic epidermis
  • Irregular hyperkeratosis and parakeratosis
  • Thick granular zone
  • Acanthosis
  • Sexual dysfunction
  • Sleep disturbances
  • Depression
  • Dissociative disturbances
Ichthyosis vulgaris[4]
  • 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
  • Reduced keratohyalin granules
  • Perinuclear keratin retractions in granular cells
  • Thick stratum corneum
  • Basket-weave pattern of stratum corneum
  • 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 Nl
  • Upper extremities
  • Lower extremities
  • Lower trunk
+ Nl
  • Chronically lesions result into central clearing leading to annular lesions.
Nl Nl Nl
  • Spongiosis
  • Perivascular lymphocytic infiltrates, with eosinophils and occasional neutrophils
  • Superinfection with staphylococcus aureus
Netherton's syndrome[5] Autosomal recessive mutations in the serine protease inhibitor of Kazal type 5 gene (SPINK5), encoding LEKTI, a serine protease inhibitor + Affects neonates
  • Atopic diseases including food allergy and strong family history of asthma, atopic dermatitis and allergic rhinitis
Multiple
  • Classic triad
    • Congenital ichthyosiform erythroderma
    • Trichorrhexis invaginata
    • Allergic diseases with elevated serum levels of immunoglobulin
  • Ichthyosis linearis circumflexa (ILC) - serpiginous migratory pink-red plaques with double-edged scale at the margins
  • Diffuse pattern
  • Axillae,
  • Hair
  • Inguinal folds
  • Gluteal cleft
  • Groin
  • Lower legs
+ + Nl
  • Trichorrhexis invaginata (hair involvement):
    • Sparse, short, spike and brittle
    • "Bamboo hair" or "ball and socket deformity" of hair and eyebrows
    • Nodes along the hair shaft
  • ↑ serum immunoglobulin E (IgE) levels
  • ↑ Eosinophilia
Nl Nl
  • psoriasiform hyperplasia
  • Reduced granular layer
  • Dyskeratosis,
  • Dermal inflammatory infiltrate including neutrophils and eosinophils
    • Systemic and skin superinfections
    • Failure to thrive
    • Electrolyte imbalances, including hypernatremic dehydration
    • Atopic diseases
Diseases Etiology Inherited Acquired Demography Associated factors Single/

Multiple

Rash Involved areas Pustule Itching Bleeding Fever BP Tenderness Other WBC Platelets ESR/CRP Histopathology Additional findings
Infection Dermatophytes
Candida
Herpes simplex
Staphylococcus aureus
Molluscum contagiosum Molluscum contagiosum virus inoculation through direct skin contact + Any, peak among children >5 years of age and young adults
  • Often asymptomatic
  • Tender or pruritic skin lesions
  • Self resolve within 2 months
  • Immunocompetent patients present with extensive and severe infections
Multiple
  • Flesh-colored, dome-shaped papules with a central umbilication
  • Lesions are 2-5mm in diameter
  • Face, trunk, antecubital, popliteal fossae and groin
+ Nl If molluscum contagiosum is acquired as sexually transmitted disease, it involves, groin and genital region. Nl Nl Nl
  • Keratinocytes containing eosinophilic inclusion bodies (Henderson-Paterson bodies)
  • H&E stain - inwards indentation of the epidermis
mMlluscum contagiosum

lesions on the eyelid may lead to follicular or papillary conjunctivitis .

Scabies
  • Positive family history
Multiple Erythematous papular lesions Flexor wrists, finger webs and genitalia +++
HIV
Diseases Etiology Inherited Acquired Demography Associated factors Single/

Multiple

Rash Involved areas Pustule Itching Bleeding Fever BP Tenderness Other WBC Platelets ESR/CRP Histopathology Additional findings
Immunologic disorders Dermatitis herpetiformis[6] Autoimmune disorder as a result of gluten sensitivity leading to the formation of IgA antibodies + Any, mean age of disease onset is 2nd-4th decade
  • Intermittent pruritic papules and vesicles
  • Associated small intestine celiac disease with villous atrophy and crypt hyperplasia
Multiple
  • Excoriated papules or plaques and vesicles arranged in a clustered fashion
  • Symmetrical
  • Erosions and excoriations
  • Extensor surfaces including arms, knees, and buttocks.
+ Nl
  • Oral manifestation such as vesicles and erosion may be present
Nl Nl Nl
  • Papillary micro-abscesses
  • Sub-epidermal blisters containing neutrophils, eosinophils, and fibrin
  • Sub-epidermal vacuolization
  • Abdominal bloating, pain, diarrhea, or constipation
Immune deficiency Wiskott-Aldrich syndrome[7]
  • Mutation in the gene encoding for Wiskott-Aldrich syndrome protein (WASp) on the short arm of the X chromosome
  • X-linked disorder
+ Seen almost exclusively in males in infancy
  • Blleeding: severe thrombocytopenia,
  • Eczema - similar to atopic dermatitis
  • Recurrent sino-pulmonary infections
  • Opportunistic infections.
  • Autoimmune diseases
  • Malignancies
Multiple
  • Rash is clinically similar to atopic dermatitis
  • Erythematous and pruritic lesions
  • Lesions can bleed due to thrombocytopenia
  • Cutaneous manifestations includes petechiae and ecchymosis
Rash can involve lesions located at the same areas of classical atopic dermatitis:

extensor surfaces of extremities and cheeks or scalp

+ + Nl Infants can present with petechiae, prolonged bleeding from umbilicus or circumcision, purpura, hematemesis, melena, epistaxis, hematuria or unusal bruising
  • ↑ Eosinophilia
Thrombocytopenia Nl
  • Epidermal psoriasiform hyperplasia
  • Marked intercellular edema with spongiotic vesiculation
  • ↑ serum immunoglobulin A (IgA) levels
  • ↑ serum immunoglobulin E (IgE) levels
Hyper-IgE syndrome[8]
  • Defects in the JAK-STAT signaling pathway leading to dysfunctional T helper cell type 17 (Th17) differentiation
+ Rare, begin in infancy
  • Cold abscesses
  • Pruritic eczema
  • Allergic diseases
  • Noneruption of permanent teeth
  • Multiple bone fractures and scoliosisis
  • Peripheral T-cell lymphoma
  • Coronary artery aneurysms
Multiple
  • Papulopustular
  • Severely pruritic eczematous rash
  • Pustular and may impetiginized
  • Lichenification may occur
  • Face and scalp
  • Upper trunk and shoulders
  • Buttocks
  • Area behind the ears and around the hairline
+ + Nl
  • Characteristic coarse facies
  • Increased alar width and broad nasal bridge
  • High-arched oral palate
  • Hyperextensible joints
  • ↑ Eosinophilia
Nl Nl
  • Eosinophil-rich infiltration around the hair follicles
  • ↑ serum immunoglobulin E (IgE) levels
DiGeorge syndrome
Severe combined immunodeficiency (SCID)
Ataxia telangiectasia
Diseases Etiology Inherited Acquired Demography Associated factors Single/

Multiple

Rash Involved areas Pustule Itching Bleeding Fever BP Tenderness Other WBC Platelets ESR/CRP Histopathology 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 Clonal expansion of CD4+ memory T cells (CD45RO+) + Mean age is 55- 60 years Multiple
Histiocytosis X
Medications Infliximab
Category Diseases Etiology Inherited Acquired Demography Associated factors Single/

Multiple

Rash Involved areas Pustule Itching Bleeding Fever BP Tenderness Other WBC Platelets ESR/CRP Histopathology Additional findings

References

  1. Nosbaum A, Vocanson M, Rozieres A, Hennino A, Nicolas JF (2009). "Allergic and irritant contact dermatitis". Eur J Dermatol. 19 (4): 325–32. doi:10.1684/ejd.2009.0686. PMID 19447733.
  2. Bains SN, Nash P, Fonacier L (October 2018). "Irritant Contact Dermatitis". Clin Rev Allergy Immunol. doi:10.1007/s12016-018-8713-0. PMID 30293200.
  3. Voicu C, Tebeica T, Zanardelli M, Mangarov H, Lotti T, Wollina U, Lotti J, França K, Batashki A, Tchernev G (July 2017). "Lichen Simplex Chronicus as an Essential Part of the Dermatologic Masquerade". Open Access Maced J Med Sci. 5 (4): 556–557. doi:10.3889/oamjms.2017.133. PMC 5535688. PMID 28785363.
  4. Thyssen JP, Godoy-Gijon E, Elias PM (June 2013). "Ichthyosis vulgaris: the filaggrin mutation disease". Br. J. Dermatol. 168 (6): 1155–66. doi:10.1111/bjd.12219. PMID 23301728.
  5. Chavanas S, Bodemer C, Rochat A, Hamel-Teillac D, Ali M, Irvine AD, Bonafé JL, Wilkinson J, Taïeb A, Barrandon Y, Harper JI, de Prost Y, Hovnanian A (June 2000). "Mutations in SPINK5, encoding a serine protease inhibitor, cause Netherton syndrome". Nat. Genet. 25 (2): 141–2. doi:10.1038/75977. PMID 10835624.
  6. Kárpáti S (2012). "Dermatitis herpetiformis". Clin. Dermatol. 30 (1): 56–9. doi:10.1016/j.clindermatol.2011.03.010. PMID 22137227.
  7. Buchbinder D, Nugent DJ, Fillipovich AH (2014). "Wiskott-Aldrich syndrome: diagnosis, current management, and emerging treatments". Appl Clin Genet. 7: 55–66. doi:10.2147/TACG.S58444. PMC 4012343. PMID 24817816.
  8. Mogensen TH (April 2013). "STAT3 and the Hyper-IgE syndrome: Clinical presentation, genetic origin, pathogenesis, novel findings and remaining uncertainties". JAKSTAT. 2 (2): e23435. doi:10.4161/jkst.23435. PMC 3710320. PMID 24058807.


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