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Clinical Features

Diagnosis of Atopic eczema
o Diagnosis of atopic eczema is largely clinical and is facilitated by using the major and minor criteria
Major Criteria Minor Criteria
1. Family history of atopy
2. Chronicity
3. Pruritus
4. Typical morphology and distribution
•  Facial & extensors in infant
•  Flexors in adult
1. Dry Skin (Xerosis)
2. Chilitis
3. Elevated IgE
4. Dennie's line/Denny Morgan fold (Infra-orbital folD.
5. White dermographism
6. Peripheral eosinophilia
7. Immediate (Type I) hypersensitivity
8. Facial pallor, orbital darkening
9. Food intolerance
10. Conjunctivitis (recurrent), Keratoconus, Cataract
11. Pityriasis alba
12. Dermatitis of hand
13. Recurrent infections
At least three major or two major plus two minor criteria are necessary for diagnosis.

  1. Clinical Features Of Atopic Dermatitis
    1. Pruritus and scratching
    2. Course marked by exacerbations and remissions
    3. Lesions typical of eczematous dermatitis
    4. Personal or family history of atopy (asthma, allergic rhinitis, food allergies, or eczema)
    5. Clinical course lasting longer than 6 weeks
  2. Pruritus
    Is the hallmark of AD. It is more severe at night and is attributed to the absence of distraction, capillary dilatation, and increased skin temperature. A natural response to itch would be scratching, and scratching results in erosions, weeping, crusts, secondary infections, prurigo papules and lichenification.
  3. Dry Skin (Xerosis)
    Manifests as scaling, chapping and a feeling of skin roughness. It is worse in winter times due to reduced ambient humidity and coldness. Dry skin is enhanced by frequent use of detergents or defatting substances.
  4. Eczematous Lesions
    The most typical skin sign of infantile AD. They are polymorphic, with an erythematous, papulovesicular, erosive and crusted appearance.
  5. Prurigo
    Is a dome-shaped papule, sometimes with a tiny vesicle on top. Excoriation is frequent. Prurigo papules vary in number and distribution.
  6. Lichenification
    A lichenified plaque is a poorly demarcated, slightly tan to red plaque with grossly accentuated skin markings. Lichenified plaques take long time to resolve. The antecubital and popliteal fossae and the neck are predilected sites.
  7. Dennie Morgan Fold
    Is an extra infraorbital eyelid fold. About 80% is bilateral. Some consider this is a consequence of scratching of the eyelids.
  8. Hand and Feet Ivolvement
    Dry, nonpruritic plaques and recurrent hyperkeratosis and fissuring of the finger pulps (and soles) are common. Linear furrows running across thenar and/or hypothenar eminences referred to as hyperlinearity of palms occurs in about 1/3 to 1/2 of AD patients. Coarse pitting and ridging of nails may occur.

  1. Four Phases of AD
    1. Infantile Phase
      Lesions first appear on the cheeks, forehead, and scalp, but may occur on the trunk, neck, hands and feet. Eczema with oozing and crusts are more typical. Nocturnal restless, irritability and crying are prominent. When the child begins to crawl, the exposed areas especially the extensor aspects of knees are affected.
    2. Childhood Phase
      At about 18 months, the eczematous lesions tend to be replaced by lichenification. Prurigo papules occur and are very itchy. Elbow and knee flexures, wrists and ankles and neck are commonly involved. The neck may show striking reticulate repigmentation (dirty neck). Hands may be dry and lichenified; sole involvement may mimic juvenile plantar dermatosis. The face is less frequently affected. Problems with schooling may occur.
    3. Adolescent/Young Adult Phase
      Predominant features are pruritus, lichenification, prurigo papules, scratch marks, and crusting. Lesions occur mostly on the face, neck, flexures, and upper trunk. Localized patches of eczema around the nipple or vermillion of the lips can occur. Psychological difficulties occur in some.
    4. Adult Phase
      AD resolves spontaneously in most patients after age of 20. Majorities of the patients, however, still have sensitive, unstable skin and a higher tendency to develop dermatitis. Full blown AD occurs in only a small percentage of patients throughout adulthood.
      Atopic Triad – AD, Asthma, Allergic rhinitis.
  2. Associations
    The association of AD with allergic rhinitis, asthma and conjunctivitis is well documented.
    Eczematous conditions like contact dermatitis, discoid eczema, pityriasis alba, lip-stick eczema and follicular eczema are more frequently seen in atopic subjects.
    Others like ichthyosis vulgaris, keratosis pilaris, Netherton's syndrome, alopecia areata and vitiligo etc. also have linkage.

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