History and exam

Key diagnostic factors

common

pruritus

Virtually all patients with atopic dermatitis describe pruritus.

xerosis (dry skin)

Xerosis is a hallmark of atopic dermatitis.

sites of skin involvement

Infants typically show involvement of the cheeks, forehead, scalp, and extensor surfaces. Affected skin is often edematous, with prominent weeping and crusting. [Figure caption and citation for the preceding image starts]: Acute atopic dermatitis on the face of an infantFrom the personal collection of A. Hebert, MD; used with permission [Citation ends].com.bmj.content.model.Caption@571d5699

Children typically have involvement of flexures, particularly the wrists, ankles, and antecubital and popliteal fossae.[8][20]

In addition to the areas affected by acute disease, chronic atopic dermatitis often affects the neck, upper back, and arms, as well as the hands and feet.[1][5]​​[64][Figure caption and citation for the preceding image starts]: Lichenification of the popliteal fossa in a child with atopic dermatitisFrom the personal collection of A. Hebert, MD; used with permission [Citation ends].com.bmj.content.model.Caption@3b0201e8[Figure caption and citation for the preceding image starts]: Chronic dermatitis affecting the palm of a 64-year-old manFrom the personal collection of A. Hebert, MD; used with permission [Citation ends].com.bmj.content.model.Caption@5e90e5c3

Overlap between acute and chronic atopic dermatitis may be seen due to the recurrent nature of the disease.[48]

Nuances in the visual appearance of atopic dermatitis can occur due to differences in pigmentation and distribution of lesions.[46] More well-demarcated lesions and increased scaling and lichenification are more common in Asian patients. Patients of African descent are less likely to develop flexural dermatitis, but rather present with extensor involvement as a more prominent feature.[46] Discoid or follicular patterns may be more common in Asian, black Caribbean, and black African children.[45]

Other diagnostic factors

common

erythema

Often noted in the acute flares.[48]

scaling

Often noted in the acute flares.[48]

vesicles

More common in acute flares and in infants.[48]

papules

More common in acute flares and in infants.[48]

keratosis pilaris

Follicular hyperkeratotic papules may be present on the extensor surfaces of the upper arms, buttocks, and anterior thighs, and are typically asymptomatic.[48]

excoriations

Commonly seen in areas that are easy to reach.[48]

lichenification

Thick, lichenified skin is evidence of chronic dermatitis.[48][Figure caption and citation for the preceding image starts]: Lichenification of the popliteal fossa in a child with atopic dermatitisFrom the personal collection of A. Hebert, MD; used with permission [Citation ends].com.bmj.content.model.Caption@4d4724f7

hypopigmentation

Seen in affected areas.[48][Figure caption and citation for the preceding image starts]: Hypopigmentation on the dorsal aspect of the hand in a 12-year-old girl with atopic dermatitisFrom the personal collection of A. Hebert, MD; used with permission [Citation ends].com.bmj.content.model.Caption@48e0d8d0[Figure caption and citation for the preceding image starts]: Papules, lichenification, and hypopigmentation in a child with chronic atopic dermatitisFrom the personal collection of A. Hebert, MD; used with permission [Citation ends].com.bmj.content.model.Caption@41df3b8d

Risk factors

strong

filaggrin gene mutation

The strongest known genetic risk factor for atopic dermatitis is null (loss-of-function) mutation of the gene encoding filaggrin.[21][22][23][24]

age <5 years

Usually presents in childhood; 45% of patients with atopic dermatitis are diagnosed by 6 months of age, and 70% to 85% of patients are diagnosed by the age of 5 years.[1][4][8]​​

Early onset of atopic dermatitis has been found to correlate with persistence of disease and more severe atopic disease within the atopic march.[34]

family history of atopic dermatitis

Concordance rates of 77% in monozygotic twins and 15% in dizygotic twins.[19]

Studies have estimated prevalence in siblings at 22% to 24%.[18]

allergic rhinitis

Occurs in 40.5% to 80% of people with atopic dermatitis.[1]​​[35] Allergen sensitization and immune dysregulation are thought to be important components in atopic disease.

asthma

Occurs in about 26% to 50% of people with atopic dermatitis.[1]​​[36] Patients with persistent or severe atopic dermatitis may be at higher risk for developing asthma.[37]

Allergen sensitization and immune dysregulation are thought to be important components in atopic disease.

weak

active and passive exposure to smoke

One systematic review and meta-analysis of observational studies concluded that active and passive exposure to smoke are associated with increased atopic dermatitis prevalence.[38]

Specifically, diagnosis of atopic dermatitis was associated with higher odds of exposure to passive smoke (OR 1.18, 95% CI 1.01 to 1.38) and active smoking (OR 1.87, 95% CI 1.32 to 2.63), but not to maternal smoking during pregnancy (OR 1.06, 95% CI 0.80 to 1.40).[38]

female sex

Atopic dermatitis affects females more than males in both the 6-7 years and the 13-14 years of age populations.[10]

African-American ethnicity

In the US, reported atopic dermatitis prevalence is 19.3% in African-American children and 16.1% in European-American children.[14]

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