eMedicine Specialties > Pediatrics: General Medicine > Dermatology

Atopic Dermatitis: Differential Diagnoses & Workup

Author: Caroline C Spagnola, MD, Consulting Staff, Department of Allergy and Immunology, Kaiser Permanente Bellflower
Contributor Information and Disclosures

Updated: Sep 30, 2009

Differential Diagnoses

Acrodermatitis Enteropathica
Phenylketonuria
Contact Dermatitis
Scabies
Herpes Simplex Virus Infection
Staphylococcus Aureus Infection
Hyperimmunoglobulinemia E (Job) Syndrome
Wiskott-Aldrich Syndrome

Other Problems to Be Considered

Seborrheic dermatitis
Psoriasis

Workup

Laboratory Studies

  • No definitive laboratory tests are used to diagnose atopic dermatitis (AD).
  • Elevated serum immunoglobulin E (IgE) levels and peripheral blood eosinophilia occur in most individuals with atopic dermatitis, and these findings may be useful in confirming the atopic status of suspected cases.
  • The presence of serum IgE directed against the cell wall of S aureus is observed in hyper-IgE syndrome and atopic dermatitis.
  • Common infections that mimic or complicate atopic dermatitis can be tested for as follows: conduct a Tzanck smear for herpes simplex virus (HSV), a potassium hydroxide (KOH) preparation for dermatophytes, and a Gram stain for bacterial infections.

Other Tests

  • Prick skin testing to common allergens can help identify specific triggers of atopic dermatitis. For accuracy, antihistamines must be discontinued for 1 week and topical steroids for 2 weeks prior to testing. Although used most often in young children with moderate-to-severe disease, false-negative and false-positive test results are not uncommon in children younger than 8 years. If positive, these tests do not necessarily indicate clinically significant triggers. Prick skin tests only indicate that the patient has been sensitized to the particular antigens. For example, most children shown to have multiple food allergies by skin tests only demonstrate clinically detectable allergic reactions to 3 or fewer foods when tested by double-blind randomized provocative testing.
  • Radioallergosorbent test (RAST) and enzyme-linked immunosorbent assay (ELISA) in vitro tests identify serum IgE directed toward specific allergens (allergen-specific IgE). As with prick skin tests, these diagnostic methods show a poor predictive value for clinically significant food allergies and may produce false-positive results when the patient's serum contains elevated nonspecific (or total) IgE levels.

Histologic Findings

  • Acute eczematous lesions show histologic markings of hyperkeratosis, parakeratosis, and acanthosis with a decreased or absent granular cell layer.
  • Important features in histologic diagnosis include spongiosis (accumulation of fluid in the intercellular and intracellular areas) and exocytosis (infiltration of leukocytes through the epidermis).
  • Chronic eczematous lesions display hyperkeratosis with areas of parakeratosis and papillomatosis (upward proliferation of dermal papillae).

More on Atopic Dermatitis

Overview: Atopic Dermatitis
Differential Diagnoses & Workup: Atopic Dermatitis
Treatment & Medication: Atopic Dermatitis
Follow-up: Atopic Dermatitis
Multimedia: Atopic Dermatitis
References
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Further Reading

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Keywords

atopic dermatitis, AD, eczema, immunologic skin disorder, hyperactive T helper cell 2, hyperactive Th2, elevated serum immunoglobulin E, elevated serum IgE, deficient levels of omega-6 fatty acids, disorder of fatty acid metabolism, pruritus, dermatitis, flexural lichenification and linearity in adults, facial and extensor involvement in infants and young children, atopy, dry skin, xerosis, skin inflammation, inflamed skin, asthma, hayfever, Staphylococcus aureus, herpes simplex virus, HSV, warts, molluscum, dermatophytes, food intolerance, keratosis pilaris, accentuated palmar creases, lichenification, atopic pleats, allergic shiners, transverse nasal crease

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Contributor Information and Disclosures

Author

Caroline C Spagnola, MD, Consulting Staff, Department of Allergy and Immunology, Kaiser Permanente Bellflower
Caroline C Spagnola, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, and American College of Allergy, Asthma and Immunology
Disclosure: Nothing to disclose.

Medical Editor

Kevin P Connelly, DO, Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center
Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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