Diagnostic Considerations

Atopic dermatitis (AD) is indistinguishable from other causes of dermatitis. In infancy, the most common difficulty is distinguishing it from seborrheic dermatitis (SD). This entity is not seen with the same frequency as a decade ago. Both AD and SD are associated with cradle cap (a retention hyperkeratosis) found on the vertex of the scalp, which is greasy and yellow in individuals with SD and dry and crusted in individuals with AD. Other areas of involvement in SD are the intertriginous areas and diaper area; erythema and a greasy scale can be seen over the eyebrows and the sides of the nose. In AD, xerosis of the skin and pruritus occur, which are not usually features of SD. Both conditions should be distinguished from psoriasis.

Scabies manifests in infancy or childhood as a pruritic eruption. Other members of the family are usually itchy, and the primary sites of involvement are moist, warm areas. The eruption is polymorphic with a dermatitis, nodules, urticaria, and 6-10 burrows. Pustules on the hands and feet are almost diagnostic of scabies in infancy. Facial involvement is rare, and xerosis does not occur.

Allergic contact dermatitis from nickel in infants and children is sometimes difficult to distinguish from AD. A central area of dermatitis on the chest from nickel snaps in undershirts or around the umbilicus from snaps in jeans is helpful for making the diagnosis, although a dermatitic eruption may occur as an id reaction in other areas, particularly the antecubital fossae. Xerosis and facial involvement are absent. AD usually starts earlier than contact dermatitis.

Infants with a severe itch and generalized dermatitis in the setting of recurrent infections should be investigated for evidence of an immunodeficiency. Failure to thrive and repeated infections help distinguish the eruption from AD. In Wiskott-Aldrich syndrome, bleeding may be prominent with the dermatitis, because of the associated thrombocytopenia. A population-based cohort study by Schmitt J et al. suggested a possible link to the development of mental health issues in patients who experienced infant eczema and concurrent sleeping problems.^[47]

In older children, mycosis fungoides (a form of T-cell lymphoma) often presents with hypopigmented patches associated with a dermatitis. This entity is being recognized with increased frequency as physicians become more aware of the disease, and it is sometimes difficult to distinguish between the 2 entities.

Tinea corporis usually manifests as a single lesion, but inappropriate treatment with steroids may cause a widespread dermatitis. Facial involvement, the presence of xerosis, the age of appearance, and an early onset (in AD) help distinguish between the two conditions.

One report describes localized varicella lesions developing in preexisting infectious or inflammatory dermatitis; no clear evidence of full-blown chickenpox was seen. The authors suggest viral testing may be needed if vesicular or ulcerative lesions develop within a preexisting dermatitis.^[48]

Differential Diagnoses

Workup

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Media Gallery

Atopic dermatitis. Typical atopic dermatitis on the face of an infant.
Atopic dermatitis. Flexural involvement in childhood atopic dermatitis.
Atopic dermatitis. Dirty neck sign in chronic atopic dermatitis.
Atopic dermatitis. Irritation around mouth of an infant with atopic dermatitis.

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Author

Brian S Kim, MD, MTR, FAAD Sol and Clara Kest Professor, Vice Chair of Research, Site Chair, Mount Sinai West and Morningside, Director, Mark Lebwohl Center for Neuroinflammation and Sensation, The Kimberly and Eric J Waldman Department of Dermatology, Precision Immunology Institute, Friedman Brain Institute, Icahn School of Medicine at Mount Sinai

Brian S Kim, MD, MTR, FAAD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Society for Investigative Dermatology

Disclosure: Received research grant from: Doris Duke Charitable Foundation, Celgene Corporation, LEO Pharma, and the National Institute of Arthritis Musculoskeletal and Skin Diseases (NIAMS) of the National Institutes of Health [NIH (K08AR065577 and R01AR070116)]<br/>Consultant for AbbVie, AstraZeneca, Cara Therapeutics, Galderma, GlaxoSmithKline, Pfizer, Regeneron, Sanofi Genzyme, Trevi Therapeutics; Scientific Advisory Board for Abrax Japan, Granular Therapeutics, and Recens Medical. .

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Van Perry, MD Assistant Professor, Department of Medicine, Division of Dermatology, University of Texas School of Medicine at San Antonio

Van Perry, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD<br/>Served as a speaker for various universities, dermatology societies, and dermatology departments.

Acknowledgements

Peter Fritsch, MD Chair, Department of Dermatology and Venereology, University of Innsbruck, Austria

Peter Fritsch, MD is a member of the following medical societies: American Dermatological Association, International Society of Pediatric Dermatology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Bernice R Krafchik, MBChB, FRCPC Professor Emeritus, Department of Pediatrics, Section of Dermatology, University of Toronto

Bernice R Krafchik, MBChB, FRCPC is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, Canadian Medical Association, College of Physicians and Surgeons of Ontario, Royal College of Physicians and Surgeons of Canada, and Society for Pediatric Dermatology

Disclosure: Nothing to disclose.