Pediatric Atopic Dermatitis Clinical Presentation

Updated: Feb 13, 2023
  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD  more...
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Diagnostic criteria for atopic dermatitis (AD) have been proposed by Hanifin and Rajka (1980) and largely adopted by the American Academy of Allergy, Asthma, and Immunology. [17] Appropriate cases must have at least 3 major characteristics and at least 3 minor characteristics.

Major characteristics include the following:

  • Pruritus

  • Typical morphology and distribution (ie, flexural lichenification and linearity in adults, facial and extensor involvement in infants and young children)

  • Chronic or chronically relapsing dermatitis

  • Personal or family history of atopy (eg, asthma, allergic rhinoconjunctivitis, atopic dermatitis)

Minor characteristics are as follows:

  • Xerosis (dry skin)

  • Ichthyosis, palmar hyperlinearity, keratosis pilaris

  • Hand dermatitis, foot dermatitis

  • Cheilitis

  • Nipple eczema

  • Susceptibility to cutaneous infection (eg, with Staphylococcus aureus, herpes simplex virus [HSV], other viruses, warts, molluscum, dermatophytes)

  • Erythroderma

  • Perifollicular accentuation

  • Pityriasis alba

  • Early age of onset

  • Impaired cell-mediated immunity

  • Recurrent conjunctivitis

  • Orbital darkening

  • Infraorbital fold (eg, Dennie pleat, Morgan fold)

  • Anterior neck folds

  • Keratoconus

  • Anterior subcapsular cataracts

  • Sensitivity to emotional factors

  • Food intolerance

  • Pruritus with sweating

  • Intolerance of wool

  • White dermographism

  • Immediate type I skin test response

  • Elevated total serum immunoglobulin E (IgE)

  • Peripheral blood eosinophilia

Most children with atopic dermatitis relate a history notable for intense pruritus and dry skin. The quality of the pruritus is referred to as a spreading itch. Affected children often have a lowered itch threshold, resulting in increased levels of cutaneous reactivity in response to stimuli. Patients may succumb to a vicious itch-scratch-itch cycle, in which pruritus stimulates a bout of scratching. This, in turn, increases skin inflammation and triggers a greater sensation of itching, thus exacerbating flares.

Altered cell-mediated immunity has been noted in patients with atopic dermatitis; these patients exhibit both impaired skin barrier function and defects in skin innate immunity. [18] This is clinically observed as a history of repeated unusual cutaneous infections (eg, eczema herpeticum, warts, molluscum, dermatophytes). [19, 20]


Physical Examination

The following three classes of skin lesions are recognized:

  • Acute - Intensely pruritic erythematous papules and vesicles overlying erythematous skin; frequently associated with extensive excoriations and erosions accompanied by serous exudates

  • Subacute - Erythema, excoriation, and scaling

  • Chronic - Thickened plaques of skin, accentuated skin markings (lichenification), fibrotic papules (prurigo nodularis); possible coexistence of all 3 types of lesions in chronic atopic dermatitis

Typical locations of lesions by age are as follows:

  • Nonmobile infant - Face and scalp

  • Crawling infant - Extensor surfaces of extremities, trunk, face, and neck

  • Older child and adolescent - Wrists, ankles, antecubital fossae, popliteal fossae, and neck

  • Adult - May be limited to hand and foot eczema

Associated findings

Associated findings in atopic dermatitis include keratosis pilaris; accentuated palmar creases; lichenification; atopic pleats; allergic shiners; transverse nasal crease; pallor around the nose, mouth, and ears; white dermographism; cataracts; and keratoconus.

Keratosis pilaris, or plucked-chicken skin, consists of large cornified plugs in the upper part of hair follicles and produces a stippled appearance of the skin on the outer aspects of the arms and legs and on the buttocks and trunk.

Hyperlinear palms are usually present at birth and persist throughout life. These consist of an increased number of fine lines and accentuated markings on the palms.

Lichenification of the wrists, ankles, popliteal fossae, or antecubital fossae is characteristic of chronic atopic dermatitis. It is observed as thickened, leathery, hyperpigmented patches of skin with a deepening of normal skin creases. Lichenification has been studied with a statistical model. [21]

Atopic pleats (also referred to as Morgan-Dennie folds, Morgan folds, Dennie pleats, or mongolian lines) are skin folds observed just below the lower lid of both eyes and are retained throughout life.

Allergic shiners are violet-gray infraorbital discolorations caused by underlying vascular stasis. Increased pressure on nasal and paranasal venous plexuses causes edema in these areas, leading to development of atopic pleats and allergic shiners.

A prominent transverse nasal crease is a common sign of concurrent allergic rhinitis and, along with allergic shiners and atopic pleats, may be a clue to the diagnosis of an atopic diathesis.

Dermographism is a normal reaction in 5% of the population. After a firm pointed instrument is stroked against the skin, the path of the instrument is observed as a red line followed by an erythematous flare that ultimately develops into a wheal. This response occurs within 3 minutes of the insult. White dermographism is a paradoxical reaction wherein the initial red line is replaced within 10 seconds by a white line and an absence of a wheal. This reaction can be observed in atopic dermatitis and allergic contact dermatitis.

Atopic cataracts affect 4-12% of patients with AD and occur much earlier in life than senile cataracts. They typically are bilateral, central, and shield-shaped, and they mature rapidly. Because patients generally are asymptomatic, diagnosis is usually made by slit lamp examination. Incidence of cataracts in atopic patients appears to be unrelated to the use of topical steroids.

Keratoconus is an elongation of the corneal surface that is thought to be caused by long-term eye rubbing and may be a degenerative change in the cornea. Keratoconus affects approximately 1% of children with atopic dermatitis and can generally be alleviated with the use of contact lenses.

Several tools have been developed to assess the severity of atopic dermatitis. No one is considered the criterion standard, but some validated tools are listed below [22, 23, 24] :

  • Eczema Area and Severity Index (EASI) - Based solely on objective clinician assessment; primarily used in clinical trials
  • SCORing Atopic Dermatitis (SCORAD) - Combines objective clinician assessment and subjective patient assessment; primarily used in clinical trials
  • Patient-Oriented Eczema Measure (POEM): Based solely on subjective patient assessment; may be more convenient in clinical practice
  • Patient-Oriented SCORing Atopic Dermatitis (PO-SCORAD): Based solely on subjective patient assessment; may be more convenient in clinical practice

Some advocate the use of a scoring system. The SCORAD (Index) is the best-validated scoring system in atopic dermatitis. [25, 26] The extent of disease is measured by "the rule of nines," applied on a front/back drawing of the patient's inflammatory lesions. They are graded from 0-100 on 6 items, including erythema, edema/papulation, excoriations, lichenification, oozing/crusts, and dryness, with each item evaluated on a scale from 0-3.