Pathogenesis, clinical manifestations, and diagnosis of atopic dermatitis (eczema)

Atopic dermatitis is a chronic pruritic inflammatory skin disease that occurs most frequently in children, but also affects adults. A family history of atopy (eczema, asthma, or allergic rhinitis) and the loss-of-function mutations in the filaggrin (FLG) gene, involved in the skin barrier function, are major risk factors for atopic dermatitis. (See 'Introduction' above and 'Epidemiology' above and 'Risk factors' above.)

●The cardinal features of atopic dermatitis are dry skin and severe pruritus that is associated with cutaneous hyperreactivity to various environmental stimuli, including exposure to food and inhalant allergens, irritants, and infection. Erythema, papulation, oozing and crusting, excoriation, and lichenification vary with the patient's age and stage of lesions. (See 'Clinical manifestations' above.)

●The diagnosis of atopic dermatitis is clinical, based upon history, morphology, and distribution of skin lesions and associated clinical signs. Diagnostic criteria for the clinical diagnosis include:

•Evidence of pruritic skin (mandatory), plus three or more of the following major criteria

•History of dermatitis involving the skin creases

•Visible dermatitis involving flexural surfaces

•Personal or family history of asthma or hay fever

•Presence of generally dry skin within the past year

•Symptoms beginning in a child before the age of 2 years or, in children <4 years, dermatitis affecting the cheeks or dorsal aspect of extremities

Skin biopsy and laboratory testing, including IgE levels, are usually not necessary in patients felt clinically to have atopic dermatitis (See 'Diagnosis' above.)

Atopic dermatitis: Infantile

Confluent erythema, microvesiculation, scaling, and crusting on the face, with similar involvement (to a lesser degree) on the trunk and arms. The facial involvement is more severe due to easier access to scratching; the baby is squeezing the breast skin to relieve the intense pruritus.

Graphic 77457 Version 3.0

Atopic dermatitis: Infantile

Confluent erythema, microvesiculation, papules, crust, and scale on the face of an infant.

Graphic 56461 Version 4.0

Atopic dermatitis - infantile

Hyperpigmented, lichenified patches are present on the face of this infant with atopic dermatitis.

Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.

Graphic 77386 Version 9.0

Atopic dermatitis - infantile

The diaper area is relatively spared in this infant with widespread atopic dermatitis.

Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.

Graphic 68746 Version 4.0

Atopic dermatitis

Hyperpigmented, slightly scaly patches and lichenified plaques are present in the popliteal fossae of this patient with atopic dermatitis.

Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.

Graphic 68215 Version 4.0

Atopic dermatitis

Severe atopic dermatitis in a 12-year-old girl showing in the typical location of the popliteal fossae. Note the oozing of serous fluid from the most involved areas, plus the papular component and erythema.

Courtesy of Scott Walsh, MD, FRPCP.

Graphic 65407 Version 1.0

Flexural atopic dermatitis

Typical appearance of atopic dermatitis in flexural areas of the legs.

Courtesy of James C Shaw, MD.

Graphic 52163 Version 1.0

Atopic dermatitis

Numerous erythematous papules are present on the hands of this patient with atopic dermatitis.

Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.

Graphic 55424 Version 5.0

Atopic dermatitis

Atopic dermatitis involving the sides of the neck. Note the scaling and characteristic reticular pigmentation.

Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.

Graphic 102395 Version 1.0

Adult atopic dermatitis

Chronic atopic dermatitis with lichenification (skin thickening and enhancement of skin markings) of the knee flexures in a 22-year-old woman with atopic dermatitis.

Graphic 64525 Version 3.0

Adult chronic atopic dermatitis

Lichenified, hyperpigmented plaque in the elbow flexure of a 35-year-old woman with atopic dermatitis.

Graphic 55375 Version 4.0

Keratosis pilaris

Keratosis pilaris. Multiple mildly erythematous follicularly-based papules.

Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.

Graphic 60786 Version 5.0

Keratosis pilaris

Keratosis pilaris. Multiple follicularly-based hyperpigmented papules are present.

Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.

Graphic 68488 Version 3.0

Pityriasis alba

Hypopigmented macules are present on the face of this young girl with pityriasis alba.

Graphic 60866 Version 6.0

Dennie-Morgan fold in atopic dermatitis

An extra skin fold is present under the eyes in this patient with facial atopic dermatitis.

Goodheart HP. Goodheart's Photoguide of Common Skin Disorders, 2nd ed, Lippincott Williams & Wilkins, Philadelphia 2003.

Graphic 62145 Version 1.0

Atopic cheilitis

Dryness and scaling of the lips in a child with atopic dermatitis. Note the blurred vermilion border of the upper lip.

Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.

Graphic 91322 Version 1.0

Eczema herpeticum

Hemorrhagic crusts and vesicles due to herpes simplex virus infection are present on the face of this infant with underlying atopic dermatitis.

Reproduced with permission from: Fleisher GR, Ludwig S, Baskin MN. Atlas of Pediatric Emergency Medicine, Lippincott Williams & Wilkins, Philadelphia 2004. Copyright © 2004 Lippincott Williams & Wilkins.

Graphic 64142 Version 3.0

Eczema herpeticum

Hemorrhagic crusts and vesicles due to herpes simplex virus infection are present on the hand of this infant with underlying atopic dermatitis.

Graphic 74838 Version 3.0

Eczema herpeticum

Punched-out ulcers are due to herpes simplex virus infection present on the arm of this patient with underlying atopic dermatitis.

Graphic 51337 Version 2.0

Palmar hyperlinearity in ichthyosis vulgaris

Characteristic palmar hyperlinearity in a patient with ichthyosis vulgaris.

Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.

Graphic 90481 Version 1.0

Acute allergic contact dermatitis

Discrete and confluent red, scaly, weepy, crusted papules and plaques. A 25-year-old woman consulted a dermatologist for an acute eczematous dermatitis on her head, neck and shoulders. The eruption appeared five days after she had black hair dye applied to her hair at the hairdresser. Patch tests were positive for para-phenylenediamine. Para-phenylenediamine is a dark dye used in almost all permanent hair dyes and some semi-permanent hair coloring. It is a potent allergen that triggers severe acute contact dermatitis in sensitized individuals.

Graphic 51066 Version 7.0

Infantile seborrheic dermatitis involving the diaper area

Large, moist, confluent erythematous plaques in a child with infantile seborrheic dermatitis involving the diaper area.

Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.

Graphic 73813 Version 4.0

Seborrheic dermatitis

Facial redness and scale involving the nasolabial folds and central face.

Reproduced with permission from: Goodheart HP. Goodheart's photoguide of common skin disorders, 2nd ed, Lippincott Williams & Wilkins, Philadelphia 2003. Copyright © 2003 Lippincott Williams & Wilkins.

Graphic 56410 Version 3.0

Facial seborrheic dermatitis

Intense erythema and scaling involving the central face and nasolabial folds.

Graphic 59104 Version 2.0

Psoriasis

Erythematous plaques in the diaper area in an infant with psoriasis.

Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.

Graphic 99441 Version 1.0

Infantile psoriasis

Erythematous and scaling plaques in an infant with psoriasis. Note the involvement of the diaper area, usually spared in infants with atopic dermatitis.

Graphic 95639 Version 1.0

Scabies, infant

The rash of scabies may be more diffuse in infants, spreading to the trunk and scalp in addition to the extremities.

Graphic 52588 Version 2.0

Exanthematous (morbilliform) drug eruption

Numerous erythematous macules and papules are present in this child with a morbilliform drug eruption.

Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.

Graphic 54205 Version 6.0

Wiskott-Aldrich syndrome

Eczematous dermatitis with associated purpura of the diaper area in an infant with Wiskott-Aldrich syndrome.

Graphic 95686 Version 1.0

Severe eczema in an infant with hyperimmunoglobulin E syndrome

Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.

Graphic 61049 Version 7.0

Acrodermatitis enteropathica

Acrodermatitis enteropathica in an infant. Moist erythematous plaques are present on the cheeks and buttocks. The buttock lesions are typically symmetric.

(Panel A) Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.
(Panel B) Courtesy of Robert Sidbury, MD.

Graphic 71329 Version 6.0

Ichthyosis linearis circumflexa in Netherton syndrome

Serpiginous, erythematous, pruritic plaques with double-edged peripheral scale develop in patients with Netherton syndrome.

Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.

Graphic 87482 Version 3.0

Netherton syndrome

Short, sparse hair is present in this patient with Netherton syndrome.

Reproduced with permission from: www.visualdx.com. Copyright Logical Images, Inc.

Graphic 87481 Version 3.0

Treatment of atopic dermatitis (eczema)

The goals of treatment for atopic dermatitis are to reduce symptoms (pruritus and dermatitis), prevent exacerbations, and minimize therapeutic risks. (See 'Introduction' above.)

●The optimal management requires a multipronged approach that involves the elimination of exacerbating factors, restoration of the skin barrier function and hydration of the skin, patient education, and pharmacologic treatment of skin inflammation. (See 'General approach' above.)

●We suggest that patients with mild to moderate atopic dermatitis be initially treated with topical corticosteroids and emollients (Grade 2B). The choice of the corticosteroid potency should be based upon the patient's age, body area involved, and degree of skin inflammation.

•For patients with mild atopic dermatitis, we suggest a low potency (groups five and six (table 1)) corticosteroid cream or ointment (eg, desonide 0.05%, hydrocortisone 2.5%). Topical corticosteroids can be applied once or twice daily for two to four weeks.

•For patients with moderate disease, we suggest medium to high potency (groups three and four (table 1)) corticosteroids (eg, fluocinolone 0.025%, triamcinolone 0.1%, betamethasone dipropionate 0.05%). (See'Topical corticosteroids' above.)

•The face and skin folds are areas that are at high risk for atrophy with corticosteroids. Initial therapy in these areas should start with a low potency corticosteroid (group VI (table 1)), such as desonide 0.05% ointment for up to three weeks. (See 'Topical corticosteroids' above.)

●We suggest that patients with atopic dermatitis involving the face or skin folds that is not controlled with topical corticosteroids, be treated with a topical calcineurin inhibitor (ie, tacrolimus or pimecrolimus) (Grade 2B). (See'Topical calcineurin inhibitors' above.)

●We suggest proactive therapy to prevent relapse in adolescents and adults with moderate to severe (picture 1A-B) atopic dermatitis that responds to continuous therapy with topical corticosteroids or calcineurin inhibitors (Grade 2A). We suggest medium to high potency topical corticosteroids (groups three to five) (table 1) rather than topical calcineurin inhibitors for proactive intermittent therapy (Grade 2B). Topical corticosteroids are applied once daily for two consecutive days per week for up to 16 weeks. (See 'Maintenance and prevention of relapses' above.)

●Patients with moderate to severe atopic dermatitis that is not controlled with optimal topical therapy may require phototherapy or systemic immunosuppressant treatment to achieve adequate disease control. These treatments are not suitable for infants and young children. In older children and adolescents, they should be used when other management options have failed and the disease has a significant impact on the quality of life. (See 'Patients with severe disease' above.)

GRAPHICS

Comparison of representative topical corticosteroid preparations (classified according to the USA system)

Potency group*	Corticosteroid	Vehicle type/form	Trade names (United States)	Available strength(s), percent (except as noted)	Generic available in United States¶
Super-high potency (group 1)	Betamethasone dipropionate, augmented	Ointment, optimized	Diprolene	0.05	Yes
		Lotion	Diprolene	0.05	Yes
		Gel	Diprolene	0.05	Yes
	Clobetasol propionate	Ointment	Temovate	0.05	Yes
		Cream	Temovate	0.05	Yes
		Cream, emollient base	Temovate E	0.05	Yes
		Gel	Temovate	0.05	Yes
		Lotion	Clobex	0.05	No
		Foam aerosol	Olux-E	0.05	No
		Foam aerosol (scalp)	Olux	0.05	Yes
		Shampoo	Clobex	0.05	No
		Solution (scalp)	Temovate, Cormax	0.05	Yes
		Spray aerosol	Clobex	0.05	No
	Diflucortolone valerate (not available in United States)	Ointment, oily cream	Nerisone Forte (United Kingdom, others)	0.3	No
	Fluocinonide	Cream	Vanos	0.1	No
	Flurandrenolide	Tape (roll)	Cordran	4 mcg/cm2	No
	Halobetasol propionate	Ointment	Ultravate	0.05	Yes
		Cream	Ultravate	0.05	Yes
		Lotion	Ultravate	0.05	No
High potency (group 2)	Amcinonide	Ointment	CyclocortΔ, AmcortΔ	0.1	Yes
	Betamethasone dipropionate	Ointment	Diprosone	0.05	Yes
	Betamethasone dipropionate	Cream, augmented formulation (AF)	Diprolene AF	0.05	Yes
	Desoximetasone	Ointment	Topicort	0.25	Yes
		Cream	Topicort	0.25	Yes
		Gel	Topicort	0.05	Yes
	Diflorasone diacetate	Ointment	ApexiConΔ, FloroneΔ	0.05	Yes
	Diflorasone diacetate	Cream, emollient	ApexiCon E	0.05	Yes
	Fluocinonide	Ointment	LidexΔ	0.05	Yes
		Gel	LidexΔ	0.05	Yes
		Cream anhydrous	LidexΔ	0.05	Yes
		Solution	LidexΔ	0.05	Yes
	Halcinonide	Ointment	Halog	0.1	No
	Halcinonide	Cream	Halog	0.1	No
High potency (group 3)	Amcinonide	Cream	CyclocortΔ, AmcortΔ	0.1	Yes
	Amcinonide	Lotion	AmcortΔ	0.1	Yes
	Betamethasone dipropionate	Cream, hydrophilic emollient	Diprosone	0.05	Yes
	Betamethasone valerate	Ointment	ValisoneΔ	0.1	Yes
	Betamethasone valerate	Foam	Luxiq	0.12	No
	Desoximetasone	Cream	Topicort LP	0.05	Yes
	Diflorasone diacetate	Cream	FloroneΔ	0.05	Yes
	Diflucortolone valerate (not available in United States)	Cream, oily cream, ointment	Nerisone (Canada, United Kingdom, others)	0.1	No
	Fluocinonide	Cream aqueous emollient	Lidex-EΔ	0.05	No
	Fluticasone propionate	Ointment	Cutivate	0.005	Yes
	Mometasone furoate	Ointment	Elocon	0.1	Yes
	Triamcinolone acetonide	Ointment	KenalogΔ	0.5	Yes
	Triamcinolone acetonide	Cream	Triderm, Aristocort HPΔ	0.5	Yes
Medium potency (group 4)	Betamethasone dipropionate	Spray	Sernivo	0.05	No
	Clocortolone pivalate	Cream	Cloderm	0.1	No
	Fluocinolone acetonide	Ointment	SynalarΔ	0.025	Yes
	Flurandrenolide	Ointment	Cordran	0.05	No
	Hydrocortisone valerate	Ointment	Westcort	0.2	Yes
	Mometasone furoate	Cream	Elocon	0.1	Yes
		Lotion	Elocon	0.1	Yes
		Solution	EloconΔ	0.1	Yes
	Triamcinolone acetonide	Cream	KenalogΔ	0.1	Yes
		Ointment	KenalogΔ	0.1	Yes
		Aerosol spray	Kenalog	0.2 mg per 2 second spray	No
Lower-mid potency (group 5)	Betamethasone dipropionate	Lotion	Diprosone	0.05	Yes
	Betamethasone valerate	Cream	Beta-Val, ValisoneΔ	0.1	Yes
	Desonide	Ointment	DesOwen, TridesilonΔ	0.05	Yes
	Desonide	Gel	Desonate	0.05	No
	Fluocinolone acetonide	Cream	SynalarΔ	0.025	Yes
	Flurandrenolide	Cream	Cordran	0.05	No
	Flurandrenolide	Lotion	Cordran	0.05	No
	Fluticasone propionate	Cream	Cutivate	0.05	Yes
	Fluticasone propionate	Lotion	Cutivate	0.05	No
	Hydrocortisone butyrate	Ointment	Locoid	0.1	Yes
		Cream	Locoid, Locoid Lipocream	0.1	Yes
		Lotion, spray	Cortizone 10 maximum	0.1	No
		Lotion	Locoid	0.1	No
		Solution	Locoid	0.1	Yes
	Hydrocortisone probutate	Cream	Pandel	0.1	No
	Hydrocortisone valerate	Cream	WestcortΔ	0.2	Yes
	Prednicarbate	Cream, emollient	Dermatop	0.1	Yes
	Prednicarbate	Ointment	Dermatop	0.1	Yes
	Triamcinolone acetonide	Lotion	KenalogΔ	0.1	Yes
	Triamcinolone acetonide	Ointment	KenalogΔ	0.025	Yes
Low potency (group 6)	Alclometasone dipropionate	Ointment	Aclovate	0.05	Yes
	Alclometasone dipropionate	Cream	Aclovate	0.05	Yes
	Betamethasone valerate	Lotion	Beta-Val, ValisoneΔ	0.1	Yes
	Desonide	Cream	DesOwen, TridesilonΔ	0.05	Yes
		Lotion	DesOwen, LoKara	0.05	Yes
		Foam	Verdeso	0.05	No
	Fluocinolone acetonide	Cream	SynalarΔ	0.01	Yes
		Solution	SynalarΔ	0.01	Yes
		Shampoo	Capex	0.01	No
		Oil (scalp)◊	Derma-Smoothe/FS	0.01	No
		Oil (body)◊	Derma-Smoothe/FS	0.01	No
	Triamcinolone acetonide	Cream	KenalogΔ, AristocortΔ	0.025	Yes
	Triamcinolone acetonide	Lotion	KenalogΔ	0.025	Yes
Least potent (group 7)	Hydrocortisone (base, ≥2%)	Ointment	Hytone	2.5	Yes
		Cream	Hytone, NutracortΔ	2.5	Yes
		Lotion	Hytone, Ala Scalp, Scalacort	2.5 or 2	Yes
		Solution	Texacort	2.5	Yes
	Hydrocortisone (base, <2%)	Ointment	Cortaid, Hytone, Nutracort	1	Yes
		Cream	Cortaid, Hytone, Synacort	1	Yes
		Lotion	Aquanil HC, Sarnol-HC, Cortizone 10	1	Yes
		Spray	Cortaid	1	Yes
		Solution	Cortaid, Noble, Scalp relief	1	Yes
		Ointment	Cortaid	0.5	Yes
		Cream	Cortaid	0.5	Yes
	Hydrocortisone acetate with pramoxine 1% combination	Ointment	Pramosone	1 or 2.5	Yes
		Cream	Pramosone, Analpram-HC	1 or 2.5	Yes
		Lotion	Pramosone, Analpram-HC	1 or 2.5	Yes
		Aerosol foam	Epifoam	1	Yes

* Listed by potency according to the USA classification system: group 1 is the most potent, group 7 is the least potent. Other countries use a different classification system with only four or five groups.
¶ Vehicle and base ingredient(s) for generic products, in some cases, may not be identical to trade version.
Δ Inactive United States trade name for specific product; brand may be available outside United States.
◊ 48% refined peanut oil.

Data from: Lexicomp Online. Copyright © 1978-2016 Lexicomp, Inc. All Rights Reserved; and Tadicherla S, Ross K, Shenefelt D, Topical corticosteroids in dermatology; Journal of Drugs in Dermatology 2009; 12:1093.

Graphic 62402 Version 34.0

Adult atopic dermatitis

Chronic atopic dermatitis with lichenification (skin thickening and enhancement of skin markings) of the knee flexures in a 22-year-old woman with atopic dermatitis.

Graphic 64525 Version 3.0

Adult chronic atopic dermatitis