Atopic Dermatitis | Visual Dermatology Atlas

llustration of the typical features of atopic dermatitis in a child, including intensely pruritic erythematous plaques, xerosis, and flexural involvement. Associated features of atopy, including asthma, allergic rhinitis, elevated IgE in some patients, an

Clinical Images

Examples of clinical presentations.

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Atopic dermatitis : Multiple faint, poorly demarcated erythematous patches scattered over the trunk.

Source: DermNet New Zealand. Atopic dermatitis.

Clinical images provided for educational purposes.

General info +

• Chronic, pruritic inflammatory skin disease with a relapsing course, associated with skin-barrier dysfunction and an atopic predisposition (asthma, allergic rhinitis, food allergies).
• Very common in children
• Approximately 60% of cases begin before 1 year of age
• >80% begin before 5 years of age
• May persist into or first develop in adulthood
• More prevalent in industrialized countries
• Characterized by xerosis and intense pruritus, resulting in an itch–scratch cycle that may lead to
lichenification
• Diagnosis is clinical; elevated total IgE is common but is neither necessary nor sufficient for diagnosis

Symptoms / presentation +

• Xerosis (dry skin)
• Intense pruritus (essential feature)
• Often worse at night
• Itch-scratch cycle
• May significantly affect sleep and quality of life
• Chronic relapsing-remitting course
• Other manifestations of atopy may be present, including asthma, allergic rhinitis, and food allergies

Clinical exam +

• Poorly demarcated erythematous papules and plaques
• Variable scaling
• Edema, vesicles, and oozing may occur during acute flares
• Excoriations and crusting secondary to scratching
• Lichenification in chronic disease
• Generalized xerosis is common
• Possible associated findings include Dennie-Morgan folds, palmar hyperlinearity, and keratosis pilaris

Distribution +

• Infants: cheeks, scalp, and extensor surfaces of the extremities
• Diaper area is typically spared
• Children: predominantly flexural, especially the antecubital and popliteal fossae
• Adolescents and adults: flexural areas, face, neck, and hands
• Eyelid and periocular involvement may occur
• Distribution is generally bilateral and symmetric

Dermoscopy +

• Dermoscopy is generally not required for diagnosis
• Possible but nonspecific findings include:
• Diffuse or patchy erythema
• White or yellow scales
• Dotted vessels may be seen in inflammatory lesions

Diagnostic +

• Diagnosis is primarily clinical
• Based on the presence of:
• Pruritus
• Chronic or relapsing eczema with age-appropriate morphology and distribution
• Xerosis
• Personal or family history of atopy as a supportive feature
• Routine laboratory testing is not required
• Total IgE is often elevated but is nonspecific and not diagnostic
• Skin biopsy is rarely required and may be considered in atypical presentations or when the diagnosis is uncertain

Differential diagnosis +

• Allergic or irritant contact dermatitis
• Seborrheic dermatitis
• Psoriasis
• Scabies
• Dermatophytosis (tinea)
• Nummular eczema
• Immunodeficiency or genetic disorders associated with eczema - particularly in severe, atypical, or
treatment-refractory presentations

Treatment plan +

Basic skin care
• Apply emollients generously ≥1–2×/day, particularly after bathing
• Short, lukewarm baths/showers; use a gentle fragrance-free cleanser
• Avoid irritants and address relevant triggers

Flares: topical corticosteroids
• Low potency: face, flexures, and sensitive areas
• Moderate-to-high potency: trunk and extremities depending on severity
• Generally once daily for 7–14 days, then taper/discontinue once controlled

Alternatives / maintenance therapy
• Topical calcineurin inhibitors (tacrolimus, pimecrolimus), particularly for the face and flexures
• Intermittent proactive treatment of frequently affected areas to prevent relapses

Refractory moderate-to-severe disease: phototherapy or systemic/biologic therapy depending on age and patient factors (e.g., dupilumab)
Treat secondary bacterial infection only when clinically present

References +

American Academy of Dermatology (AAD). Guidelines of care for the management of atopic dermatitis. Journal of the American Academy of Dermatology (JAAD).
Eichenfield LF, Tom WL, Chamlin SL, et al. Guidelines of care for the management of atopic dermatitis: Section 1. Diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol. 2014;70(2):338–351.
Wollenberg A, Kinberger M, Arents B, et al. European guideline (EuroGuiDerm) on atopic eczema. Journal of the European Academy of Dermatology and Venereology (JEADV).
UpToDate. Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, diagnosis, and management.
DermNet. Atopic dermatitis.