History

Fact Explanation
Itchy skin rash There is an increased cholinergic response to scratch, subsequently with the development of an eczema. Involved body area may differ according to the age of the patient.[1,3]
Dry skin Many patients present with dry skin (xerosis) due to the low water content and an excessive water loss through the epidermis.[1,3]
Past personal/childhood history of similar symptoms The course of the disease is highly variable with flares of varying severity and duration.[1,3]
History of known trigger factors (dietary or environmental) Patients with allergic dermatitis have an inherited tendency to produce IgE antibodies in response to minute amounts of common environmental proteins such as pollen, house dust mites, and food allergens. Most of the time patients have history of known triggering factors, which varies greatly among individuals, such as certain foods, house dust mites, pets, airborne allergens..etc.[1,2,3]
Family history of atopy, dermatitis Genetic predisposition (skin barrier defects as well as impaired innate and acquired immunity) plays important roles in both the onset of allergic dermatitis and the exacerbations.[1,3]
Fever, general ill health Infections are a common complication of allergic dermatitis and can be quite severe giving rise to systemic symptoms such as fever..etc.[1]
Age of the patient Around 50% of all those with allergic dermatitis develop symptoms within their first year of life, and probably as many as 95% experience an onset below 5 years of age. Around 75% with childhood onset of the disease have a spontaneous remission before adolescence, whereas the remaining 25% continue to have eczema into adulthood or experience a relapse of symptoms after some symptom-free years.[1,3]
History of associated diseases Allergic dermatitis is associated with other atopic diseases such as food allergies, asthma, and allergic rhinitis.[1]
Psychological status of the patient Some patients are significantly more often depressed or anxious as a result of their suffering and this has to be find out when taking the history to arrange psychotherapeutic measures.[1]
References
  1. WERFEL T, SCHWERK N, HANSEN G, KAPP A. The diagnosis and graded therapy of atopic dermatitis. Dtsch Arztebl Int [online] 2014 Jul 21, 111(29-30):509-20 [viewed 01 September 2014] Available from: doi:10.3238/arztebl.2014.0509
  2. KATTA R, SCHLICHTE M. Diet and dermatitis: food triggers. J Clin Aesthet Dermatol [online] 2014 Mar, 7(3):30-6 [viewed 01 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24688624
  3. THOMSEN SF. Atopic dermatitis: natural history, diagnosis, and treatment. ISRN Allergy [online] 2014:354250 [viewed 01 September 2014] Available from: doi:10.1155/2014/354250

Examination

Fact Explanation
Eczema In its acute form, eczema is characterised by a lively red infiltrate with oedema (erythema), vesicles, oozing and crusting. Lichenification, excoriations, papules, and nodules dominate the subacute and chronic form.[1,2]
Distribution of the eczema Distribution varies according to the age of the patient. In infants eczema is often localised to the face, scalp, and extensor aspects of the arms and legs, but it can also be widespread. In toddlers and older children, eczema lesions often confined to the flexures of the elbows and knees as well as the wrists and ankles, although it can occur at any site. In adults, the lesions are found in the face and neck (head and neck dermatitis) and some patients develop hand eczema.[1,2]
Dry, pale skin Many patients present with dry skin (xerosis) due to the low water content and an excessive water loss through the epidermis. The skin is pale because of increased tension in the dermal capillaries and the ability to sweat is reduced.[1,2]
Facial pallor, white dermographism Due to atypical vascular response, which is an associated clinical sign favouring the diagnosis of allergic dermatitis.[2]
Hives, hyperlinearity, dry, fragile hair There is an increased cholinergic response to scratch, so-called white dermographism or skin-writing, resulting in hives at the affected site. The palms of the hands and feet may show hyperlinearity, and the individuals' hair is dry and fragile.[1,2]
Ocular and periorbital changes Often, there is a double skinfold underneath the inferior eyelid (Dennie-Morgan fold) that becomes exaggerated in times of increased disease activity. The eye surroundings may be darkened due to postinflammatory hyperpigmentation.[2]
References
  1. WERFEL T, SCHWERK N, HANSEN G, KAPP A. The diagnosis and graded therapy of atopic dermatitis. Dtsch Arztebl Int [online] 2014 Jul 21, 111(29-30):509-20 [viewed 01 September 2014] Available from: doi:10.3238/arztebl.2014.0509
  2. THOMSEN SF. Atopic dermatitis: natural history, diagnosis, and treatment. ISRN Allergy [online] 2014:354250 [viewed 01 September 2014] Available from: doi:10.1155/2014/354250

Differential Diagnoses

Fact Explanation
Irritant contact dermatitis, The most common differential diagnostic consideration. Suspect when there is a history of exposure to an irritant substance.[1,2]
Early stage of cutaneous T-cell lymphoma In adults an early stage of cutaneous T-cell lymphoma should be suspected and it usually cannot be excluded microscopically.[1,2]
Hand dermatitis Hand dermatitis may often reflect a mixed picture of atopic, irritant and allergic contact dermatitis; it is generally difficult to classify precisely on the basis of etiology. [1]
Palmoplantar psoriasis Consider with the involvement of the hands and feet.[1,2]
Dermatophyte infections Should be excluded as this is a common disease which give rise to similar symptoms as allergic dermatitis.[1,2]
Immunodeficiency syndromes Less commonly one may encounter immunodeficiency syndromes which can resemble allergic dermatitis-like changes. They are Hyper IgE syndrome, Wiskott-Aldrich syndrome, Omenn syndrome and Netherton syndrome.[1,2]
Scabies Can occasionally be confused with allergic dermatitis, especially in children.[1,2]
References
  1. WERFEL T, SCHWERK N, HANSEN G, KAPP A. The diagnosis and graded therapy of atopic dermatitis. Dtsch Arztebl Int [online] 2014 Jul 21, 111(29-30):509-20 [viewed 01 September 2014] Available from: doi:10.3238/arztebl.2014.0509
  2. THOMSEN SF. Atopic dermatitis: natural history, diagnosis, and treatment. ISRN Allergy [online] 2014:354250 [viewed 01 September 2014] Available from: doi:10.1155/2014/354250

Investigations - for Diagnosis

Fact Explanation
Skin biopsy Generally not needed if the history and clinical features are typical, but may be useful when there is diagnostic uncertainty. [1]
Allergy testing (specific IgG, IgE levels and prick testing) Indications include history of immediate allergic reaction or development of dermatitis after allergen exposure, severe chronic disease without history suggesting allergic component. The determination of specific IgG levels has no diagnostic relevance in patients with suspected allergies and should not be carried out. Measuring specific IgE antibodies against autoantibodies, which can been found in a subgroup of patients, is currently not a part of the routine diagnostic approach.[1,2]
Patch testing Patch testing with contact allergens may help to uncover the presence of an additional allergic contact dermatitis in a patient with chronic or therapy-resistant atopic dermatitis.[1,2]
References
  1. WERFEL T, SCHWERK N, HANSEN G, KAPP A. The diagnosis and graded therapy of atopic dermatitis. Dtsch Arztebl Int [online] 2014 Jul 21, 111(29-30):509-20 [viewed 01 September 2014] Available from: doi:10.3238/arztebl.2014.0509
  2. THOMSEN SF. Atopic dermatitis: natural history, diagnosis, and treatment. ISRN Allergy [online] 2014:354250 [viewed 01 September 2014] Available from: doi:10.1155/2014/354250

Management - General Measures

Fact Explanation
Patient and family education Patient and his/her family should be educated properly regarding the disease condition, chronic nature of the disease with exacerbations, importance of avoiding triggering factors to control the disease and the value of adherence to therapy.[1,2]
References
  1. WERFEL T, SCHWERK N, HANSEN G, KAPP A. The diagnosis and graded therapy of atopic dermatitis. Dtsch Arztebl Int [online] 2014 Jul 21, 111(29-30):509-20 [viewed 01 September 2014] Available from: doi:10.3238/arztebl.2014.0509
  2. THOMSEN SF. Atopic dermatitis: natural history, diagnosis, and treatment. ISRN Allergy [online] 2014:354250 [viewed 01 September 2014] Available from: doi:10.1155/2014/354250

Management - Specific Treatments

Fact Explanation
Avoidance of triggering factors The importance of trigger factors varies greatly among individuals, but their identification and then avoidance play a main role in treatment approach. In patients with proven sensitization to house dust mites, both special mattress covers and regular washing of pillows and bed covers are recommended. An elimination diet is only indicated in case of a clinically relevant immediate-type food allergy or if a delayed-type reaction is identified. Patients also should avoid working in a wet environment, very dirty conditions, frequent hand washing and repeated exposure to irritants.[1,2]
Skin care Includes proper hydration of skin and use of emollients to reduce triggering factors. Note: daily application of moisturizers can lead to a reduced use of glucocorticosteroids.[1]
Anti-inflammatory therapy - Topical agents First line therapy is topical glucocorticosteroids. If it is not tolerated or contraindicated such as in areas like face, intertriginous areas,scrotum, scalp in children because of increased absorption topical calcineutin inhibitors can be used.[1,2]
Anti-inflammatory therapy - Systemic agents For persistent severe widespread dermatitis systemic anti-inflammatory agents are recommended. They are glucocorticosteroids (only short courses), cyclosporines (only for adults), azathioprine, mycophenolate mofetil and methotrexate.[1,2]
Phototherapy (UV therapy) - UVB 311 nm and UVA1 in medium doses (up to 50 J/cm2) Should be given only for adults. Children under 12 years of age should only be treated with phototherapy in exceptional cases. can be combined with topical corticosteroid therapy, depending on the chronicity and severity of the disease. Should not be used in combination with topical calcineurin inhibitors or with systemic immunosuppressive agents.[1,2]
Treatment of superinfections Superinfected areas of dermatitis can be treated with topical antiseptic drugs. Topical antibiotics should not be used because of the risks of inducing resistant bacterial strains and causing allergic contact dermatitis. Agents and method of treatment that can be used are, 1) Bacterial - Topical antiseptic agents(octenidine, triclosan, chlorhexidine), systemic antibiotics for widespread involvement 2) Viral - Mechanical(curettage) or chemical destruction, systemic acyclovir, valacyclovir 3) Fungal-Topical antimycotic agents (imidazoles).[1]
Prevention Preventive measures should be advocated for high-risk families. These include 4 months of breast feeding (or the use of extensive protein hydrolysate formulas) and the early introduction of fish in the child’s diet.[1]
Psychotherapeutic measures Sometimes individual psychotherapy may be needed and indicated, particularly behavioral therapy for patients with clear indications such as psychological issues as individually relevant trigger factors or atopic dermatitis or secondary psychosocial issues for the patient or family are attributable to allergic dermatitis.[1,2]
Occupational counseling Occupational counseling should be offered to patients with occupationally induced or exacerbated clinically significant allergic dermatitis and should be referred for evaluation to a dermatologist.[1,2]
References
  1. WERFEL T, SCHWERK N, HANSEN G, KAPP A. The diagnosis and graded therapy of atopic dermatitis. Dtsch Arztebl Int [online] 2014 Jul 21, 111(29-30):509-20 [viewed 01 September 2014] Available from: doi:10.3238/arztebl.2014.0509
  2. THOMSEN SF. Atopic dermatitis: natural history, diagnosis, and treatment. ISRN Allergy [online] 2014:354250 [viewed 01 September 2014] Available from: doi:10.1155/2014/354250