History

Fact Explanation
Itching. Due to the release of histamine and cytokines which bind to specific receptors which in turn excite the free nerve endings in the cutaneous nerve fibers [1].
Sleep disturbance. Due to severe nocturnal itching [2].
Commonly affects face, back of knees, antecubital fossae and wrists. The degree of thickness in the stratum corneum in these areas favors the development of atopic eczema, as does the variation in exposure to irritants and allergens as compared to other body sites [3].
History of asthma, hay fever, etc. Atopy is a common syndrome underlying asthma, rhinitis, and eczema, and is characterised by high immunoglobulin E (IgE) responses to common antigens [4].
Positive family history. A link has been reported between atopy and chromosome 11 [5].
References
  1. STANDER Sonja , and Martin STEINHOFF. Pathophysiology of pruritus in atopic dermatitis: an overview. Experimental Dermatology [online] 2002. 11: 12–24.[viewed 1 April 2014] Available from: DOI: 10.1034/j.1600-0625.2002.110102.x http://onlinelibrary.wiley.com/doi/10.1034/j.1600-0625.2002.110102.x/full
  2. P. REID and M.S. LEWIS-JONES. Sleep difficulties and their management in preschoolers with atopic eczema. Clinical and Experimental Dermatology[online] 1995. 20: 38–41.[viewed 1 April 2014] Available from: DOI: 10.1111/j.1365-2230.1995.tb01280.x http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2230.1995.tb01280.x/abstract?deniedAccessCustomisedMessage=&userIsAuthenticated=false
  3. CORK Micheal J., et al. New perspectives on epidermal barrier dysfunction in atopic dermatitis: Gene–environment interactions. The Journal of Allergy and Clinical Immunology[online] July 2006. Vol 118(1):3-21[viewed 1 April 2014] Available from: DOI:10.1016/j.jaci.2006.04.042 http://www.jacionline.org/article/S0091-6749(06)00935-3/abstract
  4. MAO X.Q., et al. Association between genetic variants of mast-cell chymase and eczema.The Lancet[online],August 1996. Vol 348 (9027): 581 - 583, [viewed 1 April 2014] Available from:DOI:10.1016/S0140-6736(95)10244-2 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(95)10244-2/fulltext
  5. COLEMAN R., J.I. HARPER, and R.C. TREMBATH. Chromosome 11 q13 and atopy underlying atopic eczema. The Lancet[online], May 1993. Vol 341, (8853), 1121–1122 [viewed 1 April 2014] Available from:DOI:10.1016/0140-6736(93)93130-S http://www.sciencedirect.com/science/article/pii/014067369393130S

Examination

Fact Explanation
Skin excoriation. Due to the intense scratching [1].
Erythema. Due to the associated inflammatory response [2].
Edema. Due to the associated inflammatory response [2].
Lichenification. Due to the chronic tissue damage caused by the scratching [3].
Oozing lesions. When complicated by acute bacterial infection [4].
References
  1. SAMPSON hugh A., Role of immediate food hypersensitivity in the pathogenesis of atopic dermatitis. Journal of Allergy and Clinical Immunology. [online] May 1983.71(5): 473-480 [viewed 2 April 2014]. Available from: DOI:10.1016/0091-6749(83)90464-5 http://www.sciencedirect.com/science/article/pii/0091674983904645
  2. OLSSON M., et al. Increased expression of aquaporin 3 in atopic eczema. Allergy[online]2006. 61: 1132–1137.[viewed 2 April 2014]. Available from: DOI: 10.1111/j.1398-9995.2006.01151.x http://onlinelibrary.wiley.com/doi/10.1111/j.1398-9995.2006.01151.x/full
  3. GREAVES M.W., and P.D. WALL. Pathophysiology of itching. The Lancet. [online] October 1996.Vol 348 (9032) :938–940 [viewed 2 April 2014]. Available from: DOI:10.1016/S0140-6736(96)04328-0 http://www.sciencedirect.com/science/article/pii/S0140673696043280
  4. SEGAERT S. and E. Van CUTSEM. Clinical signs, pathophysiology and management of skin toxicity during therapy with epidermal growth factor receptor inhibitors. Annals of Oncology.[online].September 2005,16 (9): 1425-1433.[viewed 2 April 2014]. Available from: DOI:10.1093/annonc/mdi279

Differential Diagnoses

Fact Explanation
Contact dermatitis. Lesions are confined to the area of contact with the allergen and resolves when exposure to the allergen is eliminated [1].
Psoriasis. Well circumscribed, dry scaly plaques are charcterisitc and sometimes maybe symmetrical in distribution [2].
Tinea infection. Well demarcated annular plaques with a scaly border and with cetral clearing is characteristic [3].
References
  1. JUNGBAUER F. H. W., P. VAN DER VLEUTEN, J.W. GROOTHOFF, and Coenraads, P. J. COENRAADS. Irritant hand dermatitis: severity of disease, occupational exposure to skin irritants and preventive measures 5 years after initial diagnosis. Contact Dermatitis[online]. 2004. vol 50: 245–251.[viewed 2 April 2014] Available from DOI: 10.1111/j.0105-1873.2004.00347.x http://onlinelibrary.wiley.com/doi/10.1111/j.0105-1873.2004.00347.x/abstract?deniedAccessCustomisedMessage=&userIsAuthenticated=false
  2. LANGLEY R.G.B., G.G. KRUEGER and C.E.M. GRIFFITHS. Psoriasis: epidemiology, clinical features, and quality of life. Ann Rheum Dis[online] 2005, vol64: ii18-ii23.[viewed 2 April 2014] Available from DOI:10.1136/ard.2004.033217 http://ard.bmj.com/content/64/suppl_2/ii18.full
  3. EL-GOHARY M., Topical antifungal treatments for tinea cruris and tinea corporis (Protocol). Cochrane Database of Systematic Reviews[online] 2012, Issue 8. Art. No.: CD009992.[viewed 2 April 2014] Available from DOI: 10.1002/14651858.CD009992 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009992/full

Investigations - for Diagnosis

Fact Explanation
Serum IgE levels. There is atopic sensitization with excessive production of IgE in atopic eczema [1].
Atopy patch test. A patch containing allergens known to induce IgE mediated sensitization is applied to the skin in order to observe a reaction [1].
Skin swabs for microbiological culture from affected areas. To identify atopic eczema that is complicated by bacterial infection [2].
References
  1. DARSOW U., et al. The prevalence of positive reactions in the atopy patch test with aeroallergens and food allergens in subjects with atopic eczema: a European multicenter study. Allergy,[online]2004. vol 59: 1318–1325.[viewed 2 April 2014] Available from: DOI: 10.1111/j.1398-9995.2004.00556.x http://onlinelibrary.wiley.com/doi/10.1111/j.1398-9995.2004.00556.x/full
  2. MCFADDEN, J.P., W.C. NOBLE, and R.D.R. CAMP. Superantigenic exotoxin-secreting potential of staphylococci isolated from atopic eczematous skin. British Journal of Dermatology[online]1993, vol 128: 631–632..[viewed 2 April 2014] Available from: DOI:10.1111/j.1365-2133.1993.tb00257.x http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2133.1993.tb00257.x/abstract

Management - General Measures

Fact Explanation
Identify and avoid triggers. Due to the genetic influence, certain environmental factors could provoke and aggravate the condition [1].
Emollients. Dry skin is accompanied by changes in the stratum corneum which in turn increases the susceptibility to develop atopic eczema. Emollients act by inhibiting transepidermal water loss by occlusion, attracting water to stratum corneum (humectant) and rejuvinating skin by replenishing its essential proteins [2].
Antihistamines. It provides syptomatic relief at night from itching associated with histamine release [3].
References
  1. RING J., K. BROCKOW and D. ABECK. The therapeutic concept of “patient management” in atopic eczema. Allergy,[online]1996, vol51: 206–215. [viewed 2 April 2014] Available from DOI: 10.1111/j.1398-9995.1996.tb04595.x http://onlinelibrary.wiley.com/doi/10.1111/j.1398-9995.1996.tb04595.x/abstract
  2. Moisturizers: What They Are And How They Work. Skin Therapy Letter .com, 2014 [viewed 3 April 2014]. Available from:http://www.skintherapyletter.com/2001/6.13/2.html
  3. BEHRENDT, H. and J. RING. Histamine, antihistamines and atopic eczema. Clinical & Experimental Allergy[online]1990, 20: 25–30.[viewed 2 April 2014] Available from DOI: 10.1111/j.1365-2222.1990.tb02473.x http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2222.1990.tb02473.x/abstract?deniedAccessCustomisedMessage=&userIsAuthenticated=false

Management - Specific Treatments

Fact Explanation
Topical corticosteroids. Due to its strong anti-inflammotory effect on the affected area of skin [1].
Photochemotherapy (PUVA). It is known have a strong immnunomodulating capacity [2].
Antimicrobials. When complicated with bacterial infection [3].
References
  1. ORANJE A.P., et al. Emollients for eczema (Protocol). Cochrane Database of Systematic Reviews[online] 2010, Issue 1. Art. No.: CD008304. [viewed 2 April 2014] Available from DOI: 10.1002/14651858.CD008304. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008304/full
  2. GRUNDMANN-KOLLMANN Marcella, et al. Phototherapy for atopic eczema with narrow-band UVB. Journal of the American Academy of Dermatology[online] 1999,Vol40(6): 995–997 [viewed 2 April 2014] Available from DOI: 10.1016/S0190-9622(99)70090-3 http://www.sciencedirect.com/science/article/pii/S0190962299700903
  3. RING J., et al. Guidelines for treatment of atopic eczema (atopic dermatitis) Part I. Journal of the European Academy of Dermatology and Venereology[online]2012. 26: 1045–1060. [viewed 2 April 2014] Available from DOI:10.1111/j.1468-3083.2012.04635.x http://onlinelibrary.wiley.com/doi/10.1111/j.1468-3083.2012.04635.x/abstract?deniedAccessCustomisedMessage=&userIsAuthenticated=false