ATOPIC DERMATITIS: CLINICAL

PRESENTATIONS AND
DIFFERENTIAL DIAGNOSIS

Mihaela PANDURU

”Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

Colentina Clinical Hospital, Bucharest, Romania

Geneva, Switzerland
2017
1
 ATOPIC DERMATITIS
UPDATE FROM 2014 TO 2017

• Diagnostic criteria

• Clinical phenotypes

• Comorbidities

• Differential diagnosis

2
 WHAT DIAGNOSTIC CRITERIA FOR
ATOPIC DERMATITIS DO YOU USE IN
DAILY PRACTICE?
1. Hanifin and Rajka

2. UK

3. American Academy of Dermatology

4. Other criteria

5. No criteria
3
 DIAGNOSTIC CRITERIA

Criteria Year Criteria Year

Wise and Sulzberger 1933 Millennium 1998
Hanifin and Rajka 1980 Indian Guidelines 2001
Kang and Tian 1987 Thai criteria in children 2004
UK Working Party 1994 Danish Allergy Research Centre 2005
Japanese Dermatological 1995 Thai criteria in adults 2007
Association
ISAAC 1995
Lillehammer 1996
Diepgen 1996

Bieber T. Dermatol Clin. 2017 4

 DIAGNOSTIC CRITERIA

Criteria Year Criteria Year

Wise and Sulzberger 1933 Millennium 1998
Hanifin and Rajka 1980 Indian Guidelines 2001
Kang and Tian 1987 Thai criteria in children 2004
UK Working Party 1994 Danish Allergy Research Centre 2005
Japanese Dermatological 1995 Thai criteria in adults 2007
Association American Academy of 2014
ISAAC 1995 Dermatology
Lillehammer 1996 Chinese criteria 2016
Diepgen 1996 (adolescents/adults)
Korean Atopic Dermatitis 2016
Research Group

Bieber T. Dermatol Clin. 2017 5

 DIAGNOSTIC CRITERIA
HR UK AAD Chinese REACH H R UK AAD Chinese REACH
pruritus + + + + facial pallor/facial + +
typical eczema + + + + + erythema
chronicity + + + + + pityriasis alba + +
history of atopy + + + + + anterior neck folds +
xerosis + + + + itch when sweating + +
ichthyosis/keratosis + + intolerance to wool and +
pilaris lipid solvents
immediate skin + perifollicular + +
reactivity accentuation
elevated serum Ig E + + + food intolerance +
early age of onset + + + influence of +
Staphylococcus + environmental /
aureus and Herpes emotional factors
simplex white dermographism + +
non-specific hand + palmar hyperlinearity + +
and foot dermatitis periauricular lesions + +
nipple eczema + perioral lesions + +
cheilitis + lichenification +
conjunctivitis + + prurigo lesions +
Dennie-Morgan fold + + positive allergen-specific +
Keratoconus, + + + IgE
cataracts eosinophilia +
orbital darkening
6
 DIAGNOSTIC CRITERIA
HR UK AAD Chinese REACH H R UK AAD Chinese REACH
pruritus + + + + facial pallor/facial + +
typical eczema + + + + + erythema
chronicity + + + + + pityriasis alba + +
history of atopy + + + + + anterior neck folds +
xerosis + + + + itch when sweating + +
ichthyosis/keratosis + + intolerance to wool and +
pilaris lipid solvents
immediate skin + perifollicular + +
reactivity accentuation
elevated serum Ig E + + + food intolerance +
early age of onset + + + influence of +
Staphylococcus + environmental /
aureus and Herpes emotional factors
simplex white dermographism + +
non-specific hand + palmar hyperlinearity + +
and foot dermatitis periauricular lesions + +
nipple eczema + perioral lesions + +
cheilitis + lichenification +
conjunctivitis + + prurigo lesions +
Dennie-Morgan fold + + positive allergen-specific +
Keratoconus, + + + IgE
cataracts eosinophilia +
orbital darkening
7
 DIAGNOSTIC CRITERIA
HR UK AAD Chinese REACH H R UK AAD Chinese REACH
pruritus + + + + facial pallor/facial + +
typical eczema + + + + + erythema
chronicity + + + + + pityriasis alba + +
history of atopy + + + + + anterior neck folds +
xerosis + + + + itch when sweating + +
ichthyosis/keratosis + + intolerance to wool and +
pilaris lipid solvents
immediate skin + perifollicular + +
reactivity accentuation
elevated serum Ig E + + + food intolerance +
early age of onset + + + influence of +
Staphylococcus + environmental /
aureus and Herpes emotional factors
simplex white dermographism + +
non-specific hand + palmar hyperlinearity + +
and foot dermatitis periauricular lesions + +
nipple eczema + perioral lesions + +
cheilitis + lichenification +
conjunctivitis + + prurigo lesions +
Dennie-Morgan fold + + positive allergen-specific +
Keratoconus, + + + IgE
cataracts eosinophilia +
orbital darkening
8
DIAGNOSTIC CRITERIA

Vakharia PP et all . Am J Clin Dermatol. 2017 9

DIAGNOSTIC CRITERIA

Vakharia PP et all . Am J Clin Dermatol. 2017 10

 WHICH CLINICAL PHENOTYPES
HAVE YOU MOST FREQUENTLY
MET IN YOUR CLINICAL PRACTICE?
1. Infantile

2. Childhood

3. Adolescent

4. Adult

5. Elderly 11
 CLINICAL PHENOTYPES
• Phenotypes of the age-related clinical aspect:

Infantile atopic dermatitis

Adolescent
Childhood and adult
atopic atopic
dermatitis
dermatitis
Elderly atopic dermatitis
Tanei
Weidinger S,R. J ClinN.Med.
Novak 2015
Lancet. 2016 12
 CLINICAL PHENOTYPES
• Phenotypes by age of onset

Bieber T et all J Allergy Clin Immunol. 2017 13

 CLINICAL PHENOTYPES

• Phenotypes based on disease severity

Bieber T et all J Allergy Clin Immunol. 2017 14

 CLINICAL PHENOTYPES
• Phenotypes based on the filaggrin mutation

Leung DYM, et all. The Journal of allergy and clinical immunology. 2014 15
 CLINICAL PHENOTYPES
Phenotypes based on ethnic origin of the
patients: Skin of color phenotype

16
Mei-Yen Yong A, Tay YK.Dermatol Clin. 2017; Vachiramon V, et all Pediatr Dermatol. 2012
 CLINICAL PHENOTYPES
• Phenotypes based on ethnic origin of the
patients: Asian phenotype

– ’’psoriasis-like’’ phenotype

- facial and eyelid dermatitis

- sandpaper-like lesions on
extensor surfaces
- wrist dermatitis
- hyperkeratotic papules

Noda S at all. J Allergy Clin Immunol. 2015.

Mei-Yen Yong A, Tay YK.Dermatol Clin. 2017 17
 IS IT ATOPIC DERMATITIS A SYSTEMIC
DISEASE ?

1. Yes

2. No

18
ATOPIC DERMATITIS AND
COMORBIDITIES
ATOPIC DERMATITIS

Brunner PM, et all. J Invest Dermatol. 2017

Schmitt J et all. J Allergy Clin Immunol. 2016
19
ATOPIC DERMATITIS AND
AUTOIMMUNE DISEASES

20
Andersen YM, et all. J Am Acad Dermatol. 2017
ATOPIC DERMATITIS
AND OBESITY

Zhang A, Silverberg JI. J Am Acad Dermatol. 2015 21

ATOPIC DERMATITIS AND
ISCHEMIC STROKE

22
VYE Su et all Annals of Medicine, 2014
 ATOPIC DERMATITIS AND
CORONARY ARTERY DISEASE

23
Hjuler KF The American Journal of Medicine 2015
 DIFFERENTIAL DIAGNOSIS
Other types of dermatitis Congenital disorders
Non atopic eczema Ichthyosis vulgaris
Flexural eczema Netherton syndrome
Seborrhoeic dermatitis Peeling skin syndrome type B
Nummular dermatitis Skin dermatitis, multiple
Irritant contact dermatitis severe allergies, and
Allergic contact dermatitis metabolic wasting (SAM)
syndrome
Nutritional deficiency
Zinc deficiency Primary
immunodeficiencies
Infectious diseases Hyper-IgE syndrome
Dermatophyte infection Wiskott-Aldrich syndrome
Impetigo Omenn syndrome
Scabies
Infective dermatitis associated with
HTLV-1
Weidinger S, Novak N. Lancet. 2016 12;387(10023):11091122. Samuelov L, Sprecher E. J Allergy Clin Immunol.
24
2014;134(4):808-15. Hlela C, Bittencourt A. Dermatol Clin. 2014 ;32(2):237-48.
ATOPIC vs NON ATOPIC ECZEMA

AE Non AE
Number 146 100
Sex girls girls
Age of onset 1-2 years 12 years of
age or later
Evolution chronic chronic
Severity severe mild/moderate
flexural flexural
Localisation surfaces of the surfaces of the
extremities, extremities
ears, face
Sensitization 59, 3% 40,7%

Johansson EK, et all Br J Dermatol. 2015 25

 ATOPIC vs NON ATOPIC ECZEMA
Atopic eczema Non atopic eczema
Immune response Th2 Th1
Infiltration of Th17 and Th 22 Low High
Positive patch tests for metals Rare Frequent
Filaggrin mutations Frequent Rare
TEWL (transepidermal water loss) Increase Normal
Total Ig E Elevated Normal
Skin prick tests Positive Negative
Specific IgE antibodies Detectable Undetectable
Atopic family history Frequent Rare
Associated atopic diseases Frequent Very -rare
Itching High Low
Palmar hyperlinearity, keratosis pilaris, pityriasis alba +++ +
Dennie-Morgan’s fold + ++
Rożalski M et all. Acta Dermatovenerol Croat. 2016 26
 FLEXURAL DERMATITIS AND
DERMATOSES

Contact dermatitis (allergic, SRACD, Mycosis fungoides

SNAS,SDRIFE,irritant, protein) Netherton syndrome
Infantile seborrheic dermatitis Nummular dermatitis
Inverse psoriasis Nutritional deficiency (zinc, biotin)
Immunodeficiency syndromes Pemphigus vegetans
Lichen planus Tinea corporis
Hailey-Hailey disease Scabies
Acanthosis nigricans Soft fibromas
Molluscum dermatitis Xanthomatosis

Jacob SE et all. Dermatitis. 2015

 SYMMETRICAL DRUG-RELATED
INTERTRIGINOUS AND FLEXURAL
EXANTHEMA

Lora V et all. Pediatr Dermatol.2016 28

 INFECTIVE
DERMATITIS ASSOCIATED WITH
HTLV-1

29
Hlela C at all. Dermatol Clin. 2014
 DIFFERENTIAL DIAGNOSIS
Clinical Characteristic IDH AD
Age at onset From 18–24 mo onward After 3 monts
Atopy Absent Present
Pruritus Slight to moderate Severe
Skin lesions Erythematous-scaly lesions Erythematous and edematous
with yellow crusts, papules, papules and plaques, sometimes
retroauricular fissures, and with vesiculation, generally
generalized fine papular rash replaced by lichenification
Distribution Scalp, retroauricular areas, Elbow and knee flexures, sides of
external ear, eyelids margins, the neck, wrists, ankles, and
perinasal skin, neck, axillae, hands
and groin
Crusting on anterior nostrils Present Absent
S aureus infection Present Present
Ocular disease Present Present
Anemia Present Absent
White blood cell High Normal
Erythrocite sedimentation rate Elevated Normal
Serum proteins Abnormal Normal
Dermathopatic lymphadenopaty Present Absent
HTLV 1 Present Absent
Hlela C at all. Dermatol Clin. 2014 30
 CONCLUSIONS

• Hanifin and Rajka criteria are still the most communly used
diagnostic criteria

• Even now not all RCTs are using validated diagnostic criteria
wich makes comparisson of the results very difficult

• New diagnostic criteria were published since 2014

• Typical eczema, chronicity and history of atopy represent the

core diagostic elements of all criteria

• New data regarding different clinical phenotypes,

comorbidities and differential diagnosis were published since
2014
31