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Atopic Dermatitis

Practice Essentials

Atopic dermatitis (AD) is a chronic, pruritic inflammatory skin condition (see image below) that typically affects the face (cheeks), neck, arms, and legs but usually spares the groin and axillary regions. AD usually starts in early infancy, but also affects a substantial number of adults. AD is commonly associated with elevated levels of immunoglobulin E (IgE). That it is the first disease to present in a series of allergic diseases—including food allergy, asthma, and allergic rhinitis, in order—has given rise to the “atopic march” theory, which suggests that AD is part of a progression that may lead to subsequent allergic disease at other epithelial barrier surfaces.

Atopic dermatitis. Flexural involvement in childho

Atopic dermatitis. Flexural involvement in childhood atopic dermatitis.

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See All About Allergies: Be Ready for Spring, a Critical Images slideshow, to help identify a variety of allergens and symptoms.

Signs and symptoms of atopic dermatitis

Incessant pruritus (itchiness) is the only symptom of AD. The disease typically has an intermittent course with flares and remissions occurring, often for unexplained reasons.

Primary physical findings include the following:

Xerosis (dry skin)

Lichenification (thickening of the skin and an increase in skin markings)

Eczematous lesions (skin inflammation)

The eczematous changes and its morphology are seen in different locations, depending on the age of the patient (ie, infant, child, or adult).

The following is a constellation of symptoms and features commonly seen in AD:


Early age of onset

Chronic and relapsing course

IgE reactivity

Peripheral eosinophilia

Staphylococcus aureus superinfection

Personal history of asthma or hay fever or a history of atopic diseases in a first-degree relative

See Clinical Presentation for more detail.

Diagnosis of atopic dermatitis

The following features should be considered in the diagnosis of AD in accordance with the American Academy of Dermatology (AAD) 2014 Guidelines

Essential features (must be present) are as follows:


Eczema (acute, subacute, chronic): (1) Typical morphology and age-specific patterns (facial/neck/extensor involvement in children, flexural involvement in any age group, sparing the groin and axillary regions); (2) chronic or relapsing history

Important features (supports the diagnosis) are as follows:

Early age of onset

Atopy: (1) Personal and/or family history; (2) IgE reactivity


Associated features (nonspecific but suggest the diagnosis of AD) are as follows:

Atypical vascular responses (eg, facial pallor, delayed blanch response)

Keratosis pilaris/pityriasis alba/hyperlinear palms/ichthyosis

Ocular/periorbital changes

Other regional findings (eg, perioral changes/periauricular lesions)

Perifollicular accentuation/lichenification/prurigo

Exclusionary conditions (conditions that should be excluded) are as follows:


Seborrheic dermatitis

Contact dermatitis


Cutaneous T-cell lymphoma


Photosensitivity dermatoses

Immune deficiency diseases

Erythroderma of other causes

Additional considerations in the diagnosis of AD are as follows:

No reliable biomarker exists for the diagnosis of AD

Laboratory testing is seldom necessary but a complete blood cell count can be useful to exclude immune deficiency; an IgE level can be helpful to confirm an atopic pattern; a swab of skin can be helpful to identify S aureus superinfection

Allergy and radioallergosorbent testing is of little value

Biopsy shows an acute, subacute, or chronic spongiotic dermatitis pattern that is nonspecific but can be helpful to rule out other conditions (eg, cutaneous T-cell lymphoma)

See Workup for more detail.

Management of atopic dermatitis

Agents typically used to treat AD include the following:

Moisturizers: Petrolatum, Aquaphor, or newer agents such as Atopiclair and Mimyx

Topical steroids (current mainstay of treatment; commonly used in conjunction with moisturizers): Hydrocortisone, triamcinolone, or betamethasone; ointment bases are generally preferred, particularly in dry environments

Broad immunomodulators: Tacrolimus and pimecrolimus (calcineurin inhibitors; generally considered second-line therapy)

Targeted biologic therapies: Dupilumab (anti-IL-4Ra monoclonal antibody)

Other treatments that have been tried include the following:

Ultraviolet (UV)-A, UV-B, a combination of both, psoralen plus UV-A (PUVA), or UV-B1 (narrow-band UV-B) therapy

In severe disease, methotrexate, azathioprine, cyclosporine, and mycophenolate mofetil



Antibiotics for clinical infection caused by S aureus or flares of disease

Intranasal mupirocin ointment and diluted bleach (sodium hypochlorite) baths

Nonmedical measures that may be helpful include the following:

Using soft clothing (eg, cotton) next to the skin; wool products should be avoided

Maintaining mild temperatures, particularly at night

Using a humidifier (cool mist) in both winter and summer

Washing clothes in a mild detergent, with no bleach or fabric softener

Avoiding specific foods as appropriate if there is concomitant food allergy

See Treatment and Medication for more detail.

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