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Atopic dermatitis presents in a variety of manners depending on the patient's age. The infantile phase from ages 2 months to 2 years is characterized by intense itching, erythema, papules, vesicles, oozing and crusting. Patients typically develop eruptions over the cheeks, forehead, and scalp, with lesser involvement of the trunk or extremities. The diaper area is characteristically spared. The childhood phase presents in ages 3-11 years as more chronic, lichenified, scaly patches and plaques that may have crusting and oozing. Classic areas include those that bend such as the wrists, ankles, backs of the thighs, buttocks, and antecubital and popliteal fossae. The adolescent phase from ages 12-20 years is characterized by thick, dry, lichenified plaques without weeping, crusting, or oozing that involves the face, neck, upper arms, back and flexures. Adults more than 20 years of age are mostly afflicted by eczema of the hands, face and neck. Approximately 25% of cases of infantile or childhood atopic dermatitis persist as adult eczema. Other general physical findings include xerosis (dry, sensitive skin), keratosis pilaris, hyperlinear palms and soles, allergic "shiners" (dark and swollen eyes) and Dennie-Morgan lines which are a non-specific infraorbital fold seen in 60 to 80% of atopic patients. Atopic dermatitis occurs with higher frequency in industrialized nations and is very common especially in Caucasians and Chinese.

Differential diagnosis

Any disorder manifested as dermatitis can be included in the differential. This can include contact dermatitis, seborrheic dermatitis, scabies, nummular eczema, molluscum contagiosum.

Treatment

There is no "cure" for atopic dermatitis and management is aimed at treating the pruritis, xerosis, and inflammation. Maintaining a cool, humid environment, and avoiding nylon and wool clothing may be helpful to the child. The mainstays of initial therapy include moisturization and topical corticosteroid therapy in addition to antihistamines to ease the pruritus. If the dermatitis is severe, wet dressings can be used overnight. Secondary infections by bacteria such as Staphylococcus aureus or Streptococcus pyogenes should be treated with systemic antibiotics and infections by herpes simplex virus should be treated with oral herpes treatment. Once improvement has been accomplished, parents may substitute lubricants and emollients for the steroid ointments to improve skin barrier function. Newer therapies include the use of topical immunomodulators such as tacrolimus or pimecrolimus as maintenance therapy. Variables that exacerbate atopic dermatitis include drying of the skin, hot water and soaping of the skin, sweating, contact sensitivity, stress and anxiety, and secondary bacterial or herpes simplex virus infections and should be avoided. Parents should be counseled that despite the most meticulous care, patients can still have flare-ups.