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Chapter 5

Clinical Symptoms of Atopic Eczema
M. Deleuran, A. Braae Olesen, K. Thestrup-Pedersen

5.1
Introduction
Engman et al. defined atopic eczema as “itch that
rashes, not an itching rash” [1]. This brief definition
underscores that itch is the primary symptom of atopic
eczema and that scratching of the skin leads to eczema.
The definition would fit every atopic eczema child, but
would include more patients than we would accept
today.
The best summary of possible symptoms in atopic
eczema is included in the definition given by Hanifin
and Rajka [2], who described the major symptoms as
itch, chronic relapsing eczema, genetic predisposition,
dry skin, and the many minor symptoms (Fig. 5.1), as
listed in Table 5.1.
However, when doing regression analysis of the
minor symptoms, it was observed by the UK Working
Party for Atopic Dermatitis that a much simpler definition of the disease sustained a high sensitivity and
specificity [3]. This definition is listed in Table 5.2. The
set of criteria has been validated and shown to be useful. The interesting thing is that the only clinical sign
needed is visible flexural dermatitis (Fig. 5.2). The rest
are questions on history. Thus, this definition is excellent for epidemiological studies.
A third definition of atopic eczema puts IgE-mediated allergy as a requirement for the diagnosis [4], but
the definition has been criticized [5]. The presence of
type I allergy is low in infants and children, but
reaches 80 % of adults with atopic eczema [6]. This
forms the background for dividing atopic eczema into
extrinsic and intrinsic eczema [7], i. e. whether allergy
is present toward environmental allergens or not. It
should be stressed that the clinical symptoms of
extrinsic vs intrinsic eczema are the same except for
the allergy.

Table 5.1. Minor symptoms of atopic dermatitis (Hanifin and
Rajka [2])
Dry skin
Ichthyosis
Palmar hyperlinearity
Keratosis pilaris
Type I allergy and increased serum IgE
Hand and foot dermatitis
Cheilitis
Nipple eczema
Increased presence of Staphylococcus aureus and Herpes
simplex
Perifollicular keratosis
Pityriasis alba
Early age of onset
Recurrent conjunctivitis
Dennie-Morgan infraorbital fold
Keratoconus
Cataract
Orbital darkening
Facial pallor/facial erythema
Anterior neck folds
Itch when sweating
Intolerance to wool and lipid solvents
Perifollicular accentuation
Food intolerance
Course influenced by environmental and emotional factors
White dermographism or delayed blanch

Table 5.2. UK Working Party’s diagnostic criteria for atopic
dermatitis [3]
History of flexural dermatitis
Onset under the age of 2 years
Presence of an itchy rash
Personal history of asthma
History of dry skin
Visible flexural dermatitis

5
38

5 Clinical Symptoms of Atopic Eczema

Fig. 5.1. An infant with xerosis of the forehead and scalp combined with erythema. Similar eczematous changes are present
on the cheeks. He has infraorbital or Morgan’s folds. Yamamoto’s sign is the lack of eczema on the tip of the nose

Fig. 5.2. Typical flexural eczema that is not well marked is
another feature of atopic eczema. Note the excoriated small
papules and longer scratch marks

Figure 5.1 shows atopic eczema. It illustrates many
facts about the disease: the xerosis, erythema, facial
eczema as a typical location, and the fact that atopic
eczema develops in infancy. It also shows Yamamoto’s
sign: the skin on the tip of the nose is never (or almost
never) involved in atopic eczema.

5.2
Evolution of Atopic Eczema

Fig. 5.3. Typical truncal dermatitis in an infant with atopic
eczema. Note that the eczema has no well-marked borders, but
does contain nummular eczema elements. These elements are
excoriated

Atopic eczema starts in the scalp and spreads in a craniocaudal direction to involve the face, the neck, the
upper extremities, the trunk, and the lower extremities
(Figs. 5.1 – 5.3). The cheeks are most commonly affected in infants, whereas antecubital and popliteal eczema
is common in children. Severe atopic eczema will
involve all regions, but mild eczema tends to stay in the
scalp-face-neck regions only. The areas affected are
those where the epidermis is thin and penetration of
irritants, infective agents and/or superantigens, and/or
allergens have the most easy access to the immune system (Fig. 5.1, Table 5.2).
5.3 Course of Atopic Eczema

5.3
Course of Atopic Eczema

Fig. 5.4. Very early atopic eczema, where a differential diagnosis of seborrhoic eczema could be discussed. However, the
course showed atopic eczema. This is the typical location for
the first symptoms of atopic eczema

Atopic eczema is not present at birth, but can develop
within the first weeks of infancy. It develops in 90 % of
subjects before the age of 4 years [8]. It is an early-life
event. A Scottish study showed that the 1-year prevalence among infants is almost equal to the point prevalence, but after the age of 2 this changes dramatically as
the 1-year prevalence among 2- to 11-year-old children
was around 9 %, whereas the point prevalence was
approximately 2.5 % [9]. Thus, from age 2 to 11 years,
atopic eczema either disappears, which may happen
among one-fifth of children, or it becomes a fluctuating
disease, where approximately two-thirds of the children
grow out of their disease before the teenage years [10].
Gender differences have been claimed, but they
depend on the age of the child. Boys develop atopic
eczema at an earlier age than girls [11].
The course of atopic eczema is thus one of almost
constant eczema in infancy (infantile eczema) followed
by a year-long period in which the eczema comes and
goes and disappears among two-thirds or even more
before the teenage years (childhood eczema). Docu-

Fig. 5.5. Cheilitis in a patient with atopic eczema of the papulous type
Fig. 5.6. Severe adult atopic eczema with lichenification of the
skin. Note the pustules and the scratch marks of papules

39
40

5 Clinical Symptoms of Atopic Eczema

mentation for the continuation or relapse of atopic
eczema into adulthood is not good, but roughly 15 % –
25 % will have eczema in their early twenties (adolescent and young adult atopic eczema). Atopic eczema in
adulthood is rare, but if present the symptoms are
often very pronounced and persistent (Fig. 5.6) [12].
The course and severity are coherent. Severe eczema
develops early in life, is more constantly present and
lasts longer. Eczema severity has a wide range: 10 %–
15 % of infants or children have severe eczema, 30 %–
40 % moderate eczema, and the rest has mild eczema
[13].

5.4
Some Typical Clinical Features
5.4.1
The Itch
The sensation of itch is the major symptom of atopic
eczema. From week 6 – 8, infants show symptoms of
itch by grabbing their skin with the fingers to scratch.
Itching is present during sleep and often leads to sleep
disturbances, where the child wakes up crying after 1 h
of sleep.
The excoriation in atopic eczema is one of damaging
the epidermis, i.e. it leaves scratch marks (Fig. 5.6, 5.7) –
an observation completely different with the reaction to
urticarial itch, where patients rub their skin without
leaving excoriations. The physical damage to the skin

can induce eczema and over time will explain the development of papules and finally lichenification (Fig. 5.6).
Itch is not a constant symptom. In the morning, itch
is not prominent. But when the child gets tired in the
afternoon then attacks of itch start. The child becomes
irritable, cries, misbehaves, and this often leads to
clashes between the parent(s) and the child, which can
be most distressing for the parents.
The following are a few stories on how adult patients
and a parent react to itch:
) “When I have my itch attacks I feel like I’m inside
a shell. I can hear what people are saying to me,
but I cannot think or respond as the itch is overwhelming me.”
) “When I have severe itch attacks in the evening,
I go outside, sit down, sometimes read a book –
until my skin feels like I have been sitting in the
fridge. Then I am fine for 1 or 2 hours.”
) “When my daughter is severely itching in the evening, I take a blanket, put it in the freezer for half
an hour, and put it on top of her bed sheet. The
cooling effect relieves her itch significantly.”
) “The silliest thing you can say to a person itching
is stop scratching.”
Itch is thus most prominent in the afternoon and evening, when the child or adult is tired. Itch is provoked
by heat. These simple observations are important as
treatment should preferably be given in the afternoon
(application of topical steroids or calcineurin inhibitors, whereas emollients are sufficient in the morning).
There is an association between increased stress and
increased itch, but its pathophysiological relation is
unknown.
5.4.2
Other Clinical Symptoms

Fig. 5.7. Atopic eczema on an upper extremity of an infant. Here
the eczema is slightly oozing – wet eczema – which is an indication of superinfection with Staphylococcus aureus. Note the
pronounced scratch marks

Table 5.3 lists 18 signs in atopic eczema and how these
symptoms were scored by seven dermatologists evaluating the same patients. Substantial agreement was
only found for truncal dermatitis [14]. This observation underlines our difficulties in estimating and scoring symptoms of atopic eczema.
In Germany, the diagnosis of eczema infantum is
sometimes used if an infant has skin changes compatible with eczema, but which are not classical of atopic
eczema. Approximately three-fourths of these infants
later develop atopic eczema [15].
5.4 Some Typical Clinical Features
Table 5.3. Interobserver agreement for 17 signs in atopic eczema
when scored by seven experienced dermatologists [14]
Agreement

Clinical symptom

Substantial

Truncal dermatitis

Moderate

Facial dermatitis, flexural dermatitis, hand/
foot dermatitis, hypopigmented patches,
orbital fold, periorbital dermatitis, ear fissure, hyperlinear palms

Fair

Follicular accentuation, perioral dermatitis,
cheilitis

Slight

Keratosis pilaris, periorbital pigmentation,
extensor dermatitis (visible), dry skin,
fine hair

It is typical that the borders of eczematous skin are ill
defined and that it tapers off into normal-looking skin.
However, even in normal-looking skin there is an increase in lymphocytes [16], meaning that atopic eczema
likely involves more than what is clinically perceptible.
Although the UK definition of atopic eczema only
has “visible flexural dermatitis” as a clinical requirement, there are many signs which support the diagnosis of eczema. The figures illustrate these signs
(Fig. 5.5, 5.8, 5.9). The typical lesions are erythema,
xerosis without true scaling, and vesicles which are
almost always excoriated and ill-defined borders. However, there are other forms of atopic eczema such as
papulous atopic eczema, as seen in Fig. 5.11, nummular
eczema as seen in Fig. 5.3, and impetiginous eczema as
also seen in Figs. 5.9, 5.11. The excoriations lead to
lichenification as seen in Fig. 5.6.
One clinical symptom which is likely underdiagnosed are urticarial rashes, which come quickly and
also disappear quickly. It is our guess that 15 % of children actually have these urticarial rashes and will benefit from antihistamines.
There are distinct features of atopic eczema beyond
those described above. Keratosis pilaris is commonly
seen on the extensor sides of the upper arms, as is pityriasis alba. Again, the list of symptoms in Hanifin and
Rajka’s definition (Table 5.1) covers special symptoms
of atopic eczema well. Atopic winter feet is a condition
with erythema, scaling and fissuring of the soles, mostly on the anterior part of the foot. The name stems from
the symptoms being most pronounced during winter.
It occurs in children and is difficult to treat. Toilet seat
eczema, with nummular eczema in the pressure area
on the buttocks and thighs, is also frequently observed.

Fig. 5.8. A typical location of atopic eczema is behind the ears
with a tendency toward fissuring skin at the lower end of the
earlobe

Fig. 5.9. Severe atopic eczema, especially as periorbital eczema,
with oozing and crust formation as signs of secondary infection. Note Yamamoto’s sign, i.e., no eczema on the tip of the
nose

41
42

5 Clinical Symptoms of Atopic Eczema

a

Fig. 5.10. Same patient as in Fig. 5.5. Note how excoriated papules are a prominent clinical symptom of his atopic eczema.
Given his African background, he develops intensive hyperpigmentation due to scratching of the skin

Fig. 5.11. The nummular type of atopic eczema with oozing as
a sign of secondary infection, also called impetiginous eczema
b

5.5
Atopic Eczema in the Adult Patient

Fig. 5.12a, b. Head-and-neck-dermatitis in a patient who most
of the time suffered from severe universal atopic eczema

Adults with atopic eczema normally have moderate to
severe eczema. A particular form is the head-and-neck
eczema as illustrated in Fig. 5.12. It has been related to
allergy to Pityrosporum ovale (now termed Malassezia
furfur) [17]. Systemic antifungal therapy has been
proven of value by some authors, but experience is

mixed. The head-and-neck eczema carries a high risk
for persistence of eczema, which occurs among 59 % of
adult patients [12]. Severe atopic eczema going toward
exfoliative dermatitis is fortunately uncommon
(Fig. 5.13). These patients need intensive systemic
immunosuppressive therapy. Complications are com-
5.8 Conclusion

mon, in particular impetiginized eczema. A rarer, but
serious event is eczema herpeticum (Fig. 5.14). This
can occur in children, but is rare.

5.6
The Prognosis of Atopic Eczema

Fig. 5.13. Exfoliative erythrodermia in an adult with life-long
atopic eczema and given vitamin C intravenously as an antioxidative therapy. It took 6 weeks on systemic prednisone to subdue his eczema

There are a number of dermatological diseases, which
tend to evolve on an atopic eczema background. Up to
40 % of adults with previous atopic eczema develop
hand eczema, most often of the irritant contact eczema
type [18]. Of patients developing dyshidrotic eczema
or pompholyx, 50 % have had atopic eczema previously
[19]. Nummular eczema is often associated with previous atopic eczema. Thus, a child with atopic eczema
has an altered immune system and is liable to experience inflammatory skin diseases later in life.
The only exclusive disease of atopic eczema may be
psoriasis [20], which is surprising as there seem to be
common inflammatory gene loci among the two disorders [21]. However, this exclusion has been questioned
[22, 23].

5.7
Atopic Eczema and Differential Diagnoses
Many physiological skin changes are present in early
infancy – from the scaling scalp of the newborn (arp),
seborrhoic eczema, diaper dermatitis, or xerotic changes
of temporary occurrence, to the flushing or urticarial
changes of early infancy, and viral exanthemas. Scabies
can resemble atopic eczema. Rare cases of Jadassohn’s
psoriatic dermatitis should not be confused with atopic
eczema as ichthyosis. Children with severe combined
immunodeficiency may develop eczema-like changes,
and Netherton’s syndrome resembles atopic eczema.

5.8
Conclusion

Fig. 5.14. 15-year-old girl who had previously suffered from
atopic eczema. Her boyfriend had herpes simplex and she
developed severe eczema herpeticum even though she did not
have atopic eczema just prior to this event. She later had a flare
up of atopic eczema upon activation of her immune system

Atopic eczema is a clinical diagnosis based on visible
eczema with a characteristic history. There are no diagnostic tests that can confirm the diagnosis. It is up to
the individual physician to learn about its symptoms,
which is again a prerequisite for giving the proper and
correct treatment.

43
44

5 Clinical Symptoms of Atopic Eczema

References
1. Engman MF, Weiss RS, Engman ME (1936) Eczema and
environment. Med Clin North Am 20:651-663
2. Hanifin JM, Rajka G (1980) Diagnostic features of atopic
dermatitis. Acta Derm Venereol (Stockh) Suppl 92:44 – 47
3. Williams HC, Burney PGJ, Hay RJ, Archer CB, Shipley MJ,
Hunter JJA, Bingham EA, Finlay AY et al. (1994) The UK
Working party’s diagnostic criteria for atopic dermatitis. I.
Derivation of a minimum set of discriminators for atopic
dermatitis. Br J Dermatol 131:383 – 396
4. Bos JD, Van Leent EJ Sillevis Smitt JH (1998) The millennium criteria for the diagnosis of atopic dermatitis. Exp Dermatol 7:132 – 138
5. Eedy DJ (2001) What is new in atopic dermatitis? Br J Dermatol 145:380 – 384
6. Rudzki E, Litweska D (1990) RAST and PRIST in children
with atopic dermatitis. Dermatologica 180: 82 – 85
7. Wuthrich B, Schmid-Grendelmeier P (2003) The atopic
eczema/dermatitis syndrome. Epidemiology, natural
course, and immunology of the IgE-associated (“extrinsic”) and the nonallergic (“intrinsic”) AEDS. J Invest Allergol Clin Immunol 13:1 – 5
8. Olesen AB, Ellingsen AR, Larsen FS, Larsen PO, Veien NK,
Thestrup-Pedersen K (1996) Atopic dermatitis may be
linked to whether a child is first- or second-born and/or
the age of the mother. Acta Derm Venereol (Stockh)
76:457 –460
9. Herd RM, Ridman TJ, Prescott RJ, Hunter JA (1996) Prevalence of atopic eczema in the community: the Lothian
Atopic Dermatitis study. Br J Dermatol 135:18 – 19
10. Williams HC, Strachan DP (1998) The natural history of
childhood eczema: observations from the British 1958
birth cohort study. Br J Dermatol 139:834 – 839
11. Bohme M, Lannero E, Wickman M, Nordvall SL, Wahlgren
CF (2002) Atopic dermatitis and concomitant disease pattern in children up to two years of age. Acta Derm Venereol
82:98 – 103
12. Sandstrom MH, Faergemann J (2004) Prognosis and prognostic factors in adult patients with atopic dermatitis: a

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long-term follow-up questionnaire study. Br J Dermatol
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Olesen AB, Bang K, Juul S, Thestrup-Pedersen K (2005)
Stable incidence of atopic dermatitis among children in
Denmark during the 1990s. Acta Derm Venereol 85: 244 –
247
Williams HC, Burney PGJ, Hay RJ, Strachan D, Hay RJ
(1994) The U. K. Working party’s diagnostic criteria for
atopic dermatitis. II. Observer variation of clinical diagnosis and signs of atopic dermatitis. Br J Dermatol 131:397 –
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Fölster-Holst R, Weichenthal M, Steinsland K, Polzhofer G,
Christophers E (2004) Eczema infantum and its prognosis.
Acta Derm Venereol 84:410 – 412
Ellingsen AR, Sorensen FB, Larsen JO, Deleuran MS, Thestrup-Pedersen K (2001) Stereological quantification of
lymphocytes in skin biopsies from atopic dermatitis
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Johansson C, Sandstrom MH, Bartosik J, Sarnhult T, Christiansen J, Zargari A, Back O, Wahlgren CF, Faergemann J,
Scheynius A, Tengvall Linder M (2003) Atopy patch test
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Rystedt I (1985) Work-related hand eczema in atopics.
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of Atopic Eczema (this volume)

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Clinical symptoms of eczema

  • 1. Chapter 5 Clinical Symptoms of Atopic Eczema M. Deleuran, A. Braae Olesen, K. Thestrup-Pedersen 5.1 Introduction Engman et al. defined atopic eczema as “itch that rashes, not an itching rash” [1]. This brief definition underscores that itch is the primary symptom of atopic eczema and that scratching of the skin leads to eczema. The definition would fit every atopic eczema child, but would include more patients than we would accept today. The best summary of possible symptoms in atopic eczema is included in the definition given by Hanifin and Rajka [2], who described the major symptoms as itch, chronic relapsing eczema, genetic predisposition, dry skin, and the many minor symptoms (Fig. 5.1), as listed in Table 5.1. However, when doing regression analysis of the minor symptoms, it was observed by the UK Working Party for Atopic Dermatitis that a much simpler definition of the disease sustained a high sensitivity and specificity [3]. This definition is listed in Table 5.2. The set of criteria has been validated and shown to be useful. The interesting thing is that the only clinical sign needed is visible flexural dermatitis (Fig. 5.2). The rest are questions on history. Thus, this definition is excellent for epidemiological studies. A third definition of atopic eczema puts IgE-mediated allergy as a requirement for the diagnosis [4], but the definition has been criticized [5]. The presence of type I allergy is low in infants and children, but reaches 80 % of adults with atopic eczema [6]. This forms the background for dividing atopic eczema into extrinsic and intrinsic eczema [7], i. e. whether allergy is present toward environmental allergens or not. It should be stressed that the clinical symptoms of extrinsic vs intrinsic eczema are the same except for the allergy. Table 5.1. Minor symptoms of atopic dermatitis (Hanifin and Rajka [2]) Dry skin Ichthyosis Palmar hyperlinearity Keratosis pilaris Type I allergy and increased serum IgE Hand and foot dermatitis Cheilitis Nipple eczema Increased presence of Staphylococcus aureus and Herpes simplex Perifollicular keratosis Pityriasis alba Early age of onset Recurrent conjunctivitis Dennie-Morgan infraorbital fold Keratoconus Cataract Orbital darkening Facial pallor/facial erythema Anterior neck folds Itch when sweating Intolerance to wool and lipid solvents Perifollicular accentuation Food intolerance Course influenced by environmental and emotional factors White dermographism or delayed blanch Table 5.2. UK Working Party’s diagnostic criteria for atopic dermatitis [3] History of flexural dermatitis Onset under the age of 2 years Presence of an itchy rash Personal history of asthma History of dry skin Visible flexural dermatitis 5
  • 2. 38 5 Clinical Symptoms of Atopic Eczema Fig. 5.1. An infant with xerosis of the forehead and scalp combined with erythema. Similar eczematous changes are present on the cheeks. He has infraorbital or Morgan’s folds. Yamamoto’s sign is the lack of eczema on the tip of the nose Fig. 5.2. Typical flexural eczema that is not well marked is another feature of atopic eczema. Note the excoriated small papules and longer scratch marks Figure 5.1 shows atopic eczema. It illustrates many facts about the disease: the xerosis, erythema, facial eczema as a typical location, and the fact that atopic eczema develops in infancy. It also shows Yamamoto’s sign: the skin on the tip of the nose is never (or almost never) involved in atopic eczema. 5.2 Evolution of Atopic Eczema Fig. 5.3. Typical truncal dermatitis in an infant with atopic eczema. Note that the eczema has no well-marked borders, but does contain nummular eczema elements. These elements are excoriated Atopic eczema starts in the scalp and spreads in a craniocaudal direction to involve the face, the neck, the upper extremities, the trunk, and the lower extremities (Figs. 5.1 – 5.3). The cheeks are most commonly affected in infants, whereas antecubital and popliteal eczema is common in children. Severe atopic eczema will involve all regions, but mild eczema tends to stay in the scalp-face-neck regions only. The areas affected are those where the epidermis is thin and penetration of irritants, infective agents and/or superantigens, and/or allergens have the most easy access to the immune system (Fig. 5.1, Table 5.2).
  • 3. 5.3 Course of Atopic Eczema 5.3 Course of Atopic Eczema Fig. 5.4. Very early atopic eczema, where a differential diagnosis of seborrhoic eczema could be discussed. However, the course showed atopic eczema. This is the typical location for the first symptoms of atopic eczema Atopic eczema is not present at birth, but can develop within the first weeks of infancy. It develops in 90 % of subjects before the age of 4 years [8]. It is an early-life event. A Scottish study showed that the 1-year prevalence among infants is almost equal to the point prevalence, but after the age of 2 this changes dramatically as the 1-year prevalence among 2- to 11-year-old children was around 9 %, whereas the point prevalence was approximately 2.5 % [9]. Thus, from age 2 to 11 years, atopic eczema either disappears, which may happen among one-fifth of children, or it becomes a fluctuating disease, where approximately two-thirds of the children grow out of their disease before the teenage years [10]. Gender differences have been claimed, but they depend on the age of the child. Boys develop atopic eczema at an earlier age than girls [11]. The course of atopic eczema is thus one of almost constant eczema in infancy (infantile eczema) followed by a year-long period in which the eczema comes and goes and disappears among two-thirds or even more before the teenage years (childhood eczema). Docu- Fig. 5.5. Cheilitis in a patient with atopic eczema of the papulous type Fig. 5.6. Severe adult atopic eczema with lichenification of the skin. Note the pustules and the scratch marks of papules 39
  • 4. 40 5 Clinical Symptoms of Atopic Eczema mentation for the continuation or relapse of atopic eczema into adulthood is not good, but roughly 15 % – 25 % will have eczema in their early twenties (adolescent and young adult atopic eczema). Atopic eczema in adulthood is rare, but if present the symptoms are often very pronounced and persistent (Fig. 5.6) [12]. The course and severity are coherent. Severe eczema develops early in life, is more constantly present and lasts longer. Eczema severity has a wide range: 10 %– 15 % of infants or children have severe eczema, 30 %– 40 % moderate eczema, and the rest has mild eczema [13]. 5.4 Some Typical Clinical Features 5.4.1 The Itch The sensation of itch is the major symptom of atopic eczema. From week 6 – 8, infants show symptoms of itch by grabbing their skin with the fingers to scratch. Itching is present during sleep and often leads to sleep disturbances, where the child wakes up crying after 1 h of sleep. The excoriation in atopic eczema is one of damaging the epidermis, i.e. it leaves scratch marks (Fig. 5.6, 5.7) – an observation completely different with the reaction to urticarial itch, where patients rub their skin without leaving excoriations. The physical damage to the skin can induce eczema and over time will explain the development of papules and finally lichenification (Fig. 5.6). Itch is not a constant symptom. In the morning, itch is not prominent. But when the child gets tired in the afternoon then attacks of itch start. The child becomes irritable, cries, misbehaves, and this often leads to clashes between the parent(s) and the child, which can be most distressing for the parents. The following are a few stories on how adult patients and a parent react to itch: ) “When I have my itch attacks I feel like I’m inside a shell. I can hear what people are saying to me, but I cannot think or respond as the itch is overwhelming me.” ) “When I have severe itch attacks in the evening, I go outside, sit down, sometimes read a book – until my skin feels like I have been sitting in the fridge. Then I am fine for 1 or 2 hours.” ) “When my daughter is severely itching in the evening, I take a blanket, put it in the freezer for half an hour, and put it on top of her bed sheet. The cooling effect relieves her itch significantly.” ) “The silliest thing you can say to a person itching is stop scratching.” Itch is thus most prominent in the afternoon and evening, when the child or adult is tired. Itch is provoked by heat. These simple observations are important as treatment should preferably be given in the afternoon (application of topical steroids or calcineurin inhibitors, whereas emollients are sufficient in the morning). There is an association between increased stress and increased itch, but its pathophysiological relation is unknown. 5.4.2 Other Clinical Symptoms Fig. 5.7. Atopic eczema on an upper extremity of an infant. Here the eczema is slightly oozing – wet eczema – which is an indication of superinfection with Staphylococcus aureus. Note the pronounced scratch marks Table 5.3 lists 18 signs in atopic eczema and how these symptoms were scored by seven dermatologists evaluating the same patients. Substantial agreement was only found for truncal dermatitis [14]. This observation underlines our difficulties in estimating and scoring symptoms of atopic eczema. In Germany, the diagnosis of eczema infantum is sometimes used if an infant has skin changes compatible with eczema, but which are not classical of atopic eczema. Approximately three-fourths of these infants later develop atopic eczema [15].
  • 5. 5.4 Some Typical Clinical Features Table 5.3. Interobserver agreement for 17 signs in atopic eczema when scored by seven experienced dermatologists [14] Agreement Clinical symptom Substantial Truncal dermatitis Moderate Facial dermatitis, flexural dermatitis, hand/ foot dermatitis, hypopigmented patches, orbital fold, periorbital dermatitis, ear fissure, hyperlinear palms Fair Follicular accentuation, perioral dermatitis, cheilitis Slight Keratosis pilaris, periorbital pigmentation, extensor dermatitis (visible), dry skin, fine hair It is typical that the borders of eczematous skin are ill defined and that it tapers off into normal-looking skin. However, even in normal-looking skin there is an increase in lymphocytes [16], meaning that atopic eczema likely involves more than what is clinically perceptible. Although the UK definition of atopic eczema only has “visible flexural dermatitis” as a clinical requirement, there are many signs which support the diagnosis of eczema. The figures illustrate these signs (Fig. 5.5, 5.8, 5.9). The typical lesions are erythema, xerosis without true scaling, and vesicles which are almost always excoriated and ill-defined borders. However, there are other forms of atopic eczema such as papulous atopic eczema, as seen in Fig. 5.11, nummular eczema as seen in Fig. 5.3, and impetiginous eczema as also seen in Figs. 5.9, 5.11. The excoriations lead to lichenification as seen in Fig. 5.6. One clinical symptom which is likely underdiagnosed are urticarial rashes, which come quickly and also disappear quickly. It is our guess that 15 % of children actually have these urticarial rashes and will benefit from antihistamines. There are distinct features of atopic eczema beyond those described above. Keratosis pilaris is commonly seen on the extensor sides of the upper arms, as is pityriasis alba. Again, the list of symptoms in Hanifin and Rajka’s definition (Table 5.1) covers special symptoms of atopic eczema well. Atopic winter feet is a condition with erythema, scaling and fissuring of the soles, mostly on the anterior part of the foot. The name stems from the symptoms being most pronounced during winter. It occurs in children and is difficult to treat. Toilet seat eczema, with nummular eczema in the pressure area on the buttocks and thighs, is also frequently observed. Fig. 5.8. A typical location of atopic eczema is behind the ears with a tendency toward fissuring skin at the lower end of the earlobe Fig. 5.9. Severe atopic eczema, especially as periorbital eczema, with oozing and crust formation as signs of secondary infection. Note Yamamoto’s sign, i.e., no eczema on the tip of the nose 41
  • 6. 42 5 Clinical Symptoms of Atopic Eczema a Fig. 5.10. Same patient as in Fig. 5.5. Note how excoriated papules are a prominent clinical symptom of his atopic eczema. Given his African background, he develops intensive hyperpigmentation due to scratching of the skin Fig. 5.11. The nummular type of atopic eczema with oozing as a sign of secondary infection, also called impetiginous eczema b 5.5 Atopic Eczema in the Adult Patient Fig. 5.12a, b. Head-and-neck-dermatitis in a patient who most of the time suffered from severe universal atopic eczema Adults with atopic eczema normally have moderate to severe eczema. A particular form is the head-and-neck eczema as illustrated in Fig. 5.12. It has been related to allergy to Pityrosporum ovale (now termed Malassezia furfur) [17]. Systemic antifungal therapy has been proven of value by some authors, but experience is mixed. The head-and-neck eczema carries a high risk for persistence of eczema, which occurs among 59 % of adult patients [12]. Severe atopic eczema going toward exfoliative dermatitis is fortunately uncommon (Fig. 5.13). These patients need intensive systemic immunosuppressive therapy. Complications are com-
  • 7. 5.8 Conclusion mon, in particular impetiginized eczema. A rarer, but serious event is eczema herpeticum (Fig. 5.14). This can occur in children, but is rare. 5.6 The Prognosis of Atopic Eczema Fig. 5.13. Exfoliative erythrodermia in an adult with life-long atopic eczema and given vitamin C intravenously as an antioxidative therapy. It took 6 weeks on systemic prednisone to subdue his eczema There are a number of dermatological diseases, which tend to evolve on an atopic eczema background. Up to 40 % of adults with previous atopic eczema develop hand eczema, most often of the irritant contact eczema type [18]. Of patients developing dyshidrotic eczema or pompholyx, 50 % have had atopic eczema previously [19]. Nummular eczema is often associated with previous atopic eczema. Thus, a child with atopic eczema has an altered immune system and is liable to experience inflammatory skin diseases later in life. The only exclusive disease of atopic eczema may be psoriasis [20], which is surprising as there seem to be common inflammatory gene loci among the two disorders [21]. However, this exclusion has been questioned [22, 23]. 5.7 Atopic Eczema and Differential Diagnoses Many physiological skin changes are present in early infancy – from the scaling scalp of the newborn (arp), seborrhoic eczema, diaper dermatitis, or xerotic changes of temporary occurrence, to the flushing or urticarial changes of early infancy, and viral exanthemas. Scabies can resemble atopic eczema. Rare cases of Jadassohn’s psoriatic dermatitis should not be confused with atopic eczema as ichthyosis. Children with severe combined immunodeficiency may develop eczema-like changes, and Netherton’s syndrome resembles atopic eczema. 5.8 Conclusion Fig. 5.14. 15-year-old girl who had previously suffered from atopic eczema. Her boyfriend had herpes simplex and she developed severe eczema herpeticum even though she did not have atopic eczema just prior to this event. She later had a flare up of atopic eczema upon activation of her immune system Atopic eczema is a clinical diagnosis based on visible eczema with a characteristic history. There are no diagnostic tests that can confirm the diagnosis. It is up to the individual physician to learn about its symptoms, which is again a prerequisite for giving the proper and correct treatment. 43
  • 8. 44 5 Clinical Symptoms of Atopic Eczema References 1. Engman MF, Weiss RS, Engman ME (1936) Eczema and environment. Med Clin North Am 20:651-663 2. Hanifin JM, Rajka G (1980) Diagnostic features of atopic dermatitis. Acta Derm Venereol (Stockh) Suppl 92:44 – 47 3. Williams HC, Burney PGJ, Hay RJ, Archer CB, Shipley MJ, Hunter JJA, Bingham EA, Finlay AY et al. (1994) The UK Working party’s diagnostic criteria for atopic dermatitis. I. Derivation of a minimum set of discriminators for atopic dermatitis. Br J Dermatol 131:383 – 396 4. Bos JD, Van Leent EJ Sillevis Smitt JH (1998) The millennium criteria for the diagnosis of atopic dermatitis. Exp Dermatol 7:132 – 138 5. Eedy DJ (2001) What is new in atopic dermatitis? Br J Dermatol 145:380 – 384 6. Rudzki E, Litweska D (1990) RAST and PRIST in children with atopic dermatitis. Dermatologica 180: 82 – 85 7. Wuthrich B, Schmid-Grendelmeier P (2003) The atopic eczema/dermatitis syndrome. Epidemiology, natural course, and immunology of the IgE-associated (“extrinsic”) and the nonallergic (“intrinsic”) AEDS. J Invest Allergol Clin Immunol 13:1 – 5 8. Olesen AB, Ellingsen AR, Larsen FS, Larsen PO, Veien NK, Thestrup-Pedersen K (1996) Atopic dermatitis may be linked to whether a child is first- or second-born and/or the age of the mother. Acta Derm Venereol (Stockh) 76:457 –460 9. Herd RM, Ridman TJ, Prescott RJ, Hunter JA (1996) Prevalence of atopic eczema in the community: the Lothian Atopic Dermatitis study. Br J Dermatol 135:18 – 19 10. Williams HC, Strachan DP (1998) The natural history of childhood eczema: observations from the British 1958 birth cohort study. Br J Dermatol 139:834 – 839 11. Bohme M, Lannero E, Wickman M, Nordvall SL, Wahlgren CF (2002) Atopic dermatitis and concomitant disease pattern in children up to two years of age. Acta Derm Venereol 82:98 – 103 12. Sandstrom MH, Faergemann J (2004) Prognosis and prognostic factors in adult patients with atopic dermatitis: a 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. long-term follow-up questionnaire study. Br J Dermatol 150:103 – 110 Olesen AB, Bang K, Juul S, Thestrup-Pedersen K (2005) Stable incidence of atopic dermatitis among children in Denmark during the 1990s. Acta Derm Venereol 85: 244 – 247 Williams HC, Burney PGJ, Hay RJ, Strachan D, Hay RJ (1994) The U. K. Working party’s diagnostic criteria for atopic dermatitis. II. Observer variation of clinical diagnosis and signs of atopic dermatitis. Br J Dermatol 131:397 – 405 Fölster-Holst R, Weichenthal M, Steinsland K, Polzhofer G, Christophers E (2004) Eczema infantum and its prognosis. Acta Derm Venereol 84:410 – 412 Ellingsen AR, Sorensen FB, Larsen JO, Deleuran MS, Thestrup-Pedersen K (2001) Stereological quantification of lymphocytes in skin biopsies from atopic dermatitis patients. Acta Derm Venereol (Stockh) 81:258 – 262 Johansson C, Sandstrom MH, Bartosik J, Sarnhult T, Christiansen J, Zargari A, Back O, Wahlgren CF, Faergemann J, Scheynius A, Tengvall Linder M (2003) Atopy patch test reactions to Malassezia allergens differentiate subgroups of atopic dermatitis patients. Br J Dermatol 148:479 – 488 Rystedt I (1985) Work-related hand eczema in atopics. Contact Dermatitis 12: 164 – 171 Lodi A, Betti R, Chiarelli G, Urbani CE, Crosti C (1992) Epidemiological, clinical and allergological observations on pompholyx. Contact Dermatitis 26:17 – 21 Christophers E, Henseler T (1987) Contrasting disease patterns in psoriasis and atopic dermatitis. Arch) Dermatol) Res) 279 [Suppl]:S48–S51 Bowcock AM, Cookson WO (2004) The genetics of psoriasis, psoriatic arthritis and atopic dermatitis. Hum Mol Genet 13 [Suppl 1]:R43–R55 Williams HC, Strachan DP (1994) Psoriasis and eczema are not mutually exclusive diseases. Dermatology 189:238 – 240 Olesen AB (2005) Diseases rarely associated with atopic eczema. In: Ring J, Przybilla B, Ruzicka T (eds) Handbook of Atopic Eczema (this volume)