Guidelines for the diagnosis and assessment of eczema

Author: Dr Diana Purvis, Paediatric Dermatologist, Starship Hospital, Auckland, New Zealand, September 2014.


This document incorporates and summarises guidelines recently published by the American Academy of Dermatology [1] and the British Association of Dermatologists [2]. It is relevant to the treatment of eczema in New Zealand.

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Definition

Eczema is a chronic inflammatory skin disease that affects about 20% of children [3,4] and 3% of adults. It is characterized by pruritus, scratching, and eczematous lesions (dry, scaling and crusted areas of skin), and when chronic may be associated with lichenification (thickening) and pigmentary changes. It follows a relapsing course with flares at varying frequency and periods of remission. Eczema is also known as atopic eczema, or atopic dermatitis (eczema).

Background

  • Onset occurs mostly between 3 and 6 months, with about 60% developing the condition before 1 year and 90% by 5 years of age.
  • Most patients have elevated serum immunoglobulin (IgE) levels and a personal or immediate family history of atopy (type I allergies, allergic rhinitis, and asthma).

Diagnosis

The diagnosis of eczema is based on patient history and clinical/physical examination. Features to consider when making a diagnosis are summarized in the following tables.

American Academy of Dermatology[1]
Diagnostic features for eczema
Essential features
Must be present
  • Pruritus
  • Eczema (acute, subacute, chronic)
    • Chronic or relapsing history
    • Typical morphology and age-specific patterns
      • Facial, neck, and extensor involvement in infants and children
      • Current or previous flexural lesions at any age
      • Sparing of the groin and axillary regions
Important features
Seen in most cases, adding support to the diagnosis
  • Early age of onset
  • Atopy
    • Personal and/or family history
    • Raised IgE levels
  • Xerosis (dry skin)
Associated features
Suggest the diagnosis but are too nonspecific to be used for defining or detecting eczema for research studies
  • Atypical vascular responses
    • Facial pallor, white dermatographism (delayed blanch response)
  • Keratosis pilaris/pityriasis alba/hyperlinear palms/ichthyosis
  • Ocular/periorbital changes
  • Other regional findings
    • Perioral/periauricular lesions
  • Perifollicular accentuation/lichenification/ prurigo lesions
Exclusionary conditions
A diagnosis of eczema depends upon excluding other conditions
See table “Differential diagnosis of eczema” below
Hanifin and Rajka Criteria for Atopic Dermatitis [5]
Major criteria
(must have 3)
  1. Pruritus
  2. Dermatitis affecting flexural surfaces in adults or face and extensor surfaces in infants
  3. Chronic or relapsing dermatitis
  4. Personal or family history of cutaneous or respiratory allergy
Minor criteria
(must have 3)
  1. Facial features
    • Facial pallor, erythema, hypopigmented patches, infraorbital darkening, cheilitis, infraorbital folds, recurrent conjunctivitis, anterior neck folds
  2. Triggers
    • Emotional factors, environmental factors, food, skin irritants
  3. Complications
    • Susceptibility to skin infections, impaired cell-mediated immunity, predisposition to keratoconus and anterior subcapsular cataracts, immediate skin reactivity
  4. Other
    • Early age of onset, dry skin, ichthyosis, hyperlinear palms, keratosis pilaris, hand and foot dermatitis, nipple eczema, white dermatographism, perifollicular accentuation
UK working party diagnostic criteria for eczema [6] *
Itchy skin condition (required)  
Three of the following:
  • Visible flexural eczema eg antecubital and popliteal fossae (or visible dermatitis of the cheeks and extensor surfaces if under 18 months)
  • Personal history of dermatitis as above
  • Personal history of dry skin in the last 12 months
  • Personal history of asthma or allergic rhinitis (or history of eczema in a first degree relative if <4 years old)
  • Onset of signs and symptoms under the age of 2 years (this criteria should not be used in children <4 years)

*These criteria were designed for use in research. They cannot be applied to young children

The diagnosis of eczema depends on excluding other skin conditions that may show similar features. Other diagnoses should be considered particularly when there is an atypical presentation, associated failure to thrive or inadequate response to treatment.

Differential diagnosis of eczema (not exhaustive)
Other inflammatory dermatoses Seborrhoeic dermatitis, psoriasis, contact allergy or irritation, pompholyx, napkin dermatitis, nummular eczema, lichen simplex, pityriasis lichenoides acuta and chronica, pityriasis alba
Ichthyoses Ichthyosis vulgaris, autosomal recessive congenital ichthyosis, X-linked ichthyosis, Netherton syndrome
Infections and infestations Scabies, tinea corporis, pityriasis versicolor, pityriasis rosea, HIV
Immunodeficiencies Severe combined immunodeficiency, Omenn syndrome, hyper-IgE syndrome, Wiskott-Aldrich syndrome, IPEX syndrome
Immunological disorders Dermatitis herpetiformis, juvenile dermatomyositis, graft-vs-host disease
Malignancies Cutaneous T-cell lymphoma (mycosis fungoides)
Metabolic disorders Zinc deficiency, pyridoxine deficiency, biotin deficiency, niacin deficiency, phenylketonuria, cystic fibrosis, neutral lipid storage disease
Other Urticaria pigmentosa, Epidermolysis bullosa pruriginosa

Infantile seborrhoeic dermatitis is often mistaken for eczema. However it is not pruritic, and causes cradle cap and moist red areas in the skin folds. It tends to improve after the age of 6 months.

Assessment

Assessment requires a careful history and physical examination.

Identification of triggers

  • Irritants eg soaps and detergents (including shampoo, bubble bath, washing up liquid), chlorinated swimming pools, sodium lauryl sulphate-containing emollients
  • Skin infections: Staphylococcus aureus, Streptococcus pyogenes, herpes simplex (eczema herpeticum), molluscum contagiosum
  • Contact allergens
  • Food and inhalant triggers
  • Stress

Eczema is associated with an increased risk of immediate hypersensitivity reactions to food proteins. Children with a history of immediate reactions to food should be assessed and managed accordingly. [7]

Assessment of current and previous treatments

History should cover:

  • Bathing/showering frequency
  • Use of soap, soap-free cleansers, shampoos
  • Use of bath additives
  • Emollient/moisturiser—frequency of application, quantity used per week
  • Topical steroids—types, sites of application, quantity used per week
  • Any adverse reaction to topical agents eg stinging
  • Antihistamine, antibiotic use

Underuse of topical treatments is a common cause of treatment failure in eczema.

Impact of eczema

History should address:

  • Psychosocial impact
  • Frequency of skin infections
  • Frequency of days off school/activities
  • Sleep

Formal measures of eczema severity may be used eg CDLQI, POEMS.

Physical examination

The examination should include:

  • Assessment for diagnostic features of eczema or other diagnoses
  • Assessment of extent and severity of eczema
  • Assessment for clinical evidence of secondary infection
  • Growth and development—regular monitoring of height and weight is recommended for all children with moderate to severe disease

Formal measures of eczema may be used eg SCORAD, EASI.

Investigations

In some instances investigations may be needed to confirm the diagnosis of eczema and rule out other diagnoses.

Holistic assessment (taken from NICE guidelines 2007 [2])
Skin and physical severityImpact on quality of life and psychosocial wellbeing
Clear Normal skin, no evidence of active eczema Clear No impact on quality of life
Mild Areas of dry skin, infrequent itching (with or without small areas of redness) Mild Little impact on everyday activities, sleep and psychosocial wellbeing
Moderate Areas of dry skin, frequent itching, redness (with or without excoriation and localized skin thickening) Moderate Moderate impact on everyday activities and psychosocial wellbeing, frequently disturbed sleep
Severe Widespread areas of dry skin, incessant itching, redness (with or without excoriation, extensive skin thickening, bleeding, oozing, cracking and alteration of pigmentation) Severe Severe limitation of everyday activities and psychosocial impact, nightly loss of sleep

The overall management of eczema should be based on clinical features, psychosocial impact, and take into account the cultural practices and beliefs of the child and family.

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References:

  1. Guidelines of care for the management of eczema. Section 1. Diagnosis and assessment of eczema. American Academy of Dermatology. J Am Acad Dermatol 10.1016/j.jaeczema.2013.10.010
  2. Atopic eczema in children. NICE Clinical guideline Dec 2007 (accessed May 2014)
  3. Clayton T, Asher MI, Crane J, Ellwood P, Mackay R, Mitchell EA, Moyes CD, Pattemore P, Pearce N, Stewart AW. Time trends, ethnicity and risk factors for eczema in New Zealand children: ISAAC Phase Three. Asia Pac Allergy. 2013 Jul;3(3):161-78. doi: 10.5415/apallergy.2013.3.3.161. Epub 2013 Jul 30. PubMed PMID: 23956963; PubMed Central PMCID: PMC3736373.
  4. Purvis DJ, Thompson JM, Clark PM, Robinson E, Black PN, Wild CJ, Mitchell EA. Risk factors for atopic dermatitis in New Zealand children at 3.5 years of age. Br J Dermatol. 2005 Apr;152(4):742-9. PubMed PMID: 15840107.
  5. Diagnostic features of atopic dermatitis. Hanifin JM, Rajka G. Acta Derm Venereol Suppl (Stockh) 1980; 92:44–7
  6. The UK working party's diagnostic criteria for atopic dermatitis III: Independent hospital validation. Williams HC, Burney PGJ, Pembroke AC, Hay RJ. Br J Dermatol 1994;131:406-416
  7. Sinclair J, Brothers S, Jackson P, Stanley T, Ang M, Brown P, Craig A, Daniell A, Doocey C, Hoare S, Lester S, McIlroy P, Ostring G, Purvis D, Sanders J, Smiley R, Sutherland M, Townend T, Wilde J, Williams G. IgE-mediated food allergy--diagnosis and management in New Zealand children. N Z Med J. 2013 Aug 16;126(1380):57-67. Review. PubMed PMID: 24126750.

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