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Diagnosis and Assessment of Eczema

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Guidelines for the diagnosis and assessment of childhood eczema

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.

In This Guideline:

Definition
Background
Diagnosis
Assessment

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 (itch), scratching, and eczematous lesions (inflamed, 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 (AD).

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Background

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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]:
Features to be considered in the diagnosis of patients with atopic dermatitis 
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
• Immunoglobulin E reactivity

Xerosis (dry skin)
Associated features
These associations 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
It should be noted that 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)
Facial features
• Facial pallor, erythema, hypopigmented patches, infraorbital darkening,
  cheilitis, infraorbital folds, recurrent conjunctivitis, anterior neck folds

Triggers
• Emotional factors, environmental factors, food, skin irritants

Complications
• Susceptibility to skin infections, impaired cell-mediated immunity,
  predisposition to keratoconus and anterior subcapsular cataracts,
  immediate skin reactivity

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 upon the exclusion of other conditions which 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's syndrome
Infection and infestation 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/nutritional 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.

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Assessment

Assessment requires a careful history and physical examination.

Identification of triggers

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:

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

Impact of eczema

History should address:

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

Physical examination

The examination should include:

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 severity Impact 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 everyday activities, 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.

References:

  1. Guidelines of care for the management of atopic dermatitis. Section 1 Diagnosis and assessment of atopic dermatitis.  L F Eichenfield, WL Tom, SL Chamlin et al J Am Acad Dermatol 2014;70:338-51.
  2. Atopic eczema in children. NICE Clinical guideline Dec 2007 (accessed May 2014)
  3. Time trends, ethnicity and risk factors for eczema in New Zealand children: ISAAC Phase three. T Clayton, MI Asher, J Crane et al. Asia Pac Allergy 2013;3:161-178.
  4. Risk factors for atopic dermatitis in New Zealand children at 3.5 years of age. Purvis DJ, Thompson JMD, Clark PM, et al. Br J Dermatol 2005 Apr;152(4):742-9.
  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. Ig-E mediated food allergy - diagnosis and management in New Zealand children. J Sinclair, S Brothers, P Jackson et al NZMJ Aug 2013 (126):1380

Document last reviewed: June 2014

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