Age-related evolution and clinical presentation
The morphology of elements and their location on the body directly depend on the patient's age. The general pattern of atopic dermatitis is that as aging progresses, the acuteness of inflammation subsides. Three key stages are distinguished.
Infantile period (from onset up to 2 years) The disease manifests at 7–8 weeks of life. During this period, the inflammation is acute or subacute with pronounced exudation (weeping).
- True polymorphism is observed: redness (erythema), papules, vesicles, and areas of weeping are replaced by the formation of crusts and scales.
- The process begins on the face (forehead, cheeks), then spreads to the extensor surfaces of the limbs and buttocks.
- By 1.5–2 years, the lesions shift to the flexural surfaces and hands. Exudation subsides, nodular (lichenoid) and scaly elements appear, along with scratch marks (excoriations). The main danger of this age is the risk of developing atopic erythroderma.
Childhood period (from 2 to 10 years) The nature of the inflammation changes radically: exudation disappears completely, and the skin becomes extremely dry.
- Lichenification (thickening of the epidermis with accentuated skin markings) and secondary dyschromia come to the forefront.
- Rashes are localized predominantly in the antecubital and popliteal fossae, on the neck, and on the dorsum of the hands.
- Painful fissures form against the background of infiltrative thickening.
Adolescent-adult period (over 10 years) In adolescents, the lesions are diffuse. Rashes concentrate on the face (lips, periorbital area, forehead, cheeks), neck, upper trunk, and limbs. Areas of lichenification, infiltration, and multiple excoriations predominate.
Risk factors and exacerbation triggers
The initiation of the pathological process and its subsequent exacerbations depend on the age stage:
- Early age: disruption of the colon microecology is of decisive importance. A decrease in protective microflora provokes an imbalance in cellular immunity (between Th1 and Th2 lymphocytes).
- Post-infectious factors: onset is often associated with severe prior infections, especially if accompanied by massive antibiotic therapy.
- Puberty: exacerbations are most often associated with psycho-emotional stress, chronic foci of infection, and self-medication.
Hanifin and Rajka diagnostic criteria (1980)
The diagnosis is established clinically. Confirmation requires the presence of at least three major criteria, as well as minor symptoms (which must occur in at least a third of patients).
Major criteria:
- Presence of pruritus.
- Early onset of the disease.
- Typical morphology and localization (flexural lichenification).
- Chronic relapsing course (with characteristic summer improvements).
Minor criteria:
- Anamnestic: family history of atopy, food/respiratory allergy, exacerbations dependent on stress.
- Skin: pronounced dryness (xerosis), white dermographism, palmar hyperlinearity, follicular keratosis, facial pallor or stash erythema.
- Local: hand/foot eczema, nipple eczema, cheilitis, post-auricular fissures.
- Ocular: Dennie-Morgan fold (an extra fold on the lower eyelid), dark circles under the eyes, cataract, keratoconus.
- Laboratory: blood eosinophilia, high total IgE levels.
- Immune: tendency to skin infections (Staphylococcus aureus, herpes simplex virus).
Differential diagnosis and allergy testing
Differential diagnosis is carried out with the following groups of diseases:
- Other dermatitides and eczemas (seborrheic, contact, diaper dermatitis, nummular eczema).
- Pruritic dermatoses (infantile prurigo, Vidal lichen, psoriasis).
- Infections (scabies, trichophytosis).
- Severe congenital disorders (ichthyosis, Leiner-Moussou exfoliative erythroderma).
To identify clinically significant triggers, a specific allergological workup is performed. It is important to observe timing: in vitro laboratory tests (determination of specific IgE) and history taking can be performed in any phase, including exacerbation. However, skin tests (scarification, prick tests) and provocation tests are allowed exclusively during remission.
To remember the four mandatory criteria for atopic dermatitis, use the mnemonic ITCH: Itching of the skin, Typical flexural distribution of lesions, Childhood onset, Hronic relapsing course.
Class and exam questions
Can skin allergy tests be performed during an exacerbation?
No. Scarification and prick tests, as well as allergen provocation tests, are strictly performed during remission. In the acute phase, only blood testing for specific IgE is permissible.
What is characteristic of rashes in the infantile period?
Under the age of 2 years, exudative (weeping) inflammation predominates. Rashes usually begin on the face, then spread to the extremities and buttocks, presenting as a mixture of erythema, vesicles, and crusts.
What parameters does the working clinical classification take into account?
The Russian classification (authors I.I. Balabolkin, V.K. Grebenyuk) is based on three parameters: clinical-morphological form, degree of inflammatory activity, and assessment of severity.
What else to study on this topic
- Features of colon microecology and the mechanism of Th1/Th2 imbalance development
- Working clinical classification (Balabolkin, Grebenyuk): grading severity
- Specific ophthalmological complications of atopic dermatitis
- Clinical presentation of atopic erythroderma in infants
- Differential diagnosis with Leiner-Moussou syndrome
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