A Comprehensive Management Guide for Atopic Dermatitis

Jennifer D. Peterson, MD; Lawrence S. Chan, MD


Dermatology Nursing. 2006;18(6):531-542. 

In This Article


There are three phases of atopic dermatitis: the infantile stage, the childhood phase, and the adult phase. Pruritus and dry skin are at the hallmark of all stages and the pruritus is frequently worse at night (Leung & Bieber, 2003). The infantile stage includes children up to 2 years of age, and is characterized by pruritic, erythematous papules, patches, and vesicles on the cheeks and extensor surfaces of the extremities. Lesions may have a weeping and exudative appearance (Rudikoff & Lebwohl, 1998; Leung & Bieber, 2003). There may be additional involvement of the scalp, forehead, chin, and trunk; but the diaper area is not involved in the majority of cases (Spergel & Paller, 2003). The next phase is known as the childhood phase and affects children age 2 years to puberty. As a result of chronic rubbing and scratching, the skin lesions become less weeping and exudative and more lichenified (thickened) and excoriated. The distribution of the lesions changes from the extensor surfaces to the flexor surfaces, particularly the antecubital and popliteal fossae (see Figure 1). The neck, periorbital, perioral, hands, feet (see Figure 2), wrists, and ankles may also be affected (Rudikoff & Lebwohl, 1998; Spergel & Paller, 2003). Black children sometimes show a follicular pattern of disease that can lead to post-inflammatory hypo or hyperpigmentation (Rudikoff & Lebwohl, 1998). Lastly, the adult phase begins at puberty and may follow a continuous course from infantile to childhood to adult stages or may be a form of recurrence from other stages. Affliction of the flexural folds is also seen in the adult stage along with lesions on the face, hands, upper arms, back, wrists, and the dorsa of the hands, fingers, feet, and toes (Spergel & Paller, 2003). A chronic course of hand or foot eczema may be the only manifestation of adult atopic dermatitis (Leung et al., 2004). Large lichenified plaques and scaling, erythematous papules and plaques, and prurigo papules are featured in the adult phase (Leung, 2003; Spergel & Paller, 2003).

Figure 1.

In the childhood phase, distribution of the lesions changes from the extensor surfaces to the flexor surfaces, particularly the antecubital and popliteal fossae.

Figure 2.

The neck, periorbital, perioral, hands, feet, wrists, and ankles may also be affected.

In 1980, Hanifin and Rajka proposed criteria for the diagnosis of AD (see Table 2 ). With these criteria, the patient must exhibit three of the major and three of the minor criteria. The major criteria include pruritus, typical morphology and distribution (facial and extensor involvement in infants and children or flexural lichenification or linearity in adults), chronic or chronically relapsing dermatitis, or personal or family history of atopy (allergic rhinitis, asthma, atopic dermatitis). The minor criteria are further explained in Table 2 (Abramovits, Goldstein, & Stevenson, 2003; Correale, Walker, Murphy, & Craig, 1999; Hanifin & Rajka, 1980; Rudikoff & Lebwohl, 1998; Williams, 2005).


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