Efficacy and Safety Considerations in Topical Treatments for Atopic Dermatitis

Noreen Heer Nicol, MS, RN, FNP


Dermatology Nursing. 2010;22(3):2-11. 

In This Article

Clinical Features and Diagnosis

Atopic dermatitis is divided into three phases on the basis of age and distribution of lesions: infantile, childhood, and adult. There continues to be no single distinguishing feature of AD or a diagnostic laboratory test. Laboratory testing is not needed in the routine evaluation and treatment of uncomplicated AD. The diagnosis is based on three major clinical features: pruritus, an eczematous dermatitis that fits into a typical distribution as described below, and a chronic or chronically relapsing course. The key feature of AD is pruritus (itchiness), which can interfere with daily activities and disrupt sleep.

In infants, AD typically presents on the cheeks, forehead, or scalp. AD lesions tend to be symmetrical, scaly, and erythematous and may remain localized or extend to the trunk or extremities. Weeping and crusting may occur in more severe or infected cases. Lesions do not usually affect the diaper area, which aids in diagnosis. General xerosis or dryness are common.

The childhood phase of AD, which can follow the infantile phase without interruption, occurs from age 2 to puberty. The exudative lesions of infancy are less likely to occur, while lichenified papules and plaques indicative of more chronic disease are usually exhibited. Typically, hands, feet, wrists, ankles, and antecubital and popliteal regions are affected. Localization at flexural areas of the extremities is more common.

The adult phase of AD usually begins at puberty, although some patients may experience onset of symptoms after puberty. Affected areas are characterized by dry, scaling, erythematous papules and plaques and the formation of large lichenified plaques resulting from chronic lesions. In adults, AD usually presents in flexural folds, the face and neck, upper arms and back, and the dorsa of hands, feet, fingers, and toes. Most children outgrow their AD but continue to have dry, easily irritated skin.

Because many inflammatory skin diseases, immunodeficiencies, infectious diseases, and infestations exhibit symptoms similar to AD, many differential diagnoses must be ruled out, and biopsies should be obtained from different sites whenever the diagnosis is unclear, particularly in adults (Nicol & Boguniewicz, 2008). Atopic dermatitis of the hands and feet should be differentiated from tinea or psoriasis. Rarer diseases also should be ruled out, including Netherton's syndrome (in pediatric patients) and cutaneous Tcell lymphoma/mycosis fungoides (in pediatric and adult patients) (see Table 1) (Akdis et al., 2006; Ong & Boguniewicz, 2008).