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In the meantime, you can enjoy access to all the latest news, events and resources for different therapy areas on our website.Clinical presentation
Atopic dermatitis
Diagnosis
Atopic dermatitis (AD) is commonly categorised into two types: extrinsic or intrinsic.
1. Extrinsic (allergic) AD exhibits high total serum immunoglobulin E (IgE) levels,
– the antibody utilised during immune defence, – the presence of specific IgE for environmental and food allergens and filaggrin gene mutations
2. Intrinsic (non-allergic) AD exhibits normal total IgE values and the absence of specific IgE, with no filaggrin gene mutations. 12
Diagnosis of AD is primarily based on clinical features and requires consideration of the following features: 34
| Essential features – must be present |
Important features – add support to the diagnosis |
Associated features – help to suggest AD but are nonspecific |
Exclusionary conditions |
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|
|
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Recommended assessment of AD severity includes asking general questions about the impact of the disorder on factors affecting quality of life (QoL), such as itching and impact on daily activity. 3
Clinical features
Manifestations of intrinsic and extrinsic AD are similar – both are characterised by skin lesions and pruritus. 56
Acute phase
- 1–2 months
- Red, weeping, crusted lesions
- Lesions can be widespread affecting the scalp, abdomen and extremities
Subacute phase
- Acute symptoms plus:
- Scaling,
crusting, some lichenification
- Scaling,
- Lesions are often localised to areas accessible to scratching
Chronic phase
- Relapsing pattern of symptoms
- Thickened dry patches, often lichenified from chronic rubbing
- Lesions resolve to dry scaly macules which fissure, resulting in exposure to allergens
The course of disease is unpredictable and exacerbations are common – sufferers are affected not only by the condition, but by the stigma associated with its visibility. 7–10
Disease prognosis is dependent on age
AD is frequently severe in infants and may continue to affect patients beyond puberty, although up to 70% of children are thought to outgrow the disorder before this point. 910
Only 17% of atopic dermatitis cases were found to have developed after adolescence in a UK cohort 11
In addition to the direct impact of the disease, patients with AD have an increased risk of developing respiratory disorders. Between 40 and 60% of patients will develop allergic rhinitis or asthma, which begin early in life and progress with age. 2712 This is thought to be linked to the ‘atopic march’, the term assigned to the sequence of allergic manifestations that may develop throughout early childhood 10
Flares in atopic dermatitis
AD is a chronic relapsing disease characterised by periods of acute worsening followed by periods of relative remission 1314
- A flare of AD can be defined as an episode requiring escalation of treatment or seeking additional medical advice 15
- Due to the episodic nature of AD, recognising and managing the flare is key to evaluating treatment success 13
Patients with severe AD experience more frequent and longer flares than patients with moderate AD. 16
Plaque psoriasis
- Most common form of psoriasis
- Typically appears as areas of inflamed skin covered with a silvery white scale
- Appearance may vary with race 20
Pustular psoriasis
- Appears as raised bumps filled with non-infectious pus and represents active, unstable disease
- Pustules may be generalized with explosive onset of widespread erythema and sterile pustules or localized to the palms and soles (palmoplantar pustulosis) with a gradual onset
Guttate psoriasis
- Develops acutely, usually following a streptococcal respiratory tract infection
- Presents as small, widely distributed erythematous papules with mild scales
Palmoplantar pustulosis
- Characterised by fresh yellow pustules (older pustules appear browner) on the palms and/or soles only
Inverse psoriasis
- Psoriasis affecting the flexural regions (primarily the inframammary, perineal and axillary regions) as distinct from typical plaques affecting the trunk and limbs
Erythrodermic psoriasis
- Total or subtotal involvement of the skin by active psoriasis
Nail psoriasis
Acrodermatitis continua of Hallopeau
Link to: http://www.dermnetnz.org/scaly/acroder matitis-hallopeau.html (Last accessed November 2015)
- Pitting, stippling, fraying, discoloration and thickening of the nails, with or without separation of the nail plate (onycholysis)
- Affects 30–50% of patients with other forms of psoriasis
- Variant of palmoplantar pustulosis confined to distal fingers or toes, sometimes just one digit
- Replaced by scale and crust when it resolves
Non-pustular psoriasis can be sub-classified into two types: 18 21
- Type 1 psoriasis (~70% of all psoriatic patients)
a. Early onset (<age 40), peak onset at 16–22 years of age
b. Positive family history
c. Association with human leukocyte antigen (HLA)-Cw6 and HLA-DR7 - Type 2 psoriasis
a. Later onset (>age 40), peak onset at 57–60 years of age
b. Negative family history
c. Lack of prominent HLA association
Diagnosis
Psoriasis diagnosis is based almost entirely on clinical evaluation. A biopsy can be considered but this is rarely necessary and may not be diagnostic.18 22
Assessment of the clinical appearance and distribution of lesions is necessary for differential diagnosis of psoriasis rather than any of the following conditions: 18,22
- Cutaneous lupus erythematosus
- Dermatophytoses
- Eczema
- Lichen simplex chronicus
- Lichen planus
- Pityriasis rosea
- Seborrheic dermatitis
- Secondary syphilis
- Squamous cell carcinoma in situ (Bowen disease, especially when on the trunk)
Psoriasis severity assessment
The most widely used measure to assess severity of disease is the Psoriasis Area and Severity Index (PASI). 18Disease is graded as mild, moderate or severe based on the body surface area affected; 23additional questionnaires (such as the DLQI) have been developed to assess how lesions affect a patient’s QoL 18
Classic co- morbidities
|
Emerging co- morbidities
|
Co-morbidities related to lifestyle
|
Co-morbidities related to treatment*
|
PASI score calculator 23
Typically, the PASI would be calculated before, during and after a treatment period in order to determine how well psoriasis responds to the treatment. 23
Clinical features
Psoriasis typically manifests as well-circumscribed papules and plaques, covered with silvery scales: 22 The appearance of psoriasis may vary depending on racial features. 20
Clinical appearance of plaque psoriasis and pustular psoriasis
a. Plaque (elevated palpable lesion) covered with thick silvery scales; b. Pustular psoriasis formed of sterile pustules 22
a
b
The increased morbidity and mortality associated with psoriasis is linked to common comorbidities: 24
* Co-morbidities are associated with specific treatments e.g. dyslipidaemia is a co-morbidity associated with acitretin and cyclosporine treatment
References:
- Tokura Y. J Dermatol Sci 2010;58:1–7
- Kabashima K. J Dermatol Sci 2013;70:3–11
- Eichenfield LF, et al. J Am Acad Dermatol 2014;70:338–51
- NICE Clinical Guidelines 57 (2007): Atopic eczema in children. Available at:
- https://www.nice.org.uk/guidance/cg57 (Last accessed September 2015)
- Beltrani VS. J Allergy Clin Immunol 1999;104:S87–98
http://www.dermnetnz.org/doctors/dermatitis/dermatitis.html Last accessed August 2015)
- Merck Manuals: Atopic Dermatitis: www.merckmanuals.com/professional/dermatologic_disorders/dermatitis/atopic_d ermatitis.html (Last accessed September 2015)
- Basra MK, Shahrukh M. Expert Rev Pharmacoecon Outcomes Res 2009;9:271–83
- Carroll CL, et al. Pediatr Dermatol 2005;22:192–9
- Watson W, Kapur S. Allergy Asthma Clin Immunol 2011;7:S4
- Ozkaya E. J Am Acad Dermatol 2005;52:579–82
- Wüthrich B. Ann Allergy Asthma Immunol 1999;83:464–70
- Langan SM, et al. Br J Dermatol 2014;170:548–556
- Sidbury R, et al. J Am Acad Dermatol 2014;71:1218–1233
- Langan SM, et al. Arch Dermatol 2006;142:1190–1196
- Zuberbier T, et al. J Allergy Clin Immunol 2006;118:226–232
- Langley RG, Krueger GG, Griffiths CE. Ann Rheum Dis. 2005;64 Suppl 2:ii18–ii23
- Pathirana D, et al. J Eur Acad Dermatol Venereol 2009;23:1–70
- Dermnetz.org: Palmoplantar pusulosis. Available at: http://www.dermnetnz.org/scaly/palmoplantar-pustulosis.html (Last accessed September 2015)
- National psoriasis foundation: People of all races overcome psoriatic disease. Available at: https://www.psoriasis.org/advance/features/people-of-all-races- overcome-the-challenge-of-psoriatic-diseases (Last accessed September 2015)
- Allen MH, et al. J Invest Dermatol 2005;124:103–6
- Merck manuals: Psoriasis. Available at: http://www.merckmanuals.com/professional/dermatologic-disorders/psoriasis- and-scaling-diseases/psoriasis (Last accessed September 2015)
- PASI training. Available at: http://www.pasitraining.com/about.html (Last accessed September 2015)
- Oliveira Mde F, Rocha Bde O, Duartee GV. An Bras Dermatol 2015;90:9–20
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