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Clinical presentation 

Atopic dermatitis


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

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Essential features
– must be present
Important features
– add support to the diagnosis
Associated features
– help to suggest AD but are nonspecific
Exclusionary conditions

  • Pruritus
  • Dermatitis/eczema (acute, subacute or chronic)
  • Personal or family history of AD
  • Typical distribution and morphology of AD flare, including:
    • Increased
    • Itching
    • Redness
    • Swelling
    • General irritability
  • Early age of onset
  • Atopy
    • Personal/ family history
    • Elevated serum IgE level
  • Xerosis
  • Keratosis pilaris/ pityriasis alba/ hyperlinear palms/ ichthyosis
  • Atypical vascular responses (e.g. facial pallor, white dermatographism)
  • Ocular or periorbital changes
  • Other regional findings (e.g. perioral changes)
  • Perifollicular accentuation/ lichenification/ prurigo lesions
  • Scabies
  • Seborrheic dermatitis
  • Contact dermatitis (irritant or allergic)
  • Ichthyoses
  • Cutaneous T-cell lymphoma
  • Psoriasis
  • Photosensitivity dermatoses
  • Immune deficiency diseases
  • Erythroderma of other causes

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
  • 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
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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

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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

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Classification of psoriasis

Psoriasis can be classified into subtypes: 717–19

Plaque psoriasis

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  • 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

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  • 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

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  • Develops acutely, usually following a streptococcal respiratory tract infection
  • Presents as small, widely distributed erythematous papules with mild scales

Palmoplantar pustulosis

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  • Characterised by fresh yellow pustules (older pustules appear browner) on the palms and/or soles only

Inverse psoriasis

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  • Psoriasis affecting the flexural regions (primarily the inframammary, perineal and axillary regions) as distinct from typical plaques affecting the trunk and limbs

Erythrodermic psoriasis

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  • Total or subtotal involvement of the skin by active psoriasis

Nail psoriasis

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Acrodermatitis continua of Hallopeau

Link to
: 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

  1. 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
  2. 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


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

  • Psoriatic arthritis
  • Inflammatory bowel disease
  • Psychological
    & psychiatric problems
  • Uveitis


Emerging co- morbidities

  • Metabolic syndrome
  • Cardiovascular diseases
  • Atherosclerosis
  • Non-alcoholic fatty liver disease
  • Lymphomas
  • Sleep apnea
  • Chronic obstructive pulmonary disease
  • Osteoporosis
  • Parkinson’s disease
  • Coeliac disease
  • Erectile dysfunction

Co-morbidities related to lifestyle

  • Anxiety
  • Smoking
  • Alcohol abuse

Co-morbidities related to treatment*

  • Dyslipidemia
  • Nephrotoxicity
  • Hypertension
  • Hepatoxicity
  • Non-melanoma skin cancer


PASI score calculator 23

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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




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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


  1. Tokura Y. J Dermatol Sci 2010;58:1–7
  2. Kabashima K. J Dermatol Sci 2013;70:3–11
  3. Eichenfield LF, et al. J Am Acad Dermatol 2014;70:338–51
  4. NICE Clinical Guidelines 57 (2007): Atopic eczema in children. Available at: 
  5. (Last accessed September 2015)
  6. Beltrani VS. J Allergy Clin Immunol 1999;104:S87–98 Last accessed August 2015)
  7. Merck Manuals: Atopic Dermatitis: ermatitis.html (Last accessed September 2015)
  8. Basra MK, Shahrukh M. Expert Rev Pharmacoecon Outcomes Res 2009;9:271–83
  9. Carroll CL, et al. Pediatr Dermatol 2005;22:192–9
  10. Watson W, Kapur S. Allergy Asthma Clin Immunol 2011;7:S4
  11. Ozkaya E. J Am Acad Dermatol 2005;52:579–82
  12. Wüthrich B. Ann Allergy Asthma Immunol 1999;83:464–70
  13. Langan SM, et al. Br J Dermatol 2014;170:548–556
  14. Sidbury R, et al. J Am Acad Dermatol 2014;71:1218–1233
  15. Langan SM, et al. Arch Dermatol 2006;142:1190–1196
  16. Zuberbier T, et al. J Allergy Clin Immunol 2006;118:226–232
  17. Langley RG, Krueger GG, Griffiths CE. Ann Rheum Dis. 2005;64 Suppl 2:ii18–ii23
  18. Pathirana D, et al. J Eur Acad Dermatol Venereol 2009;23:1–70
  19. Palmoplantar pusulosis. Available at: (Last accessed September 2015)
  20. National psoriasis foundation: People of all races overcome psoriatic disease. Available at: overcome-the-challenge-of-psoriatic-diseases (Last accessed September 2015)
  21. Allen MH, et al. J Invest Dermatol 2005;124:103–6
  22. Merck manuals: Psoriasis. Available at: and-scaling-diseases/psoriasis (Last accessed September 2015)
  23. PASI training. Available at: (Last accessed September 2015)
  24. Oliveira Mde F, Rocha Bde O, Duartee GV. An Bras Dermatol 2015;90:9–20

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