Color atlas: eczema

      Atopic dermatitis is a chronic relapsing skin disorder often presenting in infancy and early childhood and characterized by an age-dependent distribution. Lesions may be acute, subacute, or chronic. The cardinal feature of atopic dermatitis is pruritus, and many of the lesions of atopic dermatitis result from rubbing and scratching persuant to this symptom(Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9, Figure 10, Figure 11, Figure 12, Figure 13, Figure 14, Figure 15, Figure 16, Figure 17, Figure 18, Figure 19, Figure 20).
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      Figure 1Facial involvement is common in infants with atopic dermatitis but often disappears after 6 months to 1 year of age. This toddler continues to exhibit involvement of the cheeks with erythema and excoriation. Perioral lesions are evident as well. Impetigo often complicates the care of these patients.
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      Figure 2Involvement of the forearms with erythematous, scaly, and crusted subacute lesions in a 4-year-old child. Extensor involvement, common in infancy and early childhood, then gives way to a pattern of flexural predominance in older children and adolescents.
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      Figure 3Cheilitis and perioral involvement is encountered frequently in children with atopic dermatitis. Lip licking and mouth breathing results in a cycle of wetting and evaporation that promotes chapping and further dermatitis.
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      Figure 4Although not included in the Hanifin and Rajka criteria for atopic dermatitis, infra-auricular fissuring is so common among patients with atopic dermatitis that many practitioners consider it a reliable diagnostic feature.
      • Kanwar A.J.
      • Dhar S.
      • Kaur S.
      Evaluation of minor clinical features of atopic dermatitis.
      • Pauly C.R.
      • Artis W.M.
      • Jones H.E.
      Atopic dermatitis, impaired cellular immunity, and molluscum contagiosum.
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      Figure 5Atopic dermatitis in a toddler with eyelid and perioral erythema and scaling as well as extensive involvement of the chest and shoulders. Central pallor and “mournful facies” are characteristic. He has not as yet developed “atopic shiners” (darkness around the eyes).
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      Figure 6Patients with atopic dermatitis typically exhibit nasal colonization with Staphylococcus aureus. Crusting and fissuring around the external nares is a frequent consequence. Interestingly, the subungual spaces of atopic dermatitis patients are also colonized with staph.
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      Figure 7Infantile atopic dermatitis typically presents with bright red, oozing, and crusted patches on the cheeks and extensor aspects of the extremities. A variety of proprietary or prescription medications may have been applied before dermatologic consultation. Parents often express concern about the use of topical corticosteroids and some manifest frank “steroid phobia.”
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      Figure 8Infants with atopic dermatitis may have bright red erythema of the cheeks with oozing and crusting or they may have dry, erythematous patches. Central pallor of the face (“headlight sign”) is noted. Dennie-Morgan folds are also apparent and probably result from eyelid dermatitis. They are not pathognomonic of atopic dermatitis, however, and can be seen as a normal variant.
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      Figure 9Atopic eczema may be extensive, as in this child in whom dermatitis involves the trunk, arms and neck.
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      Figure 10Dermatitis of the hands with erythema, crusting, and fissuring causes significant discomfort in children and adults alike. Although flexural lichenification of the extremities is classic after the infantile stage, widespread papular involvement of the extensors can persist, as in this child with widespread papulation of the hands, arms and legs.
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      Figure 11Scalp involvement occurs in many children with atopic dermatitis but differs in appearance from the cradle cap seen in infantile seborrheic dermatitis, where thick greasy scales predominate. Dermatophyte infection should be ruled out in older children.
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      Figure 12Papulation, erosion, and crusting of the extensor aspect of the wrist in early childhood. Hand dermatitis extending to the wrists and distal forearms is a good indicator for atopic dermatitis.
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      Figure 13The process of lichenification results from chronic rubbing of a pruritic area. Lichenoid papules coalesce into plaques that subsequently display exaggeration of the skin lines. Hyperpigmentation of lesional skin in darker complected individuals results from postinflammatory hyperpigmentation.
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      Figure 14Pityriasis alba often occurs on the face but can present in other areas. It is thought to represent a low-grade eczema with postinflammatory hypopigmentation, although the exact pathophysiology is not entirely known.
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      Figure 15Prominent pruritic periumbilical papules provide a clue to childhood atopic dermatitis.
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      Figure 16Characteristic flexural involvement seen in adolescents and adults with atopic dermatitis. There is erythema, lichenification, and excoriation involving the antecubital fossae and trunk.
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      Figure 17Erythema, lichenification, and excoriations of chronic atopic dermatitis in flexure of antecubital fossa.
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      Figure 18Reticulated pigmentation of the neck, or “dirty neck,” an adjunctive sign seen sometimes in atopic dermatitis.
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      Figure 19Erythematous patches with crusted erosions and excoriations from scratching, on the wrist, a common site of involvement in atopic dermatitis,
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      Figure 20Patches, plaques, and papules of erythema over a widespread area of the back. Crusted erosions and excoriations also are seen in this acute exacerbation of atopic dermatitis.
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