Regarding the treatment of atopic dermatitis (hereafter referred to “AD”), diagnosis criteria proposed by the japanese Dermatological Association and therapeutic guidelines established by the japanese society of Allergology have been published. These guidelines enable us to conduct standard therapy for mild to severe pediatric and adult AD. Therapeutic methodology based on EBM will likely be established in the twenty-first-century. Using these criteria, all disease that meet the three requirements of itching, characteristics rashes and distribution, and chronic/recurrent progression will be diagnosed as atopic dermatitis irrespective of the severity of symptoms. From this point of view, inn this chapter, we summarize the differential diagnosis of AD, which is required for assessing daily treatment, so you know here About Diagnosis Of Atopic Dermatitis
Important differential diagnoses listed in diagnostic criteria proposed by the japanese Dermatological Association are as follows: contact dermatitis, seborrheic dermatitis, prurigo simplex, scabies, miliaria, ichthyosis, xerotic eczema, hand dermatitis (nonatopic), cutaneous lymphoma, psoriasis, immune deficiency disease, collagen diseases (systemic lupus erythematosus and dermatomyositis), and Netherton syndrome, However , skin disease, or manifestations which should be differentiated from AD are different among infantile, childhood, and adult atopic dermatitis. Misdiagnosis, or infectious diseases. Therefore, careful observation and evaluation of skin manifestations is required to make a correct diagnosis of AD.
Keywords: Atopic Dermatitis, Differential Diagnosis, Vitiligo, Cedar Pollen Dermatitis, IgE.
Regarding the treatment of atopic dermatitis (hereafter referred to “AD”), diagnosis criteria proposed by the japanese Dermatological Association and therapeutic guidelines established by the japanese society of Allergology have been published. These guidelines enable us to conduct standard therapy for mild to severe pediatric and adult AD. therapeutic methodology based on EBM will likely be established in the twenty-first century . using these criteria, all diseases that meet the three requirements of itchin, characteristic rashes and distribution, and chronic/ recurrent progression will be diagnosed as atopic dermatitis irrespective of the severity of symptoms.
From this point of view, in this chapter, we summarizes the differential diagnoses listed in diagnostic criteria proposed by the japanese Dermatological Association are as follows: contact dermatitis, seborrheic dermatitis, prurigo simplex, scabies, miliaria, ichthyosis, xerotic eczema, hand dermatitis (nonatopic), cutaneous lymphoma, psoriasis, immune deficiency disease, collagen disease (systemic lupus erythematosus and dermatomyositis), and Netherton syndrome.
Differential diagnosis of atopic dermatitis.
However, skin disease or manifestations which should be differentiated from AD are different among innfantile, childhood, and adult atopic dermatitis. Misdiagnosis occasionally results in unfavorable prognosis, especially for cutaneous lymphoma, dermatomyositis, or infectious diseases. Therefore, careful observation and evaluation of skin manifestations is required to make a correct diagnosis of AD.
Differential Diagnosis of Atopic Dermatitis
- Symptoms Associated with Sweat or Sebum
Infantile seborrheic eczema (Fig. 1, left top and bottom) is frequently observed on the head and face in infants. For diagnosis of AD, continuous observation of this eczema for longer than 2 months in infanthood or longer than 6 month in childhood is important. Observation of generalized eczema, fissured-ear base lichenification, randomly appearing dry skin, or association with atopic predisposition may be signs of transition to AD. In addition, in the summer season when sweating is promoted, serous papules or vesicles on the extremities or body trunk are occasionally observed. Hand eczema is observed in relation to irritation by sand or sweating.
2. Congenital Ichtyosis, Pediatric/Infantile Dry Eczema
Although Uehara et al. reported that 15% of observed AD patients were complicated with ichthyosis vulgaris. there are also some single cases. In the winter season, scale-like cornified lesions are clearly observed. Expression of ceramide 10 and filaggrin 11 decreases in skin with atopic dermatitis, particularly in lesions, and is considered as a primary cause of barrier dysfunction.
This is also considered as a secondary phenomenon associated with inflammation and as a cause of atopic dermatitis. patients with the above symptoms should be carefully treated because steroids have no effects on dry skin and instead disrupt skin barrier function. In winter, as children’s skin is dry and pityroid dander is sometimes observed, these symptoms are referred to simply as dry skin or pediatric, circular keratotic erythema with white-colored scales is observed. In infants patients, these lesions are frequently observed on the hip and sometimes such lesions are referred to as “diaper psoriasis”
Scabies is transmitted from the care stuff at elderly hospitals in many cases but also may be transmitted from pets such as dogs or cats (canine scabies). Symptoms are mainly pruritic lesions, in which exacerbations or delay of healing are observed in response to topical steroid application.
This disease causes family infection. It should be noted that in some dog, cat, or patients cases, no skin eruptions are observed on the predisposition site. Diagnosis is confirmed by microscopic tests to visually confirm the scabies worm white arrows or its eggs. Treatment should be guided by specialists.
4. Mast Cell Disease
Mast cell disease is also called “urticaria pigmentosa,” in which sporadically occurring brownish pigment macules or papules are observed, mainly on the trunk. Large numbers of mast cells are observed on the upper cutis, and urticaria lesions are shaped on pigment macules (Darier’s sign) by scrabbling. In some cases, histiocytosis X should be excluded because of positive CD 1 a staining.
5. pediatric strophulus (acute prurigo)
In pediatric strophulus, large numbers of erythemas similar to urticaria occur after insect bite by mosquitos, blackfly, etc., and sometimes shift to solid prurigo (known as strophulus. These symptoms frequently occur on all four limbs in the summer season.
Eczema on intertriginous areas usually found in AD patients is not obbserved in this case. The symptoms are relieved by topical steroid application and oral administration of antihistamines drugs.
6. Contact Dermatitis, Photocontact Dermatitis
Contact Dermatitis or photocontact dermatitis is sometimes observed in response to moisturizing agents, topical drugs, soaps, shampoo, etc. These symptoms may appear similar to refractory lesions of AD but rapidly disappear by discontinuation of causative agents and topical steroid application. In cases where the causatives agents are unknown, the effects of topical steroids will gradually decrease and symptoms will become refractory.
Diagnosis should be made by patch tests (contact dermatitis) or photopatch tests (photocontact dermatitis). An example of positive response in the patch test is shown in previous figure, center, with the suspected soap and shampoo in the previous figure, right.
7. Connective Tissue Disease
Childhood dermatomyositis is especially important in this disease. Erythemas on the face or body trunk or keratotic erythemas on the backside of joints are usually observed. In some cases, itching, accompanies these erythemas with elevation of the serum IgE level. The patients shown in above picture left and right, was diagnosed with AD in childhood, and the picture in the center of picture shows the clinical picture taken at the period of adolescence after growth. In this picture, calcareous deposition are observed.
8. Histiocytic Disorders
Erythemas or papules associated with bleeding or other characteristic events are observed on the face, head and body trunk (upper, Langerhans cell histiocytosis),
pathological tests should be carried out to make differential diagnosis. In this disease, CD 1 a is positive and Birbeck granules are observed by electronic microscopy. In severe cases, chemotherapy should be conducted.
9. Immune Deficiency Disease
In some cases of severe combined immune deficiency (SCID), erythemas or papules with dry pityroid dander are observed over the entire body. In Wiskott-Aldrich syndrome,
Eczema lesions similar to AD are observed. Netherton syndrome is characterized by ichthyosis, atopic diathesis, eczematous skin lesions with bamboo hairs, and SPINK5 gene mutation. Hyper-IgE syndrome is a hereditary immune deficiency syndrome characterized by atopic dermatitis-like skin-lesions, cold abscesses and pulmonary cysts with increase serum IgE and associated with STAT3, TYK2 or DOCK8 gene mutation.
10. Graft Versus Host Disease (GVHD)
According to the pathology of GVHD, apoptotic cells observed on the epidermis and the disappearance of Langerhans cells are characteristic of this disease. AD-like clinical manifestations are observed in chronic GVHD even though the donor has no predisposition to atopic dermatitis.
11. Dermatitis Caused by japanese Cedar Pollen
During the season when japanese cedar pollen is released, typically from february to march in japan, itchy urticaria and scaly dermatitis are observed on the face, especially around periorbital and nostril areas or the neck in some patients. In AD patients, this is also important as one of the seasonally exacerbated factors. patients with a history of aggravattion of dermatitis exhibits positive delayed-onset scratch-patch tests to cry j1.
12. Cutaneous T-cell lymphoma
It is important to differentiate mycosis fungoides from AD. In adult cases of AD, pruritic erythematous plaques or dirty poikilodermic lesions are occasionally observed with topical glucocorticoid resistance. Histopathological evaluation using immunohistochemical analysis is recommended for different diagnosis.
Complicated AD Disease: Skin infections
It is well known that the following infections are strongly associated with AD. Careful attention should be paid, especially in case where immunosuppressive ointment is applied.
It is reported that the defensive capability of skin is decreased in AD, and this is thought to be one of the reasons for the high frequency of complicated infections.
(a) Contagious impetigo (impetigo caused by staphylococcus aureus or hemolytic streptococcus): Contagious impetigo caused by hemolytic streptococcus, as symptoms of inflammation are relatively strong and erosions or ulcers are also severe, differentiation from kaposi varicelliform eruption is important. In some cases, glomerular nephritis may be associated; thus, early diagnosis and administration of antibiotics are necessary.
(b) Body ringworm, cutaneous candidiasis: In body ringworm, scaling erythematous macules with clear boundaries on all four limbs are characteristic. In case where erythematous occur on genitocrural regions, diagnosis is easy, but some cases where erythemas occur on the body trunk may be microscopic testing to confirm trichophyton or by cultivation. Cutaneous candidiasis is frequently observed on the external genitals, in which red plaques combined with vesicles or small pustules are observed.
(c) kaposi varicelliform eruption (Eczema herpeticum): This disease is caused by the initial infection of the herpes simple virus. In this disease, small center-umbilicated vesicles are observed. These vesicles are widely spread in an eczema-lesions-like pattern, with fever and management of transfusion are necessary for treatment.
(d) Molluscum contagious: This disease is caused by the molluscum contagious virus, which frequently infects patients in places such as swimming pools. Treatment is by removal of the molluscum before it spreads.
Complications of Atopic Dermatitis: Autoimmune Diseases
(A) Alopecia: Patients with either vitiligo or AA, especially alopecia totalis or alopecia universalis, have a significantly increased risk for AD, Sparse alopecia is occasionally observed on the temporal area of the scalp as atopic alopecia.
(B) vitiligo: Vitiligo patches in patients with AD may be induced when the autoimmune background resembles that of autoimmune vitiligo and Sutton’s nevus, bothh of which may be governed by Th 17 cells. Fifty-six percent of patients with a history of atopic dermatitis had hypopigmented skin in thee form of guttate psoriasis and patches, kierland et al. reported that vitiligo was observed more frequently in patients with atopic dermatitis.
Although it is not fully understood how vitiligo arises on atopic skin, the incidene of vitiligo in atopy seems to be higher than that of vitiligo and is accompanied by several autoimmune disorders, including diabetes mellitus, Hashimoto’s thyroiditis, Addison’s disease, or skin diseases such as psoriasis vulgaris or alopecia areata.
(C) Sjogren’s syndrome: We have recently reported four adult cases of AD complicated by Sjogren’s syndrome (SS). The Patients fulfilled the diagnostic criteria for AD and SS. All cases exhibited persistent itchy dry skin and eczematous lesions complicated with sicca symptoms including dry eyes andd dry mouth with moderate joint pain. In the present cases, impaired sweat response in AD is attributable to abnormal sudomotor function, which is accelerated and modulated when complicated by SS, resulting in dry skin.
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