Atopic Dermatitis Initial Assessment

Last updated: 13 June 2024

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Clinical Presentation

Content on this page:

Clinical Presentation

Clinical Presentation

Pain was shown to be the second most common symptom of atopic dermatitis after pruritus in an international web-based survey from 34 countries. This may be related to scratching, skin fissures, inflamed red skin, or from burning from topical medications (eg steroids).

Infants <2 Years of Age  

In this age group, the signs of inflammation usually develop during the third month of life. The patient commonly presents with dry skin. The lesions (red papules with oozing, crusting, and scaling) are usually found on the facial cheeks and/or chin. Lip licking may result in scaling, oozing, and crusting on the lips and perioral skin, eventually leading to secondary infections.

Atopic Dermatitis_Initial Assessment 1Atopic Dermatitis_Initial Assessment 1


Continued scratching or washing will create scaling, oozing, and red plaques on the cheeks. The infant may be restless or agitated during sleep. A small number of infants may present with generalized eruptions with papules, redness, and scaling. The diaper area is usually not affected. 

Children 2 to 12 Years of Age  

Patients in this age group present with inflammation in the flexural areas (eg neck, wrists, ankles, antecubital fossae). The rash may be contained in one or two areas, and it may progress to involve more areas (eg neck, antecubital and popliteal fossae, wrists, and ankles).

They may also present with papules that quickly change to plaques and then become lichenified when scratched. Scratching and chronic inflammation may lead to areas of hypo- or hyperpigmentation. 

13 Years Old to Adults  

There is a resurgence of inflammation that recurs near puberty onset. The eruptions are more likely to develop on the upper body including the face, neck, chest, and back, with additional involvement of the face and neck, and prurigo may develop on the trunk and extremities. In severe cases, rare erythroderma may occur due to the extension of eruptions all over the body.    

It is unusual for adults with no history of dermatitis in earlier years to present with new-onset dermatitis. The pattern of inflammation is similar in a child aged 2 to 12 years old with additional lesions on the nape and hands. Hand dermatitis may be present in adults due to exposure to irritating chemicals.  

Dry, erythematous papules and plaques, scaling, and lichenification may be present. 

Diagnosis or Diagnostic Criteria

The diagnosis of atopic dermatitis is based on the patient’s history, cutaneous findings (atopic stigmata), and physical examination. It is important to investigate exacerbating factors such as aeroallergens, foods, infections, irritating chemicals, emotional stress, and extreme temperature. 

Criteria for Diagnosis (Based on criteria developed by Hanifin and Rajka)

The following are the major features of atopic dermatitis and the patient must have ≥3:

  • Pruritus
  • Typical morphology and distribution: Facial and extensor involvement in infants and children; flexural lichenification and linearity in adults
  • Dermatitis that is chronic or chronically relapsing
  • Personal or family history of atopy: Asthma, allergic rhinitis, atopic dermatitis 

Atopic dermatitis_Initial Assessment 2Atopic dermatitis_Initial Assessment 2


The following are the minor or less specific features of atopic dermatitis and the patient must have three of the 23 features: 

  • Cheilitis
  • Hand or foot dermatitis
  • Ichthyosis, hyperlinearity, keratosis pilaris
  • Nipple eczema
  • Perifollicular accentuation
  • Xerosis
  • Recurrent conjunctivitis
  • Keratoconus
  • Anterior subcapsular cataract
  • Pityriasis alba
  • White dermographism
  • Dennie-Morgan infraorbital fold
  • Facial pallor or facial erythema
  • Anterior neck fold Itch when sweating
  • Intolerance to wool and lipid solvents
  • Food intolerance
  • Course influenced by environmental/emotional factors
  • Orbital darkening
  • Immediate (type 1) skin test reactivity (radioallergosorbent or prick test reactivity)
  • Increased serum IgE
  • Early age of onset
  • Cutaneous infections (Staphylococcus aureus, herpes simplex)

Disease Severity  

Disease severity is assessed using different scoring methods (eg SCORing Atopic Dermatitis [SCORAD], Eczema Area and Severity Index [EASI], Patient Oriented Eczema Measure [POEM], Three Items Severity Score [TISS]).

SCORAD is the scoring method developed by the European Task Force of Atopic Dermatitis (ETFAD) which uses the area or extent affected, intensity, and subjective symptoms to score the severity of a patient’s atopic dermatitis and are classified as follows:

  • Mild disease: <25
  • Moderate disease: 25 to 50
  • Severe disease: >50

TISS is a simplified scoring system based on three symptoms of the disease: Erythema, edema or papulation, and excoriation. POEM measures the severity by depending on the patient’s answers to seven questions based on symptoms and their frequency. Pruritus severity is based on the patient’s subjective assessment using the visual analogue scale (VAS) and the numeric rating scale (NRS). 

Other scoring systems based on the impact on the quality of life are also used (eg Children’s Dermatology Life Quality Index [CDLQI], the Dermatitis Family Impact [DFI], Skindex-16, the Dermatology Life Quality Index [DLQI], and the Infant’s Dermatology Life Quality Index [IDQOL]).  

Ocular or infectious complications may also be present in severe atopic dermatitis. Severe eczema or skin infections may require hospitalization.  

A flare is an acute, clinically significant worsening of signs and symptoms of atopic dermatitis which requires therapeutic intervention. Remission is the period without the flare for at least 8 weeks without anti-inflammatory treatment.