Atopic dermatitis: Diagnosis recommendations

Patients with presumed atopic dermatitis should have their diagnosis based on the criteria summarized below. On occasion, skin biopsy specimens or other tests (such as serum immunoglobulin E, potassium hydroxide preparation, patch testing, and/or genetic testing) may be helpful to rule out other or associated skin conditions. 

Level of Evidence: III Strength of Recommendation: C

Essential features must be present:
• Pruritus
• Eczema (acute, subacute, chronic)
Typical morphology and age specific patterns*
 Chronic or relapsing history
*Patterns include:
1. Facial, neck, and extensor involvement in infants and children
2. Current or previous flexural lesions in any age group
3. Sparing of the groin and axillary regions

Important features  seen in most cases, adding support to the diagnosis:
• Early age of onset
• Atopy
 Personal and/or family history
 Immunoglobulin E reactivity
• Xerosis

Associated features  These clinical associations help to suggest the diagnosis of atopic dermatitis but are too nonspecific to be used for defining or detecting atopic dermatitis for research and epidemiologic studies:
• Atypical vascular responses (eg facial pallor, white dermographism, delayed blanch response)
• Keratosis pilaris/ pityriasis alba/ hyperlinear palms/ icthyosis
• Ocular/periorbital changes
• Perifollicular accentuation/ lichenification/ prurigo lesions

Exclusionary conditions  It should be noted that a diagnosis of atopic dermatitis depends on excluding conditions, such as:
• Scabies
• Seborrheic dermatitis
• Contact dermatitis (irritant or allergic)
• Icthyoses
• Cutaneous T-cell lymphoma
• Psoriasis 
• Photosensitivity dermatoses
• Immune deficiency diseases
• Erythroderma of other causes

adapted from Eichenfield, et al.24

Read more about these recommendations

The diagnosis of atopic dermatitis is made clinically and is based on historical features, morphology and distribution of skin lesions, and associated clinical signs. Formal sets of criteria have been developed by various groups to aid classification.   

One of the earliest and most recognized sets of diagnostic criteria is the 1980 Hanifin and Rajka criteria, which requires that three of four major criteria and three of twenty-three minor criteria be met.11  While comprehensive and often utilized in clinical trials, such a large number of criteria are unwieldy for use in clinical practice.  Some of the minor criteria have been noted to be poorly defined or non-specific (such as pityriasis alba), while others, such as upper lip cheilitis and nipple eczema, are quite specific for AD but uncommon.11,12   Several international groups proposed modifications to address these limitations (e.g. Kang and Tian criteria, International Study of Asthma and Allergies in Childhood (ISAAC) criteria).13-16 The United Kingdom (UK) Working Party, in particular, systematically distilled the Hanifin and Rajka criteria down to a core set that is suitable for epidemiologic/population-based studies and that can be used by non-dermatologists. These consist of one mandatory and five major criteria and do not require any laboratory testing. Both the Hanifin and Rajka and UK Working Party diagnostic schemes have been validated in studies and tested in several different populations.12,13,15,17-23 

Navigate section 1 of the AD guideline: Diagnosis and assessment

Citation note 

When referencing this guideline in a publication, please use the following citation: Eichenfield LF, Tom WL, Chamlin SL, Feldman SR, Hanifin JM, Simpson EL, et al. Guidelines of care for the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol. 2014 Feb;70(2):338-51. 


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