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Dr Shi: Factors to Consider for an Making Accurate AD Diagnosis

The following is a transcript of the video Diagnostic Challenges: Important Considerations for an Accurate AD Diagnosis, featuring Vivian Shi, MD, FAAD. Dr Shi is an associate professor of the department of dermatology at the University of Arkansas for Medical Sciences in Little Rock.


Dr Vivian ShiDr Shi: Eczema is the itch that rashes, unlike many other conditions where you see the rash first, then you feel the itching and the burning. Sometimes before we even see any skin changes, we will have itching, and with itching, we scratch, then the rash develops.

There are classic areas where atopic dermatitis develops and that ranges. It can get all over the body, but generally, there are some hot spots that we look for, and we use this as a diagnostic pattern. It's interestingly also different depending on the age of the patient. For example, when babies and infants get them, they're typically on the cheeks, on the neck, and on the outer sides of the arms and legs. As the child gets older, they turn into more of a young adult distribution. Instead of having it on the outer part of the body, they have it in the skin folds. As the person gets even older, to turn into adulthood, they still have those areas like an older child, but they get more arms, and legs, and hands, and foot involvement, so there's a kind of a progression.

We do have a commonly used diagnostic criteria. It's called the Hanifin-Rajka criteria for atopic dermatitis, but it's for more like the classic atopic dermatitis. Typically, there are the major criteria and the minor criteria. I'm not going to go into details of every one of them, but you've got to have the rash. Some people may have a personal or family history of other allergic conditions like asthma and hay fever along with eczema, and there are some minor criteria of split skin findings, sometimes even eye findings, and things like that.


Click here to watch Dr Shi explain her tips for making an accurate diagnosis of atopic dermatitis!


Diagnosing classic atopic dermatitis, a lot of times, is checking the box, but the challenge here is that not everybody who walks through the door or has atopic dermatitis will read like the textbook. There's a wide spectrum of presentations. The word eczema just means dermatitis or inflammation of the skin of any kind. Any time the skin has redness, or swelling, or even itching, can be called dermatitis or eczema. These have a number of other conditions that are related, but some of them are not even remotely related to atopic dermatitis or classic eczema, and these includes seborrheic dermatitis, or sometimes just irritant hand dermatitis from a lot of washing.

Homing in on the actual diagnosis will allow us to design the appropriate treatment and give our patients and caregivers appropriate information on what to expect in the long term.

A lot of times, when patients come in—I joke around with this a lot—all it takes is a dermatologist doctor's appointment for the eczema to go away, because that's the nature of the disease. We have this remitting‑relapsing nature. There are good days, there are bad days.

When the patient presents with their family, and what I see is not what the story they're telling, then I tend to ask, "When I'm not around, show me some photos." Now, we're in the era of mobile phones and smartphones. My job has gotten a lot easier. Even when the skin is not that severe, I'm able to see the area that's involved, see their documentations and photo records. Conversely, when the skin is really bad on the day that they're visiting the doctor, I can get a better idea about what's the best they have looked in this anatomical area.

There are also other tricks on diagnosing eczema. Many times, even when the skin doesn't have eczema rash, I know that they're an eczema person. Some of this is called Dennie‑Morgan lines, for example. These are the skin folds, prominent lines, but on the lower eyelid. Many of them will have a darker skin color from chronic rubbing of the eyes and rubbing of the nose. Many eczema individuals will also have this thing called hyperlinear palms. The lines on their palms are more prominent, and more rough, and groovy.

These are the tricks that we use to link the patient with the risk for atopic dermatitis.

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