Case Studies:The diagnosis of this condition is often not straight-forward and several other conditions have to be considered in the differential diagnosis (See below). Where the disease represents mere continuation of atopic dermatitis from childhood, the diagnosis is usually easy and the clinical picture also typical. Difficulty arises where onset occurs after the age of 18 years (adult-onset atopic dermatitis) and in these cases the disease pattern is often not obvious, although it may still present with the usual flexural dermatitis seen in children. Non-typical morphology and localization are common with nummular, prurigo-like, follicular and seborrheic patterns often seen . Erythroderma is a rare manifestation of atopic dermatitis in adults . The physical and environmental factors at play in adults differ from that in children and this is responsible for the different patterns of involvement. The time-honoured criteria set out by Hanifin and Rajka have come under severe criticism over the past decade or two and these criteria are even more unreliable when applied to adult cases. A revised set of criteria was developed by Williams et al and this was validated in the hospital setting and in the community . It is the opinion of this work group that these criteria should be adopted for the diagnosis of atopic dermatitis in adults in South Africa, even though a recent study has shown that these criteria are not reliable when applied in the low prevalence, rural areas of the Eastern Cape, a study done on children. These criteria are set out in the following: The diagnosis of atopic dermatitis in adults is primarily clinical; special investigations only contribute in identifying external aggravating factors Revised Criteria for the Diagnosis of Atopic Dermatitis1:
Total IgE-levels are significantly raised in about 80% of cases, being normal in the rest, therefore reducing the value thereof in the diagnosis. The level of IgE does not correlate with severity of the dermatitis and 15% of non-atopic individuals have raised IgE levels. Several conditions have to be considered in the differential diagnosis of AD in adults, as listed in the next table. These have to be excluded on clinical grounds and by employing appropriate investigations. Differential diagnosis of atopic dermatitis in adults:
The severity of dermatitis in individual cases can be measured and monitored in several ways. The SCORAD index (SCOring Atopic Dermatitis) uses clinical parameters developed by the European Task Force on Atopic Dermatitis (1990-92) where a patient is compared to a set of standard colour photographs and parameters are scored on an easy to use computer programme, which assigns a numerical value to the severity of the dermatitis at that point in time. The Objective Severity Assessment of Atopic Dermatitis (OSAAD) score utilizes non-invasive bioengineering methods and computer-assisted estimates of disease extent to measure transepidermal water loss, stratum corneum hydration and affected body surface. A numerical score is then produced to denote severity. The reliability and sensitivity of this test in adult patients have been confirmed recently , when it was compared with SCORAD and it also significantly correlated with serum levels of Interleukin-16, which seems to be a sensitive and reliable marker of disease activity in atopic dermatitis , also in adults. The Three Item Severity score only utilizes excoriations, erythema and papulation / vesiculation as parameters and best reflects the severity of dermatitis from the patient’s point of view. This is also far more practical for use in clinical practice. It is the opinion of this panel that the severity assessment should be simplified to make it easy to use in practice. The aim is to stratify treatment accordingly in individual patients. We propose:
A flare of dermatitis can be defined as any episode of “upgrading” of the dermatitis from one group to the next, e.g. mild to moderate. Severity of Atopic Dermatitis:
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