Atopic dermatitis (Besnier's disease)

Last Updated: 2025-07-14

Author(s): Anzengruber F., Navarini A.

ICD11: EA80

1/25

Willan, 1808

Neurodermatitis, endogenous eczema, atopic dermatitis, prurigo Besnier, neurodermatitis diffusa, neurodermatitis constitutionalis sive atopica, asthma eczema.

Chronic recurrent atopic disease with eczema and often severe itching.

  • Prevalence: approx. 5-20% of all children worldwide , 1-3% of adults
  • In adults, the prevalence decreases, however many people originally affected by A.D. still have hand and foot eczema. 
  • More common in cities and western countries
  • Men are slightly more frequently affected than women
  • In about 70% there is a positive family history
  • 1 parent with atopic dermatitis: 2-3 times ↑ risk of a child developing atopic dermatitis (approx. 50%)
  • 2 parents with atopic dermatitis: 3-5 times ↑ risk of a child developing atopic dermatitis (approx. 75%)
  • Monozygotic twins: 73% concordance
     

  • Extrinsic atopic eczema
    • IgE-mediated
    • Approx. 60-70 % of all patients
    • Frequent sensitization to food or environmental allergens
  • Intrinsic atopic eczema
    • Non IgE-mediated (not elevated)
    • No sensitization to food or environmental allergens
    • Approx. 30-40% of cases
    • Possibly own entity

  • Genetic factors (familial atopy).
  • ↑ IgE formation, pathologically more Th2 cells (compared to Th1).
  • Diets for pregnant women do not reduce the risk to the newborn.
  • Dysregulation of the cellular (Th2 ↑) and humoral (IL-4, IL-5, IL-10, IL-13, 16) immune system.
  • Disruption of the skin barrier with dehydration of the skin.
  • Disorders in filaggrin structure due to various mutations (FLG, SPINK5).
  • Filaggrin can be broken down into the Natural Moisturizing Factor NMF when the stratum corneum is dry. This binds water and is therefore a moisture reserve. If filaggrin is missing, this reserve is also missing. 
  • Long showers or baths with water that is too warm. We recommend reducing the bath or shower time to 1-2 minutes with lukewarm water.
  • Very warm environments with low humidity.
  • ↓ Regreasing. 
    • Pathological, microbial colonization: e.g: Staph. aureus, enterotoxins, Pityrosporum ovale
    • Infections: Sinusitis, dental infections etc.
    • Psychological and emotional stress.
  • Type I sensitization (e.g. to house dust mite, animal epithelia, mould, pollen, etc.) is frequently observed in atopic patients. 
    • In about 30-80% of cases, there is a type I sensitization to certain foods.
       

  • Erythematous, confluent, often itchy vesicles and papules. There are linear excoriations with severe pruritus. Secondary impetiginization and lichenification common.
  • Further atopic manifestations: white dermographism, xerosis cutis or ichthyosis, fur cap-like hairline, Dennie-Morgan fold, Hertoghe's sign, earlobe rhaghade, perlèche, palmar hyperlinearity, cataracta neurodermitica, possibly diffuse alopecia, dermopathic lymphadenopathy.
     

  • Medical history (family history, personal history, atopic diathesis?, other atopic diseases? Increased bacterial or viral infections? Food allergies).
  • Clinic
  • Laboratory: eosinophilia?, IgE value (IgE > 150 kU/l), adults: rx1, rx2; children: rx1, rx2, fx5
  • Atopy score according to Diepgen 

 

Atopy score according to Diepgen et al. Source: Acta Derm Venereol 1989; Suppl 144: 50-54

  Points
Itchiness when sweating 3
Wool intolerance 3
Xerosis of the skin 3
White dermographism 3
Hertoghe sign 3
Milk scab 2
Perlèche 2
Cheilitis 2
Enhanced hand line drawing 2
Pityriasis alba 1
Positive family history of atopy    1
Rhinitis 1
Conjunctivitis 1
Asthma 1
Dyshidrosis 1
Dennie Morgan wrinkle 1
Nickel sensitisation 1
Food intolerance 1
Facial erythema 1
Light hypersensitivity 1
Follicular hyperkeratosis 1
Score  

0-  6 points: atopy unlikely

7-10 points: atopy possible

 >10 points: atopy likely

 

Other scoring systems:

  • Always the Eczema Area and Severity Index (determine  ): The spread of the eczema is measured. Erythema, edema, excoriations and lichenification are rated with points between 0-4. Excel table with all scores available. EASI
  • No longer recommended, as objective and subjective data are mixed: SCORAD ("Severity Scoring of Atopic Dermatitis") 
    1. Involvement of the BSA (body surface area).
    2. Determination of severity (1= mild, 2= moderate, 3= severe) of erythema, oedema/papularity, oozing/crusting, excoriation, lichenification, dryness
    3. VAS for itching and insomnia
    • SCORAD: A/5+7B/2+C. As subjective and objective criteria are mixed, the score is used less in studies than the EASI score.

  • Infants: face, diaper area. The nose often remains free (clinical clue).
  • Childhood and adults: More likely flexural eczema (elbow and knee bends)
     

Allergic rhinoconjunctivitis, asthma, food allergy, urticaria, eosinophilic esophagitis inquire in personal and family history.

Superficial perivascular and interstitial lymphohistiocytic/mastocytic dermatitis in the upper corium, spongiosis, spongiotic blistering, acanthosis, parakeratosis, low eosinophilia.

  • Eczema molluscatum
  • Impetiginization
  • Eczema herpeticatum
  • Erythroderma
     

  • Early skin care does not reduce the risk of atopic eczema at the age of 1-3 years (Kelleher et al. 2021). It is still controversial whether they even increase the risk of food allergies. 
  • Early introduction of peanut into the diet is now recommended for high-risk infants for peanut allergy. This is not yet clear for other foods. 
  • Probiotics: Here, too, the data is limited. However, a slight improvement in the skin condition can be expected.
  • Food supplements, vitamins, fish oil and other oils: Overall, the data is weak. Vitamin D could show a benefit. We at the USB do not recommend supplementation unless there is a deficiency.
  • Chinese medicinal herbs: A total of 3 studies were conducted (all with a very low number of patients). 2 studies showed a benefit, while one study showed no difference between the placebo and the intervention group.
     

The symptoms often disappear after childhood, but persistence and relapses do occur. A chronic recurrent course is then to be expected.

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