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ORIGINAL ARTICLE
Year : 2007  |  Volume : 52  |  Issue : 2  |  Page : 83-88
Diagnostic criteria for atopic dermatitis in adult Thai population


Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

Correspondence Address:
Rungsima Wanitphakdeedecha
Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Phran-nok Rd. Bangkoknoi, Bangkok, 10700
Thailand
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.33284

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   Abstract 

Context: Atopic dermatitis is a common disease that is diagnosed by use of Hanifin, Lobitz and Rajka's criteria based on patient history and clinical features. However these criteria are not suitable for population-based studies.
Aims: The purpose of this study is to develop a minimum list of diagnostic criteria for atopic dermatitis that is sensitive, specific, reproducible, noninvasive, applicable to adult Thai population and easy to perform in population-based studies.
Settings and Design: This study was conducted at Department of Dermatology, Faculty of Medicine Siriraj Hospital Mahidol University, Bangkok, Thailand. Materials and Methods: The new cases of typical mild to moderate atopic dermatitis and exactly age-matched and sex-matched controls presenting with an inflammatory skin disease other than atopic dermatitis were selected from Department of Dermatology, Faculty of Medicine Siriraj Hospital. Each subject was examined with reference to 31 clinically diagnostic features of atopic dermatitis proposed by Hanifin and Rajka. One hundred and forty patients (70 cases and 70 controls) were studied. Statistical Analysis Used: Sensitivity and specificity of each criterion was calculated using the dermatologist's diagnosis as the standard. Regression techniques were then used to derive a minimum set of diagnostic criteria. Results: Using multiple logistic regression techniques, a minimum set of diagnostic criteria for atopic dermatitis was derived: visible flexural dermatitis, history of flexural dermatitis, duration of rash >6 months and visible dry skin. Conclusions: A minimum list of diagnostic criteria for atopic dermatitis was derived that should be of use in Thai population-based studies.


Keywords: Atopic dermatitis, diagnosis, diagnostic criteria


How to cite this article:
Wanitphakdeedecha R, Tuchinda P, Sivayathorn A. Diagnostic criteria for atopic dermatitis in adult Thai population. Indian J Dermatol 2007;52:83-8

How to cite this URL:
Wanitphakdeedecha R, Tuchinda P, Sivayathorn A. Diagnostic criteria for atopic dermatitis in adult Thai population. Indian J Dermatol [serial online] 2007 [cited 2019 Jun 16];52:83-8. Available from: http://www.e-ijd.org/text.asp?2007/52/2/83/33284


Atopic dermatitis is a common disease, which presents as an acute, subacute or chronic pruritic dermatosis with other cutaneous findings, such as xerosis, excoriations and lichenification, often occurring in persons with asthma, allergic rhinoconjunctivitis, contact urticaria or with a family history of the same. The disease may cause physical suffering, significant disability and deep anguish for the patient and family. The reported incidence of atopic dermatitis indicates that a significant percentage of the general population, with a prevalence of 3-23%, [1] is affected with this ailment at some point in their lives. Recent studies in Thai children and adolescents with atopic dermatitis have reported prevalence of 9% [2] and 9.4% [3] respectively.

The absence of diagnostic criteria for atopic dermatitis prompted Hanifin, Lobitz and Rajka to suggest major and minor diagnostic criteria based on patient history and clinical features. [4] However, their criteria are unsuitable for population-based studies. [5]

A previous study entitled The U.K. Working Party's Diagnostic Criteria for Atopic Dermatitis was the outcome of a working party of thirteen dermatologists who aimed at developing a minimum list of reliable discriminators for atopic dermatitis.

Using the key physician's clinical diagnosis as a gold standard, the sensitivity and specificity of each of the 31 diagnostic criteria were tested and a minimum set of diagnostic criteria was derived. [6] The criteria consist of one major criterion which is itchy skin plus three or more of the minor criteria: history of flexural area involvement, history of dry skin, onset under the age of two, personal history of asthma and visible flexural dermatitis. [7]

There are some variations among studies about atopic dermatitis in Western, European and Asian countries that may be explained by racial or ethnic differences in the frequency, symptoms and severity of atopic dermatitis. These findings may be related to differences in genetics, climate, environment and pollution. It has been postulated that allergic diseases are more likely to develop in Asian countries because of the climate and allergen exposures.

The purpose of this study was thus to develop a minimum set of diagnostic criteria for atopic dermatitis that is sensitive, specific, reproducible, noninvasive, applicable to a wide range of the adult Thai population and easy to perform in population-based and clinical studies.


   Materials and Methods Top


Using a study design similar to that used by the U.K. Working Party for deriving diagnostic criteria for atopic dermatitis, patients aged more than 13 years were selected from the Dermatology Clinic at Department of Dermatology, Faculty of Medicine Siriraj Hospital during October 1997 to September 2000. Seventy consecutive new cases of typical mild to moderate atopic dermatitis and seventy exactly age-matched and sex-matched controls with an inflammatory skin disease other than atopic dermatitis were examined by trained dermatologists and the clinical diagnosis and other demographic features such as age and sex had been noted, using the list of 31 diagnostic criteria, 13 of which were history and the remainder were physical signs, contained in Appendix 1. Dermatologists recorded a positive (yes) or negative (no) response to each of the criteria on a case record form. The precise wording of the questions used in the study is shown in Appendix 2 and the standard definitions of physical signs were provided for the dermatologists given in Appendix 3.

The protocol and informed consent documents were reviewed and approved by ethics committees at Faculty of Medicine Siriraj Hospital. Informed consent was obtained from all subjects and the study protocol conformed to the guidelines of the 1975 Declaration of Helsinki.

Sensitivity and specificity of each criterion were calculated using Chi-square test statistics in the SPSS/Win statistical software package. Relative value was also calculated by adding the sensitivity and specificity together and subtracting 100. [8]

Multiple forward stepwise logistic regression approach was carried out using the SPSS/Win software package. Variables were retained in the model if their retention significantly improved the fit of that model at the 5% level of statistical significance.


   Results Top


One hundred and forty subjects (70 cases and 70 controls) were recruited into the study. Diagnoses of the 70 control patients used in the study are shown in [Table - 1]. Of the 30 eczema/dermatitis cases, 11 were contact dermatitis, five were hand/foot dermatitis, five were nonspecific eczema, four were seborrheic dermatitis, three were dyshidrosis and there was one each of exfoliative dermatitis and autosensitisation.

Of the 19 other inflammatory dermatoses, six were urticaria, three were psoriasis, two were keratosis pilaris, two were pruritic papular eruption in human immunodeficiency virus (HIV), two were drug eruption and there was one each of vasculitis, systemic lupus erythematosis, folliculitis and lichen planus.

Of the seven fungal infections, four were tinea versicolor, two were tinea corporis and one was tinea cruris.

All controls were exactly age-matched and sex-matched with cases. The minimum and maximum age was 13 and 64 respectively, mean age was 28.79 (SD=11.22).

The sensitivity and specificity of the 31 individual criteria tested in this study are shown in [Table - 2]. Relative value (RV) is derived by adding the sensitivity and specificity and subtracting 100. All χ2 values over 3.84 are significant at the 5% level and values exceeding 6.63 are significant at the 1% level.

The three most useful criteria judged from the ranking of the RV or χ2score, are flexural dermatitis (RV = 72.9, χ2 = 74.695), rash-affected skin creases (RV = 70.0, χ2 = 70.337) and duration > 6 months (RV = 41.4, χ2 = 25.940)

Using multiple forward stepwise logistic regression approach, nine criteria with a χ2 value of > 10, were recruited to enter for analysis. The results of the multiple forward stepwise logistic regression modelling are the minimum set of diagnostic criteria which are: visible flexural dermatitis, history of flexural dermatitis, duration > 6 months and visible dry skin. The goodness of fit of the regression model to the data was 99.86 and accuracy was 87.14%.

The final regression equation for the log odds of AD is as follows:

Log odds of AD = -4.49 + 2.49 visible flexural dermatitis + 2.73 history of flexural dermatitis + 2.01 Duration > 6 months + 1.94 visible dry skin.


   Discussion Top


Atopic dermatitis is a common skin disease, which is mainly diagnosed by history and clinical presentation. The U.K. Working Party's diagnostic criteria for atopic dermatitis were developed and founded to be valid, repeatable and acceptable in population-based studies. [9] These criteria composed of history of flexural involvement, history of dry skin, onset under the age of two, personal history of asthma, history of a pruritic skin condition and visible flexural dermatitis.

In 2004, Wisuthsarewong and Viravan [10] derived a minimum set of diagnostic criteria for atopic dermatitis in Thai children. The criteria consisted of history of itchy rash, history of flexural dermatitis, chronicity more than six months, visible xerosis, periorbital dermatitis and perifollicular accentuation. The authors suggested the differences in age group, genetic background, cultural and environmental factors in Thailand might be responsible for the differences in diagnostic criteria. However, clinical features and diagnostic criteria might vary with age. So the diagnostic criteria for children might not be suitable for adults.

According to our study which used a study design similar to that used by the U.K. Working Party, the diagnostic criteria for atopic dermatitis in adult Thai population are visible flexural dermatitis, history of flexural dermatitis, duration of rash >6 months and visible dry skin. Our adult criteria are similar to that of Wisuthsarewong and Viravan's children criteria except for minor criteria, which are periorbital dermatitis and perifollicular accentuation. This might be explained by the localization of skin lesions tending to persist in adolescents and adults [11] Even though there are only few reports about the differences of minor features of atopic dermatitis among age groups. [12],[13] We still believe that some features may show age-related differences, although insufficient data are available and further study is need to confirm the ethnic and age-related differences in the minor criteria.

 
   References Top

1.Rothe MJ, Grant-Kels JM. Atopic dermatitis: An update. J Am Acad Dermatol 1996;35:1-13.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Vichayanond P, Jirapohgsananuruk O, Tuchinda M, Visitsunthorn N. Prevalence of asthma, rhinitis and eczema in children from the Bangkok area using the ISAAC questionnaires. J Med Assoc Thai 1998;81:175-84.  Back to cited text no. 2      
3.Vichayanond P, Sunthornchart S, Singhirannusorn V, Ruangrat S, Kaewsomboon S, Visitsunthorn N. Prevalence of asthma, allergic rhinitis and eczema among university students in Bangkok. Respir Med 2002;96:34-8.  Back to cited text no. 3      
4.Hanifin JM, Rajka G. Diagnostic features of atopic dermatitis. Acta Derm Venereol (Stockh) 1980;92:44-7.  Back to cited text no. 4      
5.Svensson A, Edman B, Moller H. A diagnostic tool for atopic dermatitis based on clinical criteria. Acta Derm Venereol Suppl (Stockh) 1985;114:33-40.  Back to cited text no. 5      
6.Williams HC, Burey PG. The UK working party's diagnostic criteria for atopic dermatitis I: Derivation of a minimum set of discriminators for atopic dermatitis. Br J Dermatol 1994;131:383-96.  Back to cited text no. 6      
7.Williams HC, Burney PG, Pembroke AC, Hay RJ. The UK working party's diagnostic criteria for atopic dermatitis. III. Independent hospital validation. Br J Dermatol 1994;131:406-16.  Back to cited text no. 7      
8.Youden WJ. Index for rating diagnostic tests. Cancer 1950;3:32-5.  Back to cited text no. 8  [PUBMED]    
9.Williams HC, Burney PG, Pembroke AC, Hay RJ. Validation of the UK diagnostic criteria for atopic dermatitis in a population setting. UK Diagnostic criteria for atopic dermatitis working party. Br J Dermatol 1996;135:12-7.  Back to cited text no. 9      
10.Wisuthsarewong W, Viravan S. Diagnostic criteria for atopic dermatitis in Thai children. J Med Assoc Thai 2004;87:1496-500.  Back to cited text no. 10  [PUBMED]    
11.Eigenmann PA. Clinical features and diagnostic criteria of atopic dermatitis in relation to age. Pediatr Allergy Immunol 2001;12:69-74.  Back to cited text no. 11  [PUBMED]    
12.Lee HJ, Cho SH, Ha SJ, Ahn WK, Park YM, Byun DG, et al . Minor cutaneous features of atopic dermatitis in South Korea. Int J Dermatol 2000;39:337-42.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]  
13.Kang KF, Tian RM. Criteria for atopic dermatitis in a Chinese population. Acta Derm Venereol Suppl (Stockh) 1989;144:26-7.  Back to cited text no. 13  [PUBMED]    



 
 
    Tables

  [Table - 1], [Table - 2]

This article has been cited by
1 Validation of the diagnostic criteria for atopic dermatitis in the adult Thai population
Wanitphakdeedecha, R., Tuchinda, P., Sivayathorn, A., Kulthanan, K.
Asian Pacific Journal of Allergy and Immunology. 2007; 25(2-3): 133-138
[Pubmed]



 

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