Indian Journal of Paediatric Dermatology

ORIGINAL ARTICLE
Year
: 2020  |  Volume : 21  |  Issue : 1  |  Page : 31--35

A study to estimate the frequency of Hanifin and Rajka's minor criteria in children for diagnosis of atopic dermatitis in a tertiary care center in South India


Navya Parthasarathy1, Aparna Palit2, Arun C Inamadar1, Keshavmurthy A Adya1,  
1 Department of Dermatology, Shri B. M. Patil Medical College Hospital and Research Centre, BLDE (DU), Bijapur, Karnataka, India
2 Department of Dermatology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Correspondence Address:
Dr Arun C Inamadar
Department of Dermatology, Shri B. M. Patil Medical College Hospital and Research Centre, BLDE (DU), Bijapur - 586 103, Karnataka
India

Abstract

Background: Atopic dermatitis (AD) is a chronic, relapsing inflammatory skin disease characterized by intense pruritus. Hanifin and Rajka's criteria is the most common diagnostic criteria used in the hospital setup, which consists of 4 major and 23 minor criteria. The frequency of minor criteria may vary population wise. Aims: The aim of the study is to estimate the frequency of minor diagnostic criteria of Hanifin and Rajka in children with AD. Methodology: A hospital-based cross-sectional study of 174 children (≤16 years) with AD, was conducted based on history, clinical, and ophthalmological examination. Blood test to assess serum immunoglobulin E (IgE) level was conducted. Results: The most common minor criteria observed were Dennie–Morgan infraorbital fold (71.8%), early age of onset (67.8%), palmar hyperlinearity (67.8%), xerosis (67.2%), pityriasis alba (57.5%), and perifollicular accentuation (47.7%). Out of 143 cases whose serum was tested for IgE level, elevation was seen in 92. History of winter exacerbation was seen in 8% of the cases, while summer exacerbation was seen in none. On the ophthalmological examination of 111 cases, “high reading with no obvious keratoconus” was present in two cases while three cases were labeled as “keratoconus suspect.” Conclusion: Clinical features of AD vary with geographical location. The prevalence and severity of AD are influenced by several factors such as ethnic/racial, environmental, and dietary factors. Therefore, it is relevant for dermatologists to have a knowledge regarding common clinical features of AD in a given population for the diagnosis and thereby provide treatment to reduce the morbidity along with appropriate counseling.



How to cite this article:
Parthasarathy N, Palit A, Inamadar AC, Adya KA. A study to estimate the frequency of Hanifin and Rajka's minor criteria in children for diagnosis of atopic dermatitis in a tertiary care center in South India.Indian J Paediatr Dermatol 2020;21:31-35


How to cite this URL:
Parthasarathy N, Palit A, Inamadar AC, Adya KA. A study to estimate the frequency of Hanifin and Rajka's minor criteria in children for diagnosis of atopic dermatitis in a tertiary care center in South India. Indian J Paediatr Dermatol [serial online] 2020 [cited 2020 Jul 4 ];21:31-35
Available from: http://www.ijpd.in/text.asp?2020/21/1/31/273852


Full Text



Atopic dermatitis (AD) is a chronic, relapsing inflammatory skin disease characterized by intense pruritus. It may be seen in association with other atopic disorders such as asthma and allergic rhinoconjunctivitis.[1] Clinical features vary at different ages, population, and race wise.[2] Several diagnostic criteria exist for use in patients with AD. However, the effectiveness of these criteria in different population is highly variable as found in various studies. This is due to the variation of the prevalence of clinical features and intensity of symptoms of AD with genetic background, climate, geographical regions, food habits, socioeconomic status, availability of health-care facilities, and many other factors.[3] To enable AD diagnosis with certainty, Hanifin and Rajka propositioned a criteria commonly known as “Hanifin and Rajka's diagnostic criteria for AD.”[4] The minor criteria may vary population wise.

Prevalence of AD varies country wise and within a country, region wise.[5] India, in general, is a low-prevalence country for atopic disorders. However, as the incidence of atopy is increasing worldwide, Indian population is also experiencing the same rising trend. In the present study, we establish the frequency of Hanifin and Rajka's minor criteria in a section of South Indian children attending a tertiary health-care center in North Karnataka.

 Methodology



Our hospital-based cross-sectional study included 174 children aged 16 years and below with AD attending the dermatology clinic of the institute from November 2017 to August 2019.

In every patient, a detailed history with respect to the present age, age of onset of disease (early age of onset was defined as onset of symptoms of eczema before the age of 5 years, as considered by Nagaraja et al. and Böhme et al.),[6],[7] tendency toward cutaneous infections (described as the presence of at least two episodes of folliculitis/furunculosis/impetiginization or diagnosed herpes simplex infection in the past 1 year) and nonspecific hand/foot dermatitis (defined as the presence of itchy lesions on one or both hands/feet with erythema and papules/vesicles or scaling, with or without oozing, crusting, fissures, or lichenification),[7] recurrent conjunctivitis, itch when sweating, intolerance to wool and lipid solvents, food hypersensitivity, and influence of environmental and/or emotional factors on course of disease was obtained from the parents.

Clinical examination was done to record the presence of xerosis [Figure 1], ichthyosis, palmar hyperlinearity (defined by the presence of more than 5 prominent lines longer than 1 cm running across palm, similar to Böhme et al.),[7] keratosis pilaris [Figure 2] (more than 20 follicular, keratotic papules involving at least posterolateral aspects of upper arms or thighs),[7] nipple eczema, cheilitis, Dennie–Morgan infraorbital folds [Figure 3] (defined as present when at least one of the infraorbital creases running laterally crossed the pupillary midline, as described by Mevorah et al.),[8] orbital darkening, facial pallor [Figure 4] or erythema (facial erythema in our study was defined as erythema over cheeks without papules/scaling and facial pallor as skin pallor which is often accentuated perinasally and/or periorally), pityriasis alba [Figure 5]a and [Figure 5]b, anterior neck folds (defined as prominent horizontal skin crease(s) on anterior aspect of neck, when head is upright), perifollicular accentuation (defined as dermatitis enhanced around hair follicles in ≥2 areas with a diameter >5 cm),[7] and white dermographism. Ophthalmological evaluation to see for the presence of keratoconus and anterior subcapsular cataract was performed by ophthalmologist. Blood test to assess serum immunoglobulin E (IgE) level was conducted at laboratory. In addition, we evaluated the presence of lichen spinulosus [Figure 6] as minor diagnostic clue of AD.{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}

Statistical Package for the Social Sciences software v.23.0 was used for the analysis of data. Categorical data were expressed as frequencies and percentages. For continuous variables, the summary statistics of mean ± standard deviation (SD) were used. Our data were compared with previous Indian studies [Table 1].{Table 1}

 Results



A total of 174 patients were enrolled in the study. The mean age (±SD) of the patients was 4.6 (±3.9) years. Out of 174 cases included in our study, 88 were male and 86 were female.

The most common minor criteria observed among the participants was Dennie–Morgan infraorbital fold, i.e., in 125 (71.8%) of the 174 cases. The other common minor criteria observed were hyperlinear palms, xerosis, pityriais alba, and perifollicular accentuation. Early age of onset was seen in 118 children (67.8%). Among the 174 cases, 143 were tested for serum IgE levels out of which 92 cases showed elevation. The remaining 31 patients were not willing for the test. Ophthalmological examination of 111 cases aged 2 years and above revealed “high reading with no keratoconus” in two cases while three were labeled as “keratoconus suspect.” Nipple eczema, recurrent conjunctivitis, food hypersitivity, and white dermographism were not observed in any of the patients. Detailed frequency of minor criteria is presented in [Figure 7]. Apart from these, lichen spinulosus was present in 18 children.{Figure 7}

 Discussion



AD is a chronic inflammatory cutaneous disease causing great morbidity and psychological stress in both patients and their parents. Prevalence of clinical features and intensity of symptoms of AD may vary with genetic background, climate, geographical regions, food habits, socioeconomic status, availability of health-care facilities, and many other factors. Various diagnostic criteria are available for the diagnosis of AD. The most important and commonly used ones are; Hanifin and Rajka's criteria, U. K. diagnostic criteria (William et al., 1994), and ISAAC (International Study of Asthma and Allergies in childhood) questionnaire (1995).[3] Hanifin and Rajka's criteria is suitable for use in hospital setup by clinicians. It consists of 4 major criteria and 23 minor criteria. Three from each category are necessary for diagnosing AD.[4]

Mean age of the patients was 4.6 ± 3.9 years. Similar finding was observed in the studies conducted by Dhar et al. and Nagaraja et al., on children aged 3 months to 12 years, in which it was 4.37 ± 3.42 years and 4.04 ± 3.42 years, respectively.[6],[9]

The most common finding among minor criteria observed in our study was the presence of Dennie–Morgan infraorbital folds which was seen in 71.8% of the cases. Few other Indian studies also noted similar high findings.[6],[10]

Palmar hyperlinearity and xerosis were other commonly observed criteria in our study. Similar higher values of palmar hyperlinearity and xerosis were also noted by Kanwar et al.[10] The high frequency of xerosis in our study could be attributed to the dry climate in the study region.

Criteria such as pityriasis alba and perifollicular accentuation were also seen in higher frequency in our study, i.e., 57.5% and 47.7%, respectively. The high value of pityriasis alba is in contrast to the finding by Agrawal et al.[11] This difference is probably due to the higher mean age of the participants in their study, as pityriasis alba is commonly observed in children. Perifollicular accentuation was comparatively seen in higher frequency in our study than in few other Indian studies where it was around 20%.[6],[10]

Serum IgE level was screened in 143 cases in our study, out of which 92 showed elevated levels. This finding is in conformity to that reported by Agrawal et al., where raised levels of serum IgE was seen in 68.7% of the cases.[11]

Ocular examination to diagnose keratoconus and anterior subcapsular cataract was performed by ophthalmologist in our hospital. Out of 174 cases, ophthalmological examination was done in 111 cases as the remaining children aged below 2 years were noncompliant. Anterior subcapsular cataract was not observed among any of the children examined. “High reading but no obvious keratoconus” was noted in two cases, while three were labeled as “keratoconus suspect” on examining the children for the presence of keratoconus. The parents of these five children were advised to follow-up once in 6 months for ophthalmological examination of their child. “Kerataconus suspect” is defined by the presence of asymmetric bowtie/skewed radial axes pattern on videokeratography in the absence of slit-lamp findings or scissoring on retinoscopy.[12] Nagaraja et al. in their study did not observe keratoconus or anterior subcapsular cataract in any of the patients.[6] Keratoconus is postulated to arise as result of chronic rubbing of the eyes in AD patients.[13]

Nagaraja et al. observed that intolerance to wool and lipid solvents was present in 41% of the children.[6] Furthermore, Kanwar et al. noted intolerance to wool in 28% of the children in their study.[10] In our study, history of intolerance to wool was present in only 2.3% of the cases, while none gave history of intolerance to lipid solvents. This could be probably due to the fact that majority of the patients were minimally exposed to woolen items and parents used very little soap when washing their young children.

Out of 174 cases in our study, 14 of the cases gave a history of exacerbation of the lesions during winter season while none gave history of summer exacerbation. This is in contrast to other studies conducted at northern and eastern parts of India where winter and summer exacerbation were comparatively higher.[6],[14],[15] This could be attributed to the prolonged and harsh winter and summer seen in northern and eastern India compared to the southern part.

Criteria such as nipple eczema, recurrent conjunctivitis, food hypersensitivity, and white dermographism were not observed in any of the 174 cases in our study. Nagaraja et al. and Sarkar et al. also noted that none of the patients gave history of food intolerance which was in accordance with our findings.[6],[15] Kanwar et al. in their study did not find any significance of nipple eczema, white dermographism, and recurrent conjunctivitis.[10] Nipple eczema was found to be nonspecific in a study by Nagaraja et al.[6]

Apart from these 23 criteria, we also examined our cases for the presence of lichen spinulosus. Lichen spinulosus is commonly observed in patients having atopic diathesis.[16] Out of the 174 patients, 18 exhibited these lesions which accounted for 10.3%. However, in our study, as no controls were taken, significance of lichen spinulosus in AD could not be established. This finding indicates that while diagnosing AD in a patient, lichen spinulosus could be a helpful marker.

 Conclusion



From the above discussion, it is evident that clinical features of AD may be variable. Prevalence of AD varies country wise and within a country, region wise. The prevalence and severity of AD are influenced by several factors such as ethnic/racial factors, environmental factors, and dietary habits. Therefore, it is relevant for the dermatologists to have a knowledge regarding common clinical features of AD in a given population to diagnose the condition and thereby provide treatment to reduce the morbidity along with appropriate counseling.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1James WD, Berger TG, Elston DM, editors. Atopic dermatitis, eczema, and noninfectious immunodeficiency disorders. In: Andrews' Diseases of the Skin: Clinical Dermatology. 12th ed. Philadelphia: Elsevier Saunders; 2016. p. 62-70.
2Sharma L. Diagnostic clinical features of atopic dermatitis. Indian J Dermatol Venereol Leprol 2001;67:25-7.
3Brenninkmeijer EE, Schram ME, Leeflang MM, Bos JD, Spuls PI. Diagnostic criteria for atopic dermatitis: A systematic review. Br J Dermatol 2008;158:754-65.
4Ardern-Jones MR, Flohr C, Reynolds NJ, Holden CA. Atopic eczema. In: Griffiths CE, Barker J, Bleiker T, Chalmers R, Creamer D, editors. Rook's Textbook of Dermatology. 9th ed., Vol. 41. Oxford: Blackwell Publishing 2016. p. 1-41, 34.
5Kanwar AJ, De D. Epidemiology and clinical features of atopic dermatitis in India. Indian J Dermatol 2011;56:471-5.
6Nagaraja, Kanwar AJ, Dhar S, Singh S. Frequency and significance of minor clinical features in various age-related subgroups of atopic dermatitis in children. Pediatr Dermatol 1996;13:10-3.
7Böhme M, Svensson A, Kull I, Wahlgren CF. Hanifin's and Rajka's minor criteria for atopic dermatitis: Which do 2-year-olds exhibit? J Am Acad Dermatol 2000;43:785-92.
8Mevorah B, Frenk E, Wietlisbach V, Carrel CF. Minor clinical features of atopic dermatitis. Evaluation of their diagnostic significance. Dermatologica 1988;177:360-4.
9Dhar S, Kanwar AJ. Epidemiology and clinical pattern of atopic dermatitis in a North Indian pediatric population. Pediatr Dermatol 1998;15:347-51.
10Kanwar AJ, Dhar S, Kaur S. Evaluation of minor clinical features of atopic dermatitis. Pediatr Dermatol 1991;8:114-6.
11Agrawal DP, Lavanya MS, Sathyanarayana BD, Swaroop MR, Jain M, Dukkipati M. Evaluation of clinical diagnostic criteria of atopic dermatitis and serum IgE levels in patients with chronic eczema. Int J Health Sci Res 2015;5:84-9.
12Li X, Yang H, Rabinowitz YS. Keratoconus: Classification scheme based on videokeratography and clinical signs. J Cataract Refract Surg 2009;35:1597-603.
13Leung DY, Eichenfield LF, Boguniewicz M. Atopic dermatitis (Atopic eczema). In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K, editors. Fitzpatrick's Dermatology in General Medicine. 8th ed. The McGraw-Hill Companies; 2012. p. 165-82.
14Dhar S, Mandal B, Ghosh A. Epidemiology and clinical pattern of atopic dermatitis in 100 children seen in a city hospital. Indian J Dermatol 2002;47:202-204.
15Sarkar R, Kanwar AJ. Clinico-epidemiological profile and factors affecting severity of atopic dermatitis in North Indian children. Indian J Dermatol 2004;49:117-22.
16Forman SB, Hudgins EM, Blaylock WK. Lichen spinulosus: Excellent response to tretinoin gel and hydroactive adhesive applications. Arch Dermatol 2007;143:122-3.