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American Journal of  Medical 
Science and Innovation (AJMSI) 

A Clinical Profile Observational Study in a Tertiary Care Hospital of  Children with
Atopic Dermatitis

Naveen Divakaran1*

Volume 4 Issue 2, Year 2025
ISSN: 2836-8509 (Online)

DOI: https://doi.org/10.54536/ajmsi.v4i2.4413
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: January 12, 2025
Accepted: February 20, 2025
Published: July 09, 2025

Atopic dermatitis, which is simply referred to as eczema, is a common persistent skin 
condition that impacts children and infants across the globe, accounting for 10-30% of  
them. Extreme itching, skin swelling, infections, and additional itching characterize it. There 
has been a rise in the incidence of  the disease in the last 30 years primarily due to the 
effluent environment, breastfeeding, increased prevalence and awareness of  the disease, and 
urbanization. The present study aimed to describe the clinical aspects of  children diagnosed 
with atopic dermatitis, fulfilling the Hanifin and Rajka clinical and visiting outpatient pediatrics 
and derma. Also, the study had a specific objective of  identifying the possible factors that 
could worsen atopic dermatitis among the participants in the study. This trial covered 59 kids 
with atopic dermatitis; they filled questionnaires concerning their age, sex, complaints, things 
that worsen their condition, age of  disease onset, and related symptoms. The other explored 
history included dietary one, breastfeeding history and the family or individual atopic 
history. A clinical assessment was carried out comprising localization and type of  lesions 
and other features. It was revealed that females experience more atopic dermatitis than males 
and most of  the children are affected from an early age. Food intolerance was the most 
common reason reported, with milk as the most frequent substance, followed by wool and 
lipid solvents. Half  of  the patients showed aggravation during the cold season. Dermatitic 
lesions involved the face and flexural areas more compared with the limbs. We found that 30 
percent of  the patients took complementary therapies, while 30 percent were malnourished. 
This work examined 59 children with atopic dermatitis ranging from 2 months to 12 years. 
It found that females were more affected than males, with an M: F ratio of  0.84:1. The most 
common manifestation experienced by the patients was purpuritus which was worse at night 
in about one-third of  the population. Recurrence during the particular season was noticeable 
in half  of  the patients. Facial rash and flexural areas of  extremities were found to be more 
affected by dermatitic lesions. 

Keywords
Atopic Dermatitis, Children’s 
Health, Observational Study, 
Pediatrics, Precipitating Factors

1 Sheikh Khalifa Medical City, United Arab Emirates
* Corresponding author’s e-mail: duttusan010@gmail.com

INTRODUCTION
Eczema, also referred to as atopic dermatitis, is among 
the most frequent persistent, relapsing skin diseases in 
infancy and childhood. It is manifested in inflammation 
and pruritus and also physiological skin dysfunction 
(Bieber, 2022). Such a condition is frequent in those 
individuals who had asthma, or allergic rhinitis in the 
family, or had it themselves at some point; it is typical for 
early childhood (Frazier & Bhardwaj, 2020). Estimates for 
children indicate that the incidence of  atopic dermatitis 
is between 10% and 20% in the United States, Japan, 
Australia and other developed nations (Faye et al., 2024). 
Estimations to this effect suggest that the current status 
of  this disease poses considerable threat to global public 
health (Hadi et al., 2021). According to data, modern 
children are affected by atopic dermatitis more than three 
times than in the 1960s (Becerril-Ángeles et al., 2023). As 
to why the incidence has started rising, we are yet to fully 
understand. The prevalence of  the said diseases above, 
however, varies greatly across nations with similar ethnic 
groups, suggesting that there is strong influence of  the 
environment in the manifestation of  diseases (Bylund 
et al., 2020). The exact relationship between atopic 

dermatitis and atopy is not well understood; however, 
the following affiliations are possible. It is important 
to note that as many as 60% of  the children with the 
clinical phenotype, although identified as atopic, show 
no signs of  IgE-driven sensitization to food allergens 
(Mocanu et al., 2021). Also, there is no specific test for 
atopic dermatitis diagnosis, as well as no specific physical 
sign that would separate this disease from other similar 
conditions (Frazier & Bhardwaj, 2020).

Aims and Objective
In this study, the goal was to describe initial clinical 
characteristics of  the children, who suffer from atopic 
dermatitis. It was done directly by enrolling people affected 
by the condition, based on the Hanifin and Rajka defining 
criteria, from the pediatric and dermatology outpatient 
departments. Moreover, the literature expanded its 
examination, aiming to identify factors that occasion 
flare in atopic dermatitis in the specified subpopulation. 
This study also seeks to incorporate an assessment of  
the symptomatology and likely precipitating factors in 
atopic dermatitis among children to offer substantive 
information on its management.



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LITERATURE REVIEW
Epidemiology and Impact on Pediatric Populations
Eczema cannot be restricted by age and therefore can start 
from the early infancy, which is distinguished by 75% of  
the cases with the first signs and symptoms by six months 
old. There is genetic susceptibility to develop atopic 
dermatitis (Barbarot et al., 2022). From the epidemiologic 
data it is seen that atopy risk is higher if  either or both 
the parents are suffering from the disorder. It is noted 
that atopic dermatitis develops at the first three months 
of  life in infants from atopic mothers in more than a 
quarter of  cases (Ezzedine et al., 2020). Over 50 per cent 
of  the children who develop an allergy exhibition from 
an atopic parent are affected by the time they are two 
years old (Dierick et al., 2020). If  both parents possess 
the disease, then, the rate is higher. Most of  the genetic 
factors are fixed in atopic dermatitis (Bylund et al., 2020). 
Twin studies showed that if  one of  the identical twins, 
i.e. the monozygotic twin, develops atopic dermatitis it is 
extremely likely that the other twin also will develop the 
disease, in 86% of  cases; on the other hand, if  one of  the 
fraternal twins, i.e. the dizygotic twin gets the disease the 
other twin will develop the disease only in 21% of  cases 
(Hartmane, 2024). 
Moreover, infections of  the skin due to bacteria, viruses, 
or fungi (for example; Staphylococcus aureus, Herpes 
simplex, Molluscum contagiosum, etc.) are among those 
who are detected more in patients with atopic dermatitis 
(Alexander et al., 2020). There is a strong correlation 
between food allergy and atopic dermatitis including 
the first occurrence of  the skin condition (Dierick et 
al., 2020). These are some of  the primary food allergies 
that are frequently observed; eggs, milk and any dairy 
products, fish, peanuts, soybeans, wheat and tree nuts 
(Domínguez et al., 2020). As can be seen, even if  the 
disease becomes worse when the patient is exposed to 
allergens, irritants or infections, thus looking clinically 
like the symptoms manifested during the intake of  foods 
that are causing an adverse reaction, the case is tricky to 
diagnose (Papapostolou et al., 2022).

Clinical Manifestations and Severity
Atopic dermatitis is an episodic eczema type skin disease 
and thereby has been found to have complaints that 
come in cycles of  increase and decrease (Wollenberg et 
al., 2023). They seem to be highly related to the age and 
stage of  the disease, and the worst presented in childhood 
and get better in adolescence and adulthood (Chovatiya, 
2023). Signs are that it is dry, becomes red skinned and 
the skin frequently develops a tendency of  itching. The 
itching may be very severe, to the extent that the patient 
can hardly carry out his or her daily activities (Mocanu 
et al., 2021). Common rashes appear in the regions such 
as elbows, behind the knees, wrists, cheeks, and neck 
of  an affected person. The texture of  the rash depends 
with the stage: acute lesions are associated with pus and 
crusting while the chronic ones are associated with thick 

lichenification (Hui-Beckman et al., 2023). Other signs 
which are also manifested with this skin condition are 
hyper linearity of  palms, skin ulcerations, infections, 
and sleeplessness due to itching (Siegels et al., 2021). 
The degree of  a burn condition possible and probable 
adverse effect balances the extent of  the burned area, the 
depth of  the burn layer, and the effect on the individual’s 
quality of  life and their functioning capabilities and 
abilities, including activities of  daily living and response 
to treatments (Dreno et al., 2021). Skin manifestations 
are negligible with a few patches; skin disease is severe 
and has a tendency to become localized into thick skin, 
causes bleeding, painful and often requires other system 
affecting treatments (Bocheva et al., 2021). The highlight 
of  the points regarding the management of  skin condition 
is that no matter how severe it is, environmental control 
and gentle handling are of  paramount importance (Sekita 
et al., 2023).

Importance of  Understanding the Clinical Profile of  
Atopic Dermatitis in Children
It is noteworthy for clinical diagnosis in children with AD 
that lesions are mainly distributed in flexural areas of  limbs 
and curves, age of  onset is before six years and disease 
progression (Napolitano et al., 2022). Documenting the 
average time and outcome of  the disease in children help 
creating the best approach for handling the disease and 
the execution of  an efficient plan. Different studies focus 
on atopic dermatitis focuses on the clinical characteristics 
of  the disease in children, and therefore may contain 
information on the identified factors and relationships: 
family history, environment, and co-morbidities (Siegels 
et al., 2021). The symptoms, signs and severity of  atopic 
dermatitis also differs from one child to another; this 
implies that the variation in the clinical appearance of  
AD is relatively large (Al-Adawiyah et al., 2021). This 
understanding helps health care providers to map out 
unique care strategies for each child given that children’s 
ailments can vary from the next. The follow-up of  clinical 
status of  children with atopic dermatitis provides an 
understanding of  its severity and changes in the course 
of  the disease, and to compare the results of  therapeutic 
interventions and determine the prognosis (Frazier & 
Bhardwaj, 2020). 
Therefore, the following information is very valuable for 
better understanding of  the quality of  patients’ lives, for 
making clinical and further research decisions on the case 
of  pediatric atopic dermatitis (Maksimovic et al., 2020). 
A sufficient knowledge of  the clinical, demographic, 
and health-related characteristics of  children with 
atopic dermatitis may enhance healthcare workers’ 
communication and teaching capabilities of  the disease 
and the expectations for its treatment among families 
(Zhao et al., 2023). It can also contribute to identifying 
specific educational materials and assistance programs for 
children with atopic dermatitis and their parents (Yoo et 
al., 2022).



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MATERIALS AND METHODS
Study Area and Population
The following study included patients who were present 
at Little Flower Hospital & Research Centre, Angamaly, 
located in the Ernakulam district of  state Kerala in India. 
The duration of  this study was for a year, starting from 
November 2015 to October 2016. The study population 
consisted of  infants and children under 12 years, 
attending the Pediatrics and Dermatology OPD. All the 
patients were diagnosing with atopic dermatitis as per the 
Hanifin and Rajka clinical criteria.

Study Design
Serving as a cross-sectional research, the study looked 
at several aspects of  patient information. The patient 
completed a detailed medical questionnaire that included 
the patient’s age, sex, initial complaints, including itching, 
factors that worsened or predisposed the patient to the 
specific disease, patient’s age at the first occurrence of  
the disease, and symptoms associated with the disease, 
including cheilitis and recurrent conjunctivitis. We sought 
to examine the dietary history of  the patient in terms of  
foods that worsened the complaints and breastfeeding. 
Such observations were made in atopic families or on 
a personal level. Distribution and morphology of  the 
lesions were observed during physical examination by 
general survey and palpation. The extra dimensions of  the 
Hanifin and Rajka criteria were equally worth mentioning. 
Pearson’s chi-square test was utilized to analyze the final data.

Ethical Considerations 
The permission to conduct the study was sought and later 
on, the informed written consent was obtained from the 
Institutional human ethics committee of  the study setting. 
This improved the chances of  attaining certain ethical 
principles by the research and the reduced likelihood 
of  any harm coming to the participants. The parents or 
the close relatives or whoever takes up the responsibility 
of  a parent for the families of  the study participants 
agreed to participate in the study by willingly putting 
their signatures on the consent forms after explaining to 
them the details of  the role and responsibilities, benefits, 
and risks of  participating in the study and the right to 
withdraw their children from the study at any time of  
their choice. The control of  participant was applied in the 
study as only participants who had given their voluntary 
written consent to participate in the research. The name 
of  the specific participant of  the study and the data that 
was collected and analyzed in the present research was 
kept anonymous or pseudonymous at all stages. This 
made sure that the name of  the participant is concealed 
and there is no trace or chances that somebody might 
recognize any of  the participants.

Inclusion and Exclusion Criteria
Inclusion Criteria
Age
Patients of  required age limit, between 0-12 years of  age.

Diagnosis
Documentation of  atopic dermatitis according to the 
Hanifin and Rajka 

Severity
Patients with atopic dermatitis of  required age group and 
any gender corresponding to the objectives of  the study 
and details of  their disease such as mild, moderate or 
severe form of  atopic dermatitis.

Willingness to Participate
Children who were available and willing to participate 
in the study and parents or primary caregivers who 
were willing to sign informed consent for the child’s 
involvement in the research.

Exclusion Criteria
Underlying Medical Conditions
Participants with chronic diseases, especially those that 
may affect the assessment of  the results obtained during 
the study (such as scabies, insect bite reaction, intellectual 
disability, etc.)

Current Treatment
Patients with atopic dermatitis receiving treatments that 
may affect the obtained clinical picture at the moment (e. 
g., participating in other trials). 

Inability to Follow-Up
Patients who included children or families that would not 
be able to continue follow-up procedures with the study 
(frequently migratory, no access to the hospital).

Statistical Analysis
The results of  the descriptive statistics in terms of  
percentage, mean and standard deviation were used on 
the variables in the study. Regarding Inferential statistics, 
Pearson’s Chi – square test was used to determine the 
statistical difference between the association of  major and 
minor clinical features of  atopic dermatitis in the study 
population with, males and females, personal/family 
history atopy, age at onset less than one year, inadequate 
breast feeding history, malnutrition, food allergy history, 
seasonal exacerbation history. Significance level of  p < 0. 
05 was used in the study. 
Based on the pilot study, we used the power analysis 
that works with 5% level of  significance (p value) and 
90% test power and using the software Sigma-plot 11, 
we determined the following sample size for each group. 
This proposed research presents the findings of  the 
analysis in the following Table 1.

Table 1: Statistical analysis of  sample size
Type of  test Minimum 

Sample
Maximum 
Sample

Chi-square test 19 51
So required Sample Size 51



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RESULTS AND DISCUSSION
Results
Distribution of  Patients on the Basis of  Age Group
The study samples involved 59 young patients with all 
patrons under the age of  12. The age variation came to 
cater for many aspects of  childhood development as 
the youngest child was but 2 months and the oldest just 
below the adolescence age of  12 years. Yet, the average 

age that the group had was 3.5 years, this shows that the 
respondents were skewed slightly to the younger children 
as may be expected. Out of  59 patients, 37 were below 
three years thus indicating the major impacts of  this 
disease on the little children. It can be assumed that this 
sample might need more accommodation concerning the 
treatment of  cases and data gathering techniques than 
elders may need in the same study.

Figure 1: Shows the number and distribution of  male and female patients included in the study, according to the age group

The following study consisted of  27 male and 32 female 
patients, with a M:F ratio of  1.18:1 in the study group. 
The value in percentage of  the patients and the final 
mean value of  their age in months is mentioned in Table 
2 and Table 3, respectively.

Socioeconomic Status (SES) and Atopic Dermatitis
Socioeconomic status can also be seen among the 
study population. The largest portion of  children was 
characterized as belonging to the upper middle class, 29 
(or 49. 15%); next were the children from the lower middle 
class, 19 (or 32. 20%); and the last category indicated 6 (or 
10. 16%) as being from the upper lower class. Only 5 of  
the participants (8.4%) were classified as belonging to the 
upper socioeconomic class and none as lower according 
to the modified Kuppuswamy scale. This difference in the 
distribution of  the variables in the population based on 
SES may need to be taken into account when interpreting 
this study’s results because factors such as access to 
adequate healthcare and exposure to environmental 
stimuli are known to have different distributions across 
SES (Podder et al., 2022).

Table 2: Number of  patients
Sex Frequency Percent
Male 27 45.8
Female 32 54.2
Total 59 100.0

Table 3: Mean value of  age in months
Age in months

Mean 40.22

Age at the Time of  Diagnosis
Among the 59 children with atopic dermatitis, 19 children 
(32.2%) developed the condition within three months 
after birth and 47 (79.6%) within infancy. Finally, 4 (6.7%) 
patients of  them had the disease onset after 5 years of  
when they were born, while 8 (13.5%) patients had the 
onset of  disease between the first and the fifth birthday. 
In regard to the age of  onset, the disease developed in 55 
(93.2%) of  the children when they were 5 years old or less, 
as per shown in Figure 2. In other words, the mean age of  
onset for the patients was one year and four months.

Figure 2: Age of  onset of  disease

Figure 3: Distribution of  patients according to SES.

Geographic Distribution
Residence of  Patients
The following study narrates the participants involved 
with regard to their residence. Two categories are 
represented: which includes the urban and rural groups. 
Thus, urban areas represent a much more significant share 
in the study, involving about 35 participants (62.7%). On 
the other hand, the ‘Rural’ area category constitutes only 
a small proportion of  the participants that were around 
24 in number (37.3%). Such a case implies that there are 



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more participants from the urban areas of  the country 
than from the rural areas.

Moreover, for patients suffering from atopic dermatitis, 
choosing the right clothing material is really crucial for 
managing symptoms, its effects and improving comfort 
for the patients (Jaros et al., 2020). In this study, there 
were 8 (13.55%) children who complained of  itching on 
contact with wool and 11 (18.64%) children gave history 
of  exacerbation of  the disease with the use of  lipid 
solvents like soaps and detergents as shown in Figure 6.

Figure 4: Distribution of  patients according to area of  
residence

Moreover, 11 of  the patients had to relocate due to 
personal reasons. This movement either had flare-ups 
or the onset of  the disease. Two of  them experienced 
exacerbations on moving to cities, while four of  them 
had the beginning of  their illness on moving from a town 
into a more rural area.

Climatic Interventions on Patients
Atopic dermatitis can be worsened by climate change 
because it gets affected by temperature increases, pollution 
and production of  pollen and allergens, humidity, and 
increased levels of  UV radiation (Wang et al., 2024). In 
the present study, exacerbation of  the condition occurred 
in 13 children (22.03%) during winter and in 15 children 
(25.42%) during summer, especially after sweating.

Figure 5: Seasonal variation of  number of  patients

Figure 6: Effect of  irritants (i.e. wool or lipid solvents)

Examination Findings
History of  Atopy or Allergic Disorders
In the shortlisted 59 children having atopic dermatitis, 44 
(74.5%) patients had family / personal history of  atopy or 
other allergic diseases and 26 (44.06%) patients had personal 
history of  atopy or other allergic diseases. Although both 
parents transmitted Atopy in the family history, it was more 
dominant in mothers with 40 percent. Inheritance through 
the mother was found to be more common at 67% as 
opposed to the paternal inheritance at 35.59%. Concerning 
the parents’ health status, 10 children (16. 94%) had a 
history of  atopy/allergic disorders previously reported in 
their parents. Details of  previous allergic disorders in the 
siblings were taken from 10 (16. 94%) patients. In regard to 
the atopic manifestation, allergic rhinitis was most frequent, 
then bronchial asthma (Akhmedova & Akhmedova, 2021). 
For personal history of  atopy in patients with the disease, 
7 (11. 86%) among the patients had episodic viral wheeze. 
Table 4 and Figure 7 shows a detailed and comprehensive 
analysis of  these number mentioned above.

Table 4: Number of  patients classified according to the presence of  existing atopy or allergic disorder
Atopy/Allergic 
disorders

AR BA EVW AD Total Percentage AR - Allergic rhinitis
BA – Bronchial 
Asthma
EVW- Episodic viral 
wheeze
AD- atopic 
dermatitis

Maternal 17 7 24 40.67
Paternal 9 12 21 35.59
Sibling 1 5 4 10 16.94
Personal 11 8 7 26 44.06

Furthermore, Xerosis was the most frequent cutaneous 
morphology; 58 (98.3%) of  the patients described their 
skin as being very much dry, at some time or all the time. 
Desquamation of  the skin in the form of  hyper pigmented 
diamond shaped scales was identified in 24 (40.67%) of  

children with atopic dermatitis. Palmar hyper linearity 
was present in 24 (40.70%) of  the children investigated 
in the present study with atopic dermatitis. However, 
hyper linearity of  palms was present in 24 patients and 
among these, 20 have ichthyosis as an additional attribute. 



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This feature characterized by tiny follicular papules was 
noted predominantly over outer arms in (13. 6%) of  our 
patients. Ichthyosis was seen in two patients with positive 
family history; hyper linearity of  palms and keratosis 
pilaris were seen in one patient.

Minor Examined Features
Apart from major physical features related to the patients 
suffering from AD, there were few minor features as 
well that corresponds to provide further analysis about 
the severity of  the conditions. Few of  these features are 
mentioned below as well represented as a demographic 
graph in Figure 8.

Nipple Eczema
Nipple eczema was noted in 3 patients (5.01 %) among 
our 59 patients. This finding was more common in the 
older children, 

Cheilitis
There were 10 (16.9%) children with atopic dermatitis, 
who presented with dryness and fissuring of  lower lip.

Nonspecific Hand/ Foot Dermatitis
There were 8 (13.6%) patients had eczematous lesions 
over hands and feet.

Dennie Morgan Fold
This finding characterized by folding of  lower eyelid 
was noted in 34 (57.60%) children. There was associated 
lower eyelid dermatitis among 4 (11.76%) of  them.

Facial Pallor / Erythema
Sixteen (27.1 %) out of  59 children had facial pallor. In 
most of  them it was confined to the perinasal area, with a 
few showing involvement of  periorbital area also.

Orbital Darkening
This feature was characterized by hyperpigmentation 
below the lower eyelid was present in 18 (30.50%) patients 

with atopic dermatitis.

Pityriasis Alba
There were 15 (25.4%) children with pityriasis alba 
of  which 10 had the lesions over the face only and the 
remaining 5 children showed extensive lesions over the 
trunk also.

Anterior Neck Folds
This finding characterized by horizontal creases on the 
anterior aspect of  the neck was present in 4 (6.77%) 
children with atopic dermatitis.

Perifollicular Accentuation
Nine (15.3%) children with atopic dermatitis showed 
perifollicular accentuation characterized by pebbled 
appearance which was noted over the thighs, upper arms 
and back of  trunk.

White Dermographism
Stroking of  involved and uninvolved skin of  patients with 
a blunt object produced a white line in 7 (11.9%) children.
In addition to the above mentioned features described by 
Hanifin and Rajka, other findings noted were:

Scalp Scaling
Out of  59 patients with atopic dermatitis, 13 (22%) had 
diffuse scaling of  the scalp.

Eyelid Dermatitis
Scaling and redness of  the eyelid was noted in 10 (16.9%) 
of  children with atopic dermatitis.

Itch When Sweating
There were 26 (44.06%) children who complained of  itch 
when sweating, which was more in the axilla and groins. 

Recurrent Conjunctivitis
There were 12 (20.33%) children who complained of  
recurrent conjunctivitis.

Figure 7: Family history of  Atopy or Allergic disorders



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Figure 8: Minor features corresponding the severity of  AD in different patients

Skin Lesions and Their Distribution
Particularly, the study identified that the AD targeted face 
and the flexural surfaces in the limbs, or course, refers to 
the inner parts of  the joints as such as elbows and knees. 
Interestingly, the distribution of  involvement showed 
some variation: 

Facial Involvement
Still, only 9 patients (15.3%) had atopic dermatitis 
exclusively on the facial skin; it was evident in total. This 
raises the aspect of  esteem as a patient may be at risk of  
losing confidence and social interactions.

Combined Involvement
The most common site of  involvement was faces and 

flexures (17 patients or almost 28.8%). This implies that 
the condition may be wider than what has been estimated 
by the director of  the research.

Extensor Involvement
In only 5 (8.5%) patients the AD became involved only 
in the extensor aspect (the area in direct opposition to the 
bend, e. g., the outer region of  the arms and the forearm). 
This pattern is more unusual for AD.

Isolated Flexural Involvement
Only the flexural surfaces were affected in another 9 
patients (15.3 %). This underlines the significance of  
assessing these regions in the process of  the disease’s 
identification.

Table 5:  Sites of  different skin extremities and number of  patients affected
Site Number Percent
Generalized eczema 8 13.5
Eczema in face alone 9 15.3
Eczema in flexures alone 9 15.3
Eczema in extensors alone 5 8.5
Eczema in face and extensors 9 15.3
Eczema in face and flexures 17 28.8
Eczema in face, flexures and extensors 2 3.4
Total 59 100.0

Secondary Cutaneous Infections
In addition to atopic dermatitis, some children also presented 
with secondary skin infections or infestations which can also 
be observed via demographic status in Figure 9: 

Impetiginisation (13.55%)
Among all the secondary diseases, this bacterial 
superinfection was the most common in the study 
reappearing in more than 8 children. Impetiginisation 
aggravates the symptoms of  eczema and the use of  
antibiotics is needed for the treatment. 

Tinea Versicolor (6.77%)
There are 4 children who have such a fungal infection 

that is characterized white and tannish colored patches. 
Though it doesn’t belong to the category of  eczema, 
it is similar to it and may be confused with the latter 
sometimes. 

Hand, Foot, and Mouth Disease (3.38%)
This viral infection presents with a fever and a rashes 
accompanied by blistering of  the hands, feet and the oral 
cavity and two children were diagnosed with this. 

Molluscum Contagiosum (1.69%)
Only one patient had this viral infection, and there were 
small, painless, bumpy lesions on the skin.



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Figure 9: Patients affected by secondary skin infections

Identifying Food Triggers
Eczema or the atopic dermatitis is indeed very irritable, 
making the skin on the affected area feel itchy. The 
specific cause is still unexplained, nevertheless, there are 
certain foods that are believed to worsen the condition 
in patients (Papapostolou et al., 2022). Consequently, our 
study showed that 41(69.49%) children had worsening 

of  the disease manifestations with particular foods. The 
food products that had more frequent associations with 
allergies were milk in 12 irregular cases (28.57%) and 
followed by egg in 9 cases (21.4%). Other foods that 
are included were meat, wheat, biscuits, ragi, fishes, 
sea foods, nuts chocolates, and orange as per shown in 
Table 6.

Table 6:  Food allergens affecting number of  patients
Food Allergens No: of  patients Percent
Wheat 4 9.5
Milk 12 28.57
Meat 5 11.9
Ragi 3 7.1
Egg 9 21.4
Biscuits 3 7.1
Orange 1 2.38
Nuts 1 2.38
Chocolate 1 2.38
Seafood 1 2.38
Fish 1 2.38
Total 41 69.49

Moreover, on the aspect of  adequate breast feeding, it 
was revealed that all except 8 children (13. 55%) were 
adequately breast fed. As for the inadequately breast 
fed children, all 8 of  them had onset of  disease before 
1 year of  age. In the following study, among 59 children 
with atopic dermatitis, 12 children were evaluated to be 
malnourished based on their weight for age status as per 
the WHO 2006 and IAP 2015 centile charts.

Treatment Induced to The Patients
Out of  the 59 children with atopic dermatitis, 13 
(22.03%) of  them were receiving management through 
moisturizers alone. Among the twenty of  them, majority 
(75%) were on topical corticosteroids which was often 
used with moisturizers. Of  these 59, five (8.47%) of  
them were on topical calcineurin inhibitors combined 
with moisturizers and topical corticosteroids. Among 

them 21 (35.59%) were used resorted to other system 
of  medicines. Out of  which, 18 patients (30.50%) were 
taking Ayurvedic treatment and 3 patients (5. 08%) were 
taking homoeopathic treatment.

Statistical Analysis
The correlation between the clinical aspects of  the 
major and minor enrollees themselves together with 
gender, personal/family history of  atopy, age on the 
onset of  the disease below 1 year, inadequate breast 
feeding, malnutrition, history of  food allergy and history 
of  seasonal worsening of  symptoms were investigated. 
Pearson joint Chi square test was also used in the analysis 
and p value was greater than 0.05 (p > 0.05), which 
indicates that there has no statistical relationship between 
the major and minor clinical entities among the children 
in the study group. 



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Discussion
In this investigation, a prospective analysis of  59 cases of  
children with AD during one year from November 2015 
to October 2016 was carried out. Ours’ was primarily a 
historical and clinical examination centered study. Many 
authors globally have also as well investigated clinical 
manifestations of  atopic dermatitis. Such studies have 
often drawn different conclusions which might be due to 
ethnic variation or differences in definitions, materials or 
methods used.
The following study included children with AD within the 
age-group of  2 months to 12 years. Children with atopic 
dermatitis participating in the study ranged from the age 
of  2 months to 12 years of  age with the average age of  
3.5 years. Srinivas in his study also involved children those 
who belonged to the same age group thus the mean age 
of  the AD patient was 2.7 years (Srinivas et al., 2023). In 
a similar fashion, findings in the study by Parthasarathy, 
established that the mean and median age were 4.6 and 
3.9 years respectively (Parthasarathy et al., 2020). Hence, 
the age distribution of  our patients is thus well in parallel 
with the other studies done in India.
Similarly, the following study identified cutaneous 
infections in 25.42% of  children with AD having 
Impetiginisation in 8 of  the patients, Tinea versicolor 
in 5, HFMD in 2 and Molluscum contagiosum in only 
1 patient. That is why the level of  infections is relatively 
low – due to better hygiene measures in Kerala and the 
use of  antibiotics in time (Aggithaya et al., 2021). The 
study also revealed that in the subjects with AD, 57.60% 
of  the children had Dennis Morgan (DM) fold present, 
indicating a status due to persistent vasoconstriction, 
thus the lower percentage may be due to less severe 
manifestation of  the disease in the children and the 
higher rate identified in some Indian studies due to ethnic 
difference and darker skin color (Nath et al., 2020).
Moreover, in our study, orbital darkening was present in 
only 30.50% of  cases, whereas different studies show 
different numbers. Probably, the reason for this difference 
may be the persistence of  nasal congestion for a longer 
time period in atopic adults. Increased exposure to 
pollution in cities like Bangalore or Delhi might increase 
its incidence (Ailawadi et al., 2024). In the present study, 
44.1%) of  the patients with atopic dermatitis experienced 
itch when sweating, and exacerbation during summer. 
Probably, the humid climate of  Kerala may be responsible 
for the increased incidence. Around 11 patients (18.64%) 
reported worsening of  the disease with the use of  soap 
and detergent.
Furthermore, food items also played a crucial role in 
severity of  AD depending on the patient’s status (Mehta 
& Fulmali, 2022). Of  59 children, 41 (69. 49%) definitely 
noted worsening of  the disease after consuming certain 
foods. Among the foods, milk was most incriminated and 
posed threat to disease complications in 12 (28. 57%) 
children. In 10 of  the 12 studies, cow’s milk was implicated 
while formula feeds were found to be responsible for 
the rest of  the three cases and goat’s milk in one patient 

respectively (Ramírez-Marín et al., 2022). This was 
succeeded by egg in 9 (21. 4%) and meat in 5 (11. 9%) 
patients. Meat is the most recurrent food identified in all 
the four children with chicken being the most common 
implicated food (Liao et al., 2022). This was succeeded 
by wheat, biscuits, ragi and fish as the foods that were 
mentioned as likely causes of  the situation in 9.5%, 7.1%, 
7.15% and 2.38% patients respectively. Other highlighted 
foods were nuts, chocolate, seas foods and oranges. 
Different studies have discussed about the link between 
Food allergy (FA) and atopic dermatitis (AD) which are 
prevalent. It is often established that food sensitization 
can be present in such patients (Domínguez et al., 2020). 
However, before suggesting that the patient follows a 
restrictive diet which may prove to be detrimental to his/
her health, allergy should be proven (Rustad et al., 2022). 
Preschool children with AD are most commonly sensitized 
to egg, milk or peanut whereas school aged children and 
adults are commonly sensitized to HDM’s, molds, animal 
dander or pollens. A barrier disturbance was found to play 
a main role in the process of  sensitization and allergy, 
which is quite well known indeed (Ramírez-Marín et al., 
2022). Hence, concerning the fact that AD begins in early 
infancy, newborns’ skin care using emollients and the 
early introduction of  food seem to be crucial to define 
the tolerance to food (Mehta & Fulmali, 2022).
Apart from edible allergies, lack of  breastfeeding was 
also a common factor associated with the prevalence 
of  AD (Lin et al., 2020). Inadequate breastfeeding was 
seen in 13.5% of  59 patients with atopic dermatitis, with 
a collective duration of  less than one year. This may 
support the role of  a varied solid food diet in exacerbating 
the disease. Additionally, atopic dermatitis was noted in 
20.33% children whose weight was below the 3rd centile 
on the new combined WHO 2006 and IAP 2015 weight 
charts. Probably, nutrition will remain of  interest for as 
long as safe and effective therapy methods against AD are 
being pursued (Trikamjee et al., 2021).
While discussing about the severity of  AD compared to 
the sample area population, Atopic dermatitis increased 
evidently in the study area of  patients with winter 
exacerbation was significantly different from summer 
exacerbations (Belzer & Parker, 2023). According to the 
consequences of  the disease, it was worsened in winter 
in 67.14% of  patients with an infantile atopic dermatitis 
disease, and it occurred in summer in 25.42% of  the 
patients. The research conducted also noted that the 
temperature of  the environment did not fluctuate much 
from one year to the next in the coastal tropical zone 
which might have led to low prevalence. The researcher 
also found again that that majority of  the patients were 
from upper or upper middle-income families.

CONCLUSION 
The present work aimed to assess children with atopic 
dermatitis in a tertiary care hospital. Female patients 
were more frequent than male ones. It was identified 
that children had the onset of  the disease at an early 



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age, below 1 year of  age, and there was significant 
itching as a common symptom in most children, which 
was worse at night (Song et al., 2024). Thus, the most 
frequent and significant finding in patients’ history was 
the presence of  atopy in the first- and second-degree 
relatives, especially on the maternal side (Ai et al., 2024). 
Food intolerance was evident mainly in milk products and 
foods containing milk, while contact urticaria and contact 
dermatitis from wool and lipid solvents were reported in 
one-third of  the cases (Eyerich et al., 2024). There was 
evident a seasonal pattern in the patients with half  of  
the interviewees complaining of  worsening of  symptoms 
during summer (Fitzmaurice & Silverberg, 2024). Facial 
lesions were observed frequently, and the limbs’ flexor 
surfaces had more extensive involvement than extensor 
surfaces (Geng & Sibbald, 2024). Xerosis contributed 
to almost all the patients; ichthyosis was more prevalent 
than keratosis pilaris. More to the point, there was a low 
prevalence of  skin infections, and signs such as orbital 
darkening, pale face, dermatitis eyelids, and anterior neck 
folds (Herzum et al., 2024). It is also noteworthy that 
most of  the children had a rural origin, while most of  
them belonged to the upper or upper-middle social class. 
One alarming fact was that a major portion of  children 
suffering from malnutrition were observed as 19% of  the 
total study group (von Kobyletzki et al., 2024).

Recommendations
• Even though a simple observation of  ‘itching and 

dryness of  the skin’ confirms the disease in atopic 
dermatitis, other aspects mentioned as the major and 
minor criteria should be sought.  

• Babies born to parents having personal/family history 
of  atopy or any other allergic disorder should be put on 
‘no other milk’ for the first 6 months and should continue 
breast feeding till 2 years as this postpones the onset and 
severity of  the disease.

• Knowing certain triggers such as food will enable one 
to prevent the worsening of  the disease.

• Parents should be made aware of  the treatment 
options available that is there are facilities available for 
exact treatment rather than using other medicines like 
Ayurveda and Homoeopathy and proper advice should 
be provided to stick to Allopathy.

Limitations
• This study is limited by the fact that the values 

that were derived represent the result of  one particular 
hospital and from a selected population and therefore 
the findings of  this research cannot be generalized to the 
whole population. 

• This cross-sectional study orientation also precluded 
establishing causality between the identified precipitating 
factors and the clinico-radiological features of  the disease. 

• The age of  onset, breastfeeding and other practices, 
type of  precipitating factors like food, season and other 
irritants to diarrhea might suffer recall bias from the 
mothers or the primary care givers. 

• They might also present reporting bias during the 
taking of  the history.

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