- Email: [email protected]
Color atlas: eczema
Color Atlas: Eczema DONALD RUDIKOFF, MD ARASH AKHAVAN, BA STEVEN R. COHEN, MD, MPH
A
topic dermatitis is a chronic relapsing skin disorder often presenting in infancy and early childhood and characterized by an age-dependent distribution. Lesions may be acute, subacute, or chronic. The cardinal feature of atopic dermatitis is pruritus, and many of the lesions of atopic dermatitis result from rubbing and scratching persuant to this symptom. Patients with atopic dermatitis have alterations in cutaneous immunity and barrier function that may cause them to be more susceptible to skin infection including viruses, certain bacteria and dermatophytic fungi.4,11 Should smallpox vaccination be reinstituted in the U.S., patients with eczema or household contacts of patients with eczema should not be vaccinated because of the risk of eczema vaccinatum.
Figure 2. Involvement of the forearms with erythematous, scaly, and crusted subacute lesions in a 4-year-old child. Extensor involvement, common in infancy and early childhood, then gives way to a pattern of flexural predominance in older children and adolescents.
Figure 1. Facial involvement is common in infants with atopic dermatitis but often disappears after 6 months to 1 year of age.1 This toddler continues to exhibit involvement of the cheeks with erythema and excoriation. Perioral lesions are evident as well. Impetigo often complicates the care of these patients. From the Department of Dermatology, Mount Sinai School of Medicine, New York, New York. Address correspondence to Dr. Donald Rudikoff, Mount Sinai School of Medicine, Department of Dermatology, Box 1048, 1 Gustave L. Levy Place, New York, NY 10029. E-mail address: [email protected] © 2003 by Elsevier Science Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010
Figure 3. Cheilitis and perioral involvement is encountered frequently in children with atopic dermatitis. Lip licking and mouth breathing results in a cycle of wetting and evaporation that promotes chapping and further dermatitis. 0738-081X/03/$–see front matter doi:10.1016/S0738-081X(02)00359-0
102 RUDIKOFF ET AL
Clinics in Dermatology
Y
2003;21:101–108
Figure 6. Patients with atopic dermatitis typically exhibit nasal colonization with Staphylococcus aureus. Crusting and fissuring around the external nares is a frequent consequence.5 Interestingly, the subungual spaces of atopic dermatitis patients are also colonized with staph.6
Figure 4. Although not included in the Hanifin and Rajka criteria2 for atopic dermatitis, infra-auricular fissuring is so common among patients with atopic dermatitis that many practitioners consider it a reliable diagnostic feature.3,4
Figure 7. Infantile atopic dermatitis typically presents with bright red, oozing, and crusted patches on the cheeks and extensor aspects of the extremities. A variety of proprietary or prescription medications may have been applied before dermatologic consultation. Parents often express concern about the use of topical corticosteroids and some manifest frank “steroid phobia.”7
Figure 5. Atopic dermatitis in a toddler with eyelid and perioral erythema and scaling as well as extensive involvement of the chest and shoulders. Central pallor and “mournful facies” are characteristic. He has not as yet developed “atopic shiners” (darkness around the eyes).
Figure 8. Infants with atopic dermatitis may have bright red erythema of the cheeks with oozing and crusting or they may have dry, erythematous patches. Central pallor of the face (“headlight sign”) is noted. Dennie-Morgan folds are also apparent and probably result from eyelid dermatitis. They are not pathognomonic of atopic dermatitis, however, and can be seen as a normal variant.
Clinics in Dermatology
Y
2003;21:101–108
AN ATLAS OF ECZEMA
103
Figure 9. Atopic eczema may be extensive, as in this child in whom dermatitis involves the trunk, arms and neck.
Figure 11. Scalp involvement occurs in many children with atopic dermatitis but differs in appearance from the cradle cap seen in infantile seborrheic dermatitis, where thick greasy scales predominate.3 Dermatophyte infection should be ruled out in older children.
Figure 10. Dermatitis of the hands with erythema, crusting, and fissuring causes significant discomfort in children and adults alike. Although flexural lichenification of the extremities is classic after the infantile stage, widespread papular involvement of the extensors can persist, as in this child with widespread papulation of the hands, arms and legs.
Figure 12. Papulation, erosion, and crusting of the extensor aspect of the wrist in early childhood. Hand dermatitis extending to the wrists and distal forearms is a good indicator for atopic dermatitis.
104 RUDIKOFF ET AL
Figure 13. The process of lichenification results from chronic rubbing of a pruritic area. Lichenoid papules coalesce into plaques that subsequently display exaggeration of the skin lines. Hyperpigmentation of lesional skin in darker complected individuals results from postinflammatory hyperpigmentation.
Clinics in Dermatology
Y
2003;21:101–108
Figure 16. Characteristic flexural involvement seen in adolescents and adults with atopic dermatitis. There is erythema, lichenification, and excoriation involving the antecubital fossae and trunk.
Figure 17. Erythema, lichenification, and excoriations of chronic atopic dermatitis in flexure of antecubital fossa. Figure 14. Pityriasis alba often occurs on the face but can present in other areas. It is thought to represent a low-grade eczema with postinflammatory hypopigmentation, although the exact pathophysiology is not entirely known.8
Figure 15. Prominent pruritic periumbilical papules provide a clue to childhood atopic dermatitis.9
Figure 18. Reticulated pigmentation of the neck, or “dirty neck,” an adjunctive sign seen sometimes in atopic dermatitis.10
Clinics in Dermatology
Y
2003;21:101–108
AN ATLAS OF ECZEMA
105
Figure 22. Molluscum contagiosum occur frequently in children with atopic dermatitis and may sometimes cause scarring.12 Figure 19. Erythematous patches with crusted erosions and excoriations from scratching, on the wrist, a common site of involvement in atopic dermatitis,
Figure 23. In addition to viral skin infections, atopic skin— both involved and uninvolved—is frequently colonized with Staphylococcus aureus, often superantigen-producing strains that can exacerbate the eczema. Patients may develop frank infection such as folliculitis, as seen in this patient. A short course of antistaphylococcal antibiotics is indicated to eradicate the infection.
Figure 20. Patches, plaques, and papules of erythema over a widespread area of the back. Crusted erosions and excoriations also are seen in this acute exacerbation of atopic dermatitis.
Figure 21. Eczema herpeticum can occur in patients with even mild atopic dermatitis after a trivial herpetic infection on the lip or elsewhere. This patient had minimal eczema when she developed this painful vesicular eruption that was at first misdiagnosed as impetigo. The presence of multiple 1- to 2-mm sharply circumscribed erosions on the forehead and other areas suggested eczema herpeticum. The patient was treated with oral famcyclovir, but subsequently developed shallow scarring.
Figure 24. Approximately one third of patients with atopic dermatitis may have ichthyosis vulgaris with fishlike scales prominent on the arms and legs with flexural sparing as seen here. Increased palmar markings referred to as “hyperlinear palms” are commonly seen in atopic patients with or without ichthyosis.13–17 Keratosis pilaris also is commonly noted.
106 RUDIKOFF ET AL
Figure 25. Nummular dermatitis lesions in a patient with atopic dermatitis. Sharply marginated erythematous plaques with oozing and crusting are noted.
Figure 26. Erythematous, hyperpigmented, and excoriated plaque of eczema on the nipple and areola of a male with atopic dermatitis. Eczema in this region can be an isolated manifestation of atopic dermatitis.18 Paget’s disease of the breast should be considered in cases of nipple eczema and biopsy obtained if there is doubt as to the diagnosis.
Clinics in Dermatology
Y
2003;21:101–108
Figure 27. Lichenification of the anterior aspect of the ankles and dorsa of the feet in a 4-year-old boy with atopic dermatitis. Patients often rub the ankles with the heel of the contralateral foot.
Figure 28. Eyelid dermatitis affecting both the upper and lower eyelids of one or both eyes is frequently seen in atopic dermatitis. Thinning of the lateral eyebrows, Hertoghe’s sign, is sometimes present. Increased skin folds and darkening under the eyes is common.
Clinics in Dermatology
Y
2003;21:101–108
AN ATLAS OF ECZEMA
107
References
Figure 29. Toilet-seat dermatitis or lichenification of the lower gluteal and upper posterior thighs most commonly peaks at age 7 to 8 years.19,20 Eczema in this area has been attributed to sweat retention in children sitting at their school desks all day long.
Figure 30. Netherton syndrome (NS) is an autosomal recessive disease characterized by ichthyosis, atopic diathesis, and hair shaft abnormalities, typically trichorrhexis invaginata (bamboo hair). Erythroderma often is present at birth, but after a year or two, children often display ichthyosis linearis circumflexa with “double edged scale.” IgE levels are typically elevated. The NS gene has been linked to mutations of SPINK 5 on Chromosome 5q32.21,22,23
1. Bonifazi E. Factors influencing the localization of atopic dermatitis. Acta Derm Venereol Suppl (Stockh) 1992;176: 24 –5. 2. Hanifin JM, Rajka G. Diagnostic features of atopic dermatitis. Acta Derm Venereol Suppl (Stockh) 1980;92:44 –7. 3. Kanwar AJ, Dhar S, Kaur S. Evaluation of minor clinical features of atopic dermatitis. Pediatr Dermatol 1991;8: 114 –6. 4. Pauly CR, Artis WM, Jones HE. Atopic dermatitis, impaired cellular immunity, and molluscum contagiosum. Arch Dermatol 1978;114:391–3. 5. Namura S, Nishijima S, Higashida T, Asada Y. Staphylococcus aureus isolated from nostril anteriors and subungual spaces of the hand: comparative study of medical staff, patients, and normal controls. J Dermatol 1995;22: 175–80. 6. Nishijima S, Namura S, Higashida T, Kawai S. Staphylococcus aureus in the anterior nares and subungual spaces of the hands in atopic dermatitis. J Int Med Res 1997;25: 155–8. 7. Charman CR, Morris AD, Williams HC. Topical corticosteroid phobia in patients with atopic eczema. Br J Dermatol 2000;142:931–6. 8. Urano-Suehisa S, Tagami H. Functional and morphological analysis of the horny layer of pityriasis alba. Acta Derm Venereol 1985;65:164 –7. 9. Rencic A, Cohen BA. Prominent pruritic periumbilical papules: a diagnostic sign in pediatric atopic dermatitis. Pediatr Dermatol 1999;16:436 –8. 10. Colver GB, Mortimer PS, Millard PR, et al. The ‘dirty neck’—a reticulate pigmentation in atopics. Clin Exp Dermatol 1987;12:1–4. 11. Ghura HS, Camp RD. Scarring molluscum contagiosum in patients with severe atopic dermatitis: report of two cases. Br J Dermatol 2001;144:1094 –5. 12. Blattner RJ. Molluscum contagiosum: eruptive infection in atopic dermatitis. J Pediatr 1967;70:997–9. 13. Uehara M, Hayashi S. Hyperlinear palms: association with ichthyosis and atopic dermatitis. Arch Dermatol 1981;117:490 –1. 14. Smith DA. Hyperlinear palms in atopic dermatitis: a manifestation of ichthyosis vulgaris? Cutis 1984;34:49 –51. 15. Tada J, Toi Y, Akiyama H, Arata J. Infra-auricular fissures in atopic dermatitis. Acta Derm Venereol 1994;74:129 –31. 16. Dupre A, Christol B, Lassere J Atopic dermatitis and pox-virus superinfections [(author’s transl)]. Ann Dermatol Venereol 1981;108:829 –34. 17. Shirasawa K, Akai K, Kawaguchi Y, et al. Widespread eczema vaccinatum acquired by contacts. A report of an autopsy case. Acta Pathol Jpn 1979;29:435–55. 18. Mevorah B, Frenk E, Wietlisbach V, Carrel CF. Minor clinical features of atopic dermatitis. Evaluation of their diagnostic significance. Dermatologica 1988;177:360 –4. 19. Fredriksson T, Faergemann J. The atopic thigh: a “starting-school” symptom? Acta Derm Venereol (Stockh) 1981; 61: 452–3. 20. Lindskov R, Jensen O. Toilet-seat dermatitis. Infragluteal eczema. Ugeskr Laeger 1980;142:514 –6.
108 RUDIKOFF ET AL
21. Sprecher E, Chavanas S, DiGiovanna JJ, et al. The spectrum of pathogenic mutations in SPINK5 in 19 families with Netherton syndrome: implications for mutation detection and first case of prenatal diagnosis. J Invest Dermatol 2001;117:179 –87. 22. Chavanas S, Garner C, Bodemer C, et al. Localization of
Clinics in Dermatology
Y
2003;21:101–108
the Netherton syndrome gene to chromosome 5q32, by linkage analysis and homozygosity mapping. Am J Hum Genet 2000;66:914 –21. 23. Judge MR, Morgan G, Harper JI. A clinical and immunological study of Netherton’s syndrome. Br J Dermatol 1994;131:615–21.
A
topic dermatitis is a chronic relapsing skin disorder often presenting in infancy and early childhood and characterized by an age-dependent distribution. Lesions may be acute, subacute, or chronic. The cardinal feature of atopic dermatitis is pruritus, and many of the lesions of atopic dermatitis result from rubbing and scratching persuant to this symptom. Patients with atopic dermatitis have alterations in cutaneous immunity and barrier function that may cause them to be more susceptible to skin infection including viruses, certain bacteria and dermatophytic fungi.4,11 Should smallpox vaccination be reinstituted in the U.S., patients with eczema or household contacts of patients with eczema should not be vaccinated because of the risk of eczema vaccinatum.
Figure 2. Involvement of the forearms with erythematous, scaly, and crusted subacute lesions in a 4-year-old child. Extensor involvement, common in infancy and early childhood, then gives way to a pattern of flexural predominance in older children and adolescents.
Figure 1. Facial involvement is common in infants with atopic dermatitis but often disappears after 6 months to 1 year of age.1 This toddler continues to exhibit involvement of the cheeks with erythema and excoriation. Perioral lesions are evident as well. Impetigo often complicates the care of these patients. From the Department of Dermatology, Mount Sinai School of Medicine, New York, New York. Address correspondence to Dr. Donald Rudikoff, Mount Sinai School of Medicine, Department of Dermatology, Box 1048, 1 Gustave L. Levy Place, New York, NY 10029. E-mail address: [email protected] © 2003 by Elsevier Science Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010
Figure 3. Cheilitis and perioral involvement is encountered frequently in children with atopic dermatitis. Lip licking and mouth breathing results in a cycle of wetting and evaporation that promotes chapping and further dermatitis. 0738-081X/03/$–see front matter doi:10.1016/S0738-081X(02)00359-0
102 RUDIKOFF ET AL
Clinics in Dermatology
Y
2003;21:101–108
Figure 6. Patients with atopic dermatitis typically exhibit nasal colonization with Staphylococcus aureus. Crusting and fissuring around the external nares is a frequent consequence.5 Interestingly, the subungual spaces of atopic dermatitis patients are also colonized with staph.6
Figure 4. Although not included in the Hanifin and Rajka criteria2 for atopic dermatitis, infra-auricular fissuring is so common among patients with atopic dermatitis that many practitioners consider it a reliable diagnostic feature.3,4
Figure 7. Infantile atopic dermatitis typically presents with bright red, oozing, and crusted patches on the cheeks and extensor aspects of the extremities. A variety of proprietary or prescription medications may have been applied before dermatologic consultation. Parents often express concern about the use of topical corticosteroids and some manifest frank “steroid phobia.”7
Figure 5. Atopic dermatitis in a toddler with eyelid and perioral erythema and scaling as well as extensive involvement of the chest and shoulders. Central pallor and “mournful facies” are characteristic. He has not as yet developed “atopic shiners” (darkness around the eyes).
Figure 8. Infants with atopic dermatitis may have bright red erythema of the cheeks with oozing and crusting or they may have dry, erythematous patches. Central pallor of the face (“headlight sign”) is noted. Dennie-Morgan folds are also apparent and probably result from eyelid dermatitis. They are not pathognomonic of atopic dermatitis, however, and can be seen as a normal variant.
Clinics in Dermatology
Y
2003;21:101–108
AN ATLAS OF ECZEMA
103
Figure 9. Atopic eczema may be extensive, as in this child in whom dermatitis involves the trunk, arms and neck.
Figure 11. Scalp involvement occurs in many children with atopic dermatitis but differs in appearance from the cradle cap seen in infantile seborrheic dermatitis, where thick greasy scales predominate.3 Dermatophyte infection should be ruled out in older children.
Figure 10. Dermatitis of the hands with erythema, crusting, and fissuring causes significant discomfort in children and adults alike. Although flexural lichenification of the extremities is classic after the infantile stage, widespread papular involvement of the extensors can persist, as in this child with widespread papulation of the hands, arms and legs.
Figure 12. Papulation, erosion, and crusting of the extensor aspect of the wrist in early childhood. Hand dermatitis extending to the wrists and distal forearms is a good indicator for atopic dermatitis.
104 RUDIKOFF ET AL
Figure 13. The process of lichenification results from chronic rubbing of a pruritic area. Lichenoid papules coalesce into plaques that subsequently display exaggeration of the skin lines. Hyperpigmentation of lesional skin in darker complected individuals results from postinflammatory hyperpigmentation.
Clinics in Dermatology
Y
2003;21:101–108
Figure 16. Characteristic flexural involvement seen in adolescents and adults with atopic dermatitis. There is erythema, lichenification, and excoriation involving the antecubital fossae and trunk.
Figure 17. Erythema, lichenification, and excoriations of chronic atopic dermatitis in flexure of antecubital fossa. Figure 14. Pityriasis alba often occurs on the face but can present in other areas. It is thought to represent a low-grade eczema with postinflammatory hypopigmentation, although the exact pathophysiology is not entirely known.8
Figure 15. Prominent pruritic periumbilical papules provide a clue to childhood atopic dermatitis.9
Figure 18. Reticulated pigmentation of the neck, or “dirty neck,” an adjunctive sign seen sometimes in atopic dermatitis.10
Clinics in Dermatology
Y
2003;21:101–108
AN ATLAS OF ECZEMA
105
Figure 22. Molluscum contagiosum occur frequently in children with atopic dermatitis and may sometimes cause scarring.12 Figure 19. Erythematous patches with crusted erosions and excoriations from scratching, on the wrist, a common site of involvement in atopic dermatitis,
Figure 23. In addition to viral skin infections, atopic skin— both involved and uninvolved—is frequently colonized with Staphylococcus aureus, often superantigen-producing strains that can exacerbate the eczema. Patients may develop frank infection such as folliculitis, as seen in this patient. A short course of antistaphylococcal antibiotics is indicated to eradicate the infection.
Figure 20. Patches, plaques, and papules of erythema over a widespread area of the back. Crusted erosions and excoriations also are seen in this acute exacerbation of atopic dermatitis.
Figure 21. Eczema herpeticum can occur in patients with even mild atopic dermatitis after a trivial herpetic infection on the lip or elsewhere. This patient had minimal eczema when she developed this painful vesicular eruption that was at first misdiagnosed as impetigo. The presence of multiple 1- to 2-mm sharply circumscribed erosions on the forehead and other areas suggested eczema herpeticum. The patient was treated with oral famcyclovir, but subsequently developed shallow scarring.
Figure 24. Approximately one third of patients with atopic dermatitis may have ichthyosis vulgaris with fishlike scales prominent on the arms and legs with flexural sparing as seen here. Increased palmar markings referred to as “hyperlinear palms” are commonly seen in atopic patients with or without ichthyosis.13–17 Keratosis pilaris also is commonly noted.
106 RUDIKOFF ET AL
Figure 25. Nummular dermatitis lesions in a patient with atopic dermatitis. Sharply marginated erythematous plaques with oozing and crusting are noted.
Figure 26. Erythematous, hyperpigmented, and excoriated plaque of eczema on the nipple and areola of a male with atopic dermatitis. Eczema in this region can be an isolated manifestation of atopic dermatitis.18 Paget’s disease of the breast should be considered in cases of nipple eczema and biopsy obtained if there is doubt as to the diagnosis.
Clinics in Dermatology
Y
2003;21:101–108
Figure 27. Lichenification of the anterior aspect of the ankles and dorsa of the feet in a 4-year-old boy with atopic dermatitis. Patients often rub the ankles with the heel of the contralateral foot.
Figure 28. Eyelid dermatitis affecting both the upper and lower eyelids of one or both eyes is frequently seen in atopic dermatitis. Thinning of the lateral eyebrows, Hertoghe’s sign, is sometimes present. Increased skin folds and darkening under the eyes is common.
Clinics in Dermatology
Y
2003;21:101–108
AN ATLAS OF ECZEMA
107
References
Figure 29. Toilet-seat dermatitis or lichenification of the lower gluteal and upper posterior thighs most commonly peaks at age 7 to 8 years.19,20 Eczema in this area has been attributed to sweat retention in children sitting at their school desks all day long.
Figure 30. Netherton syndrome (NS) is an autosomal recessive disease characterized by ichthyosis, atopic diathesis, and hair shaft abnormalities, typically trichorrhexis invaginata (bamboo hair). Erythroderma often is present at birth, but after a year or two, children often display ichthyosis linearis circumflexa with “double edged scale.” IgE levels are typically elevated. The NS gene has been linked to mutations of SPINK 5 on Chromosome 5q32.21,22,23
1. Bonifazi E. Factors influencing the localization of atopic dermatitis. Acta Derm Venereol Suppl (Stockh) 1992;176: 24 –5. 2. Hanifin JM, Rajka G. Diagnostic features of atopic dermatitis. Acta Derm Venereol Suppl (Stockh) 1980;92:44 –7. 3. Kanwar AJ, Dhar S, Kaur S. Evaluation of minor clinical features of atopic dermatitis. Pediatr Dermatol 1991;8: 114 –6. 4. Pauly CR, Artis WM, Jones HE. Atopic dermatitis, impaired cellular immunity, and molluscum contagiosum. Arch Dermatol 1978;114:391–3. 5. Namura S, Nishijima S, Higashida T, Asada Y. Staphylococcus aureus isolated from nostril anteriors and subungual spaces of the hand: comparative study of medical staff, patients, and normal controls. J Dermatol 1995;22: 175–80. 6. Nishijima S, Namura S, Higashida T, Kawai S. Staphylococcus aureus in the anterior nares and subungual spaces of the hands in atopic dermatitis. J Int Med Res 1997;25: 155–8. 7. Charman CR, Morris AD, Williams HC. Topical corticosteroid phobia in patients with atopic eczema. Br J Dermatol 2000;142:931–6. 8. Urano-Suehisa S, Tagami H. Functional and morphological analysis of the horny layer of pityriasis alba. Acta Derm Venereol 1985;65:164 –7. 9. Rencic A, Cohen BA. Prominent pruritic periumbilical papules: a diagnostic sign in pediatric atopic dermatitis. Pediatr Dermatol 1999;16:436 –8. 10. Colver GB, Mortimer PS, Millard PR, et al. The ‘dirty neck’—a reticulate pigmentation in atopics. Clin Exp Dermatol 1987;12:1–4. 11. Ghura HS, Camp RD. Scarring molluscum contagiosum in patients with severe atopic dermatitis: report of two cases. Br J Dermatol 2001;144:1094 –5. 12. Blattner RJ. Molluscum contagiosum: eruptive infection in atopic dermatitis. J Pediatr 1967;70:997–9. 13. Uehara M, Hayashi S. Hyperlinear palms: association with ichthyosis and atopic dermatitis. Arch Dermatol 1981;117:490 –1. 14. Smith DA. Hyperlinear palms in atopic dermatitis: a manifestation of ichthyosis vulgaris? Cutis 1984;34:49 –51. 15. Tada J, Toi Y, Akiyama H, Arata J. Infra-auricular fissures in atopic dermatitis. Acta Derm Venereol 1994;74:129 –31. 16. Dupre A, Christol B, Lassere J Atopic dermatitis and pox-virus superinfections [(author’s transl)]. Ann Dermatol Venereol 1981;108:829 –34. 17. Shirasawa K, Akai K, Kawaguchi Y, et al. Widespread eczema vaccinatum acquired by contacts. A report of an autopsy case. Acta Pathol Jpn 1979;29:435–55. 18. Mevorah B, Frenk E, Wietlisbach V, Carrel CF. Minor clinical features of atopic dermatitis. Evaluation of their diagnostic significance. Dermatologica 1988;177:360 –4. 19. Fredriksson T, Faergemann J. The atopic thigh: a “starting-school” symptom? Acta Derm Venereol (Stockh) 1981; 61: 452–3. 20. Lindskov R, Jensen O. Toilet-seat dermatitis. Infragluteal eczema. Ugeskr Laeger 1980;142:514 –6.
108 RUDIKOFF ET AL
21. Sprecher E, Chavanas S, DiGiovanna JJ, et al. The spectrum of pathogenic mutations in SPINK5 in 19 families with Netherton syndrome: implications for mutation detection and first case of prenatal diagnosis. J Invest Dermatol 2001;117:179 –87. 22. Chavanas S, Garner C, Bodemer C, et al. Localization of
Clinics in Dermatology
Y
2003;21:101–108
the Netherton syndrome gene to chromosome 5q32, by linkage analysis and homozygosity mapping. Am J Hum Genet 2000;66:914 –21. 23. Judge MR, Morgan G, Harper JI. A clinical and immunological study of Netherton’s syndrome. Br J Dermatol 1994;131:615–21.