Characterization of Classical Flexural and Nummular Forms of Atopic Dermatitis in Childhood with Regard to Anamnestic, Clinical and Epidermal Barrier Aspects


  • Folke Hüppop
  • Stephan Dähnhardt-Pfeiffer
  • Regina Fölster-Holst Department of Dermatology, Venereology and Allergology, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller Str. 3, DE-24105 Kiel, Germany



atopic dermatitis, nummular eczema, children, epidermal barrier


Nummular (coin-shaped) and classical (flexural) atopic dermatitis differ morphologically, but no other distinguishing features are known. The aim of this study was to determine differences and similarities of both variants in children. Detailed interviews, clinical examinations, biophysical measurements and electron microscopic analyses were performed on 10 children with nummular atopic dermatitis, 14 with classical atopic dermatitis and 10 healthy controls. Nummular atopic dermatitis affected more boys than girls and manifested less frequently within the first year of life than classical atopic dermatitis. Localization, distribution and morphology of the eczema varied more over time, and expression of keratosis pilaris was more severe in children with nummular atopic dermatitis. Both disease groups showed reduced hydration, increased transepidermal water loss and reduced intercellular lipid lamellae in lesional skin areas compared with non-lesional areas. These findings underline the separate classification of both variants. Further research is necessary to investigate the potential of diverging therapeutic approaches.


Download data is not yet available.


Bylund S, Kobyletzki LB, Svalstedt M, Svensson Å. Prevalence and incidence of atopic dermatitis: a systematic review. Acta Derm Venereol 2020; 100: 320-329.

Silverberg JI, Barbarot S, Gadkari A, Simpson EL, Weidinger S, Mina-Osorio P, et al. Atopic dermatitis in the pediatric population: a cross-sectional, international epidemiologic study. Ann Allergy Asthma Immunol 2021; 126: 417-428.

Lewis-Jones MS. Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema. Int J Clin Pract 2006; 60: 984-992.

Drucker AM, Wang AR, Li WQ, Sevetson E, Block JK, Qureshi AA. The burden of atopic dermatitis: summary of a report for the National Eczema Association. J Invest Dermatol 2017; 137: 26-30.

Langan SM, Irvine AD, Weidinger S. Atopic dermatitis. Lancet 2020; 396: 345-360.

Bieber T, D'Erme AM, Akdis CA, Traidl-Hoffmann C, Lauener R, Schäppi G, et al. Clinical phenotypes and endophenotypes of atopic dermatitis: where are we, and where should we go? J Allergy Clin Immunol 2017; 139: S58-S64.

Ring J, Przybilla B, Ruzicka T, editors. Handbook of atopic eczema. Berlin/Heidelberg: Springer; 2006.

Fölster-Holst R. Neurodermitis. Ophthalmologe 2017; 114: 498-503.

Silverberg NB. Typical and atypical clinical appearance of atopic dermatitis. Clin Dermatol 2017; 35: 354-359.

Proksch E, Dähnhardt D, Dähnhardt-Pfeiffer S, Fölster-Holst R. Epidermale Barrierestörung bei Dermatosen. Hautarzt 2016; 67: 907-921.

Janssens M, van Smeden J, Gooris GS, Bras W, Portale G, Caspers PJ, et al. Lamellar lipid organization and ceramide composition in the stratum corneum of patients with atopic eczema. J Invest Dermatol 2011; 131: 2136-2138.

Elias PM, Steinhoff M. "Outside-to-inside" (and now back to "outside") pathogenic mechanisms in atopic dermatitis. J Invest Dermatol 2008; 128: 1067-1070.

Proksch E, Brandner JM, Jensen JM. The skin: an indispensable barrier. Exp Dermatol 2008; 17: 1063-1072.

Dähnhardt-Pfeiffer S, Surber C, Wilhelm KP, Dähnhardt D, Springmann G, Böttcher M, et al. Noninvasive stratum corneum sampling and electron microscopical examination of skin barrier integrity: pilot study with a topical glycerin formulation for atopic dermatitis. Skin Pharmacol Physiol 2012; 25: 155-161.

Hanifin JM, Rajka G. Diagnostic features of atopic dermatitis. Acta Derm Venereol 1980; 92: 44-47.

Lewis-Jones MS, Finlay AY. The Children's Dermatology Life Quality Index (CDLQI): Initial validation and practical use. Br J Dermatol 1995; 132: 942-949.

Lewis-Jones MS, Finlay AY, Dykes PJ. The Infants' Dermatitis Quality of Life Index (IDQOL). Br J Dermatol 2001; 144: 104-110.

Basra MKA, Sue-Ho R, Finlay AY. The Family Dermatology Life Quality Index: measuring the secondary impact of skin disease. Br J Dermatol 2007; 156: 528-538.

Kunz B, Oranje AP, Labrèze L, Stalder JF, Ring J, Taïeb A. Clinical validation and guidelines for the SCORAD index: consensus report of the European Task Force on Atopic Dermatitis. Dermatology 1997; 195: 10-19.

Fischer TW, Wigger-Alberti W, Elsner P. Assessment of "dry skin": current bioengineering methods and test designs. Skin Pharmacol Appl Skin Physiol 2001; 14: 183-195.

Berardesca E, Loden M, Serup J, Masson P, Rodrigues LM. The revised EEMCO guidance for the in vivo measurement of water in the skin. Skin Res Technol 2018; 24: 351-358.

Langen U, Schmitz R, Steppuhn H. Häufigkeit allergischer Erkrankungen in Deutschland. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2013; 56: 698-706.

Schmitz R, Thamm M, Ellert U, Kalcklösch M, Schlaud M. Verbreitung häufiger Allergien bei Kindern und Jugendlichen in Deutschland: Ergebnisse der KiGGS-Studie - Erste Folgebefragung (KiGGS Welle 1). Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2014; 57: 771-778.

Werfel T, Aberer W, Ahrens F, Augustin M, Biedermann T, Diepgen T, et al; Association of Scientific Medical Societies of Germany. Leitlinie Neurodermitis [atopisches Ekzem; atopische Dermatitis]. J Dtsch Dermatol Ges 2016; 14: e1-e75.

Weidinger S, Novak N. Atopic dermatitis. Lancet 2016; 387: 1109-1122.

Gånemo A, Svensson Å, Lindberg M, Wahlgren C. Quality of life in Swedish children with eczema. Acta Derm Venereol 2007; 87: 345-349.

Kim DH, Li K, Seo SJ, Jo SJ, Yim HW, Kim CM, et al. Quality of life and disease severity are correlated in patients with atopic dermatitis. J Korean Med Sci 2012; 27: 1327-1332.

De Marchi F, Piacentini GL, Piazza M, Sandri M, Boner AL, Peroni DG. Correlation of skin barrier impairment in atopic dermatitis with aeroallergen sensitization. Allergy Asthma Proc 2015; 36: 127-133.

Novak N, Baurecht H, Schäfer T, Rodriguez E, Wagenpfeil S, Klopp N, et al. Loss-of-function mutations in the filaggrin gene and allergic contact sensitization to nickel. J Invest Dermatol 2008; 128: 1430-1435.

Seidenari S, Giusti G. Objective assessment of the skin of children affected by atopic dermatitis: a study of pH, capacitance and TEWL in eczematous and clinically uninvolved skin. Acta Derm Venereol 1995; 75: 429-433.

Heinrich U, Koop U, Leneveu-Duchemin MC, Osterrieder K, Bielfeldt S, Chkarnat C, et al. Multicentre comparison of skin hydration in terms of physical-, physiological- and product-dependent parameters by the capacitive method (Corneometer CM 825). Int J Cosmet Sci 2003; 25: 45-53.

Engebretsen KA, Johansen JD, Kezic S, Linneberg A, Thyssen JP. The effect of environmental humidity and temperature on skin barrier function and dermatitis. J Eur Acad Dermatol Venereol 2016; 30: 223-249.

Eberlein-König B, Schäfer T, Huss-Marp J, Darsow U, Möhrenschlager M, Herbert O, et al. Skin surface pH, stratum corneum hydration, trans-epidermal water loss and skin roughness related to atopic eczema and skin dryness in a population of primary school children. Acta Derm Venereol 2000; 80: 188-191.

Loden M, Olsson H, Axell T, Linde YW. Friction, capacitance and transepidermal water loss (TEWL) in dry atopic and normal skin. Br J Dermatol 1992; 126: 137-141.

Jensen JM, Fölster-Holst R, Baranowsky A, Schunck M, Winoto-Morbach S, Neumann C, et al. Impaired sphingomyelinase activity and epidermal differentiation in atopic dermatitis. J Invest Dermatol 2004; 122: 1423-1431.

Alexander H, Brown S, Danby S, Flohr C. Research techniques made simple: Transepidermal water loss measurement as a research tool. J Invest Dermatol 2018; 138: 2295-2300.

Conti A, Schiavi ME, Seidenari S. Capacitance, transepidermal water loss and causal level of sebum in healthy subjects in relation to site, sex and age. Int J Cosmet Sci 1995; 17: 77-85.

Kottner J, Lichterfeld A, Blume-Peytavi U. Transepidermal water loss in young and aged healthy humans: a systematic review and meta-analysis. Arch Dermatol Res 2013; 305: 315-323.

Kleesz P, Darlenski R, Fluhr JW. Full-body skin mapping for six biophysical parameters: Baseline values at 16 anatomical sites in 125 human subjects. Skin Pharmacol Physiol 2012; 25: 25-33.

Pinnagoda J, Tupkek RA, Agner T, Serup J. Guidelines for transepidermal water loss (TEWL) measurement. A report from the Standardization Group of the European Society of Contact Dermatitis. Contact Dermatitis 1990; 22: 164-178.

Dähnhardt-Pfeiffer S, Dähnhardt D, Buchner M, Walter K, Proksch E, Fölster-Holst R. Comparison of effects of tacrolimus ointment and mometasone furoate cream on the epidermal barrier of patients with atopic dermatitis. J Dtsch Dermatol Ges 2013; 11: 437-443.


Additional Files



How to Cite

Hüppop, F., Dähnhardt-Pfeiffer, S., & Fölster-Holst, R. (2022). Characterization of Classical Flexural and Nummular Forms of Atopic Dermatitis in Childhood with Regard to Anamnestic, Clinical and Epidermal Barrier Aspects. Acta Dermato-Venereologica, 102, adv00664.