Provide a detailed physical examination for chronic eczema.

Physical Examination for Chronic Eczema

A comprehensive skin examination should systematically document the extent, location, and severity of eczema while actively looking for signs of secondary infection—the two most critical factors that directly impact treatment decisions and patient outcomes 1.

Essential Components of the Physical Exam

Primary Assessment Areas

Document disease distribution and morphology:

• Flexural involvement: Examine folds of elbows, behind knees, around the neck (in children under 4, check cheeks, forehead, and outer limbs instead) 1
• Extent of involvement: Record percentage of body surface area affected—note that patient-perceived severity increases little beyond 30% involvement 2
• Severity markers: Assess the three clinical signs that best correlate with patient-rated disease severity:
  • Excoriations (scratching marks)
  • Erythema (redness)
  • Edema/papulation (swelling/raised bumps) 2

Critical Signs of Complications

Bacterial infection (requires immediate treatment consideration):

• Crusting or weeping lesions
• Honey-colored exudate
• If suspected, obtain bacteriological swabs for Staphylococcus aureus 1

Herpes simplex infection (eczema herpeticum—a dermatologic emergency):

• Grouped, punched-out erosions
• Discrete vesicles in clusters
• If suspected, send swabs for virological screening and smear for electron microscopy 1

Additional Morphologic Features

Acute eczema characteristics:

• Erythema, papules, seropapules, vesicles
• Pustules, scales, crusts
• Polymorphic appearance (multiple lesion types simultaneously) 3

Chronic eczema characteristics:

• Lichenification (thickened, leathery skin from chronic scratching)
• Hyperpigmentation or hypopigmentation
• Fissuring (particularly on hands) 3

Specific Anatomic Considerations

For hand eczema (common in chronic cases):

• Examine for erythema, scaling, fissures
• Assess functional impairment
• Document involvement of finger webs (to exclude scabies) 4, 5

General skin assessment:

• Evaluate for generalized xerosis (dry skin)
• Check nail length (should be kept short to minimize excoriation damage) 1
• Look for signs of contact dermatitis (may complicate atopic eczema)

Associated Findings

Lymphadenopathy: May be present but is usually secondary to extensive skin disease in otherwise healthy patients—not typically concerning unless accompanied by systemic symptoms 1

Exclude alternative diagnoses:

• Scabies: Look for burrows in finger webs
• Immunodeficiency: Check for petechiae, signs of recurrent systemic infections 1

Documentation Strategy

Record systematically:

1. Location: Specific body areas involved
2. Extent: Percentage of body surface area
3. Severity: Using the three key signs (excoriations, erythema, edema/papulation)
4. Infection: Presence or absence of bacterial/viral superinfection
5. Chronicity markers: Lichenification, pigmentary changes

Clinical Pitfall

Deterioration in previously stable or mild eczema warrants careful examination for secondary bacterial or viral infection, or development of contact dermatitis—these complications are frequently missed and lead to treatment failure 1. Don't assume worsening disease is simply inadequate eczema control; actively look for and document signs of superinfection or new allergen exposure.