Atopic dermatitis (AD) is a chronic inflammatory skin disease clinically characterized by eczematous skin manifestations. Sometimes, it can manifest with non-specific clinical features, which are common with other skin conditions, such as infectious and neoplastic diseases. We would like to underline the importance of accurate dermatologic examination and rigorous anamnesis in patients affected by AD to avoid misdiagnosis and delayed treatments.

Atopic dermatitis (AD) is a chronic inflammatory skin disease that classically affects children but can also occur in adolescents and adults. It is clinically characterized by erythematous and eczematous skin patches and plaques on flexural areas, trunk, face, and hands accompanied by intense itch.1 AD can reduce the patient’s quality of life (QoL), with a negative influence on daily activities and sleep. The treatment includes topical and systemic drugs, phototherapy, biologics, and Jak inhibitors, according to the severity of the disease and the impairment of the patient’s QoL.

A 20-year-old female patient was referred to our dermatology outpatient for an itching eczematous rash. She suffered from atopic dermatitis from childhood, with a progressive worsening during adolescence. The dermatology examination revealed the presence of erythematous papules, scaling patches, and eczematous lesions on the trunk, extremities, and face, accompanied by severe pruritus and impairment of the patient’s QoL (Eczema Area and Severity Index [EASI]: 26; pruritus-Numeric Rating Scale [p-NRS]: 10; Dermatology Life Quality Index [DLQI]: 27). She was previously treated with topical emollients and short courses of systemic steroids with unsatisfactory results. Subsequently, dupilumab 300 mg was administered every 15 days with good improvement, but it was interrupted after 5 months for the development of severe conjunctivitis. For this reason, we decided to start therapy with upadacitinib 15 mg, with a fast clinical response and a reduction of pruritus after only 1 month (EASI: 10; pruritus NRS: 2; DLQI: 3). However, after 3 months of treatment, a clinical worsening was observed, with an apparent relapse of AD. In fact, the clinical examination revealed the presence of erythematous papules, excoriations, oozing, and crust on hands, buttocks, nipples, armpits, and abdomen (Figure 1A). The patient complained of intense itching with sleep disturbance without response to systemic antihistamines. In addition, burrows were observed on interdigital areas of the hands and wrists, suggesting the hypothesis of scabies. The patient reported similar signs and symptoms in family members. The diagnosis was confirmed, demonstrating the presence of mites and eggs from scrapings of the cutaneous lesions and direct microscopy (Figure 2).2 Topical permethrin 5% and oral ivermectin were administered with a complete resolution of clinical manifestations and pruritus (Figure 1B).

Scabies is a mite infestation caused by Sarcoptes scabiei, which is characterized by intense pruritus and the presence of papules and burrows on the interdigital spaces of the hands, axillae, wrists, buttocks, and genitalia. The presentation of scabies can mimic other skin conditions, making it tricky to diagnose and leading to possible outbreaks.3 Also, AD can sometimes manifest with non-specific clinical features, which can be in common with other skin conditions, such as inflammatory, neoplastic, or infectious diseases.1,4

The purpose of this case report is to underline the importance of accurate dermatologic examination and rigorous anamnesis in AD patients in order to avoid misdiagnosis and delayed treatments without interfering with effective underlying therapy, resulting in an aggravation of dermatologic disease5 and, in the case of an infectious condition, a possible spread to family and close contacts.