Describing eczema on a physical exam means systematically noting five things: the morphology of individual lesions (vesicles, papules, plaques, scale, crust), the stage of the disease (acute, subacute, or chronic), the anatomical distribution, the estimated body surface area involved, and any secondary changes like excoriation or pigment shifts. Getting these elements into your documentation clearly and consistently matters because eczema can look dramatically different depending on when in its course you catch it, how old the patient is, and what their baseline skin tone happens to be.
Morphology by Stage
Eczema is not one static picture. The lesions evolve, and the words you use to describe them should reflect where the disease currently sits on that timeline. Clinicians generally divide the morphology into three stages, and each has a distinct set of features you can see and feel.
In the acute stage, look for erythematous papules and plaques topped with vesicles. Those vesicles may be intact, or they may have ruptured, leaving behind oozing, crusted, or eroded surfaces. The skin around the lesions is often edematous and warm. When documenting, note whether the vesicles are grouped or scattered and whether serous fluid is visible.
Subacute eczema is the middle ground you see most often in clinic. The intense oozing and vesiculation have calmed down, but the skin is still red, dry, and scaly. Plaques with fine flaking and mild excoriation marks are typical. The edges of patches tend to be less sharply defined than in psoriasis, which is a useful descriptor to include in your note.
Chronic eczema is dominated by lichenification, which means the skin has thickened and its surface markings have become exaggerated from prolonged scratching. These lichenified plaques look leathery, feel firm, and often appear hyperpigmented or hypopigmented compared to surrounding skin. A review of lichen simplex chronicus describes the hallmark finding as lichenified plaques that result from persistent scratching, which is exactly what chronic eczema produces when it has been present long enough.1PubMed Central. Lichen Simplex Chronicus: Clinical Perspectives and Emerging Therapeutic Strategies When you see it, describe the texture, the degree of skin-line accentuation, and whether the thickening is focal or widespread.
Distribution Patterns by Age
Where eczema shows up on the body changes with age, and documenting the distribution is one of the strongest diagnostic clues you can capture. In infants, lesions favor the face, scalp, and extensor surfaces of the limbs. In older children, the disease migrates to the classic flexural areas: antecubital fossae, popliteal fossae, wrists, and ankles. Adults may follow that flexural pattern too, but the picture is often more varied.
A study comparing adult-onset and childhood-onset atopic dermatitis found meaningful differences in where the disease localizes. Childhood-onset disease showed higher rates of involvement of the face, scalp, eyelids, anterior neck fold, and hands or feet. Adult-onset disease, by contrast, was more likely to present with nummular (coin-shaped) lesions and with a pattern featuring hand or head-and-neck dermatitis without the classic flexural emphasis.2PubMed Central. Phenotypical differences of child- and adult-onset atopic dermatitis That matters for your documentation. If a 35-year-old walks in with coin-shaped plaques on the limbs and minimal flexural disease, note it as nummular morphology in a distribution consistent with adult-onset atopic dermatitis, rather than forcing it into the flexural mold you were taught for children.
Describing Eczema Across Skin Tones
Erythema is the single most commonly described feature of eczema, and it is also the feature most likely to be missed or underestimated in darker skin. In lighter skin, inflamed patches are obviously red. In medium and dark skin tones, the same inflammation may present as violaceous (purple-tinged), dark brown, or even grayish rather than classically red. A review on managing atopic dermatitis in patients with skin of color notes that assessment of erythema in darker skin is challenging and can lead to underscoring disease severity.3Elsevier. Managing Atopic Dermatitis in Patients With Skin of Color
Beyond erythema, there are morphological variations worth capturing. Darker skin tones are more prone to follicular accentuation, where the inflammation highlights individual hair follicles and gives the skin a bumpy, papular texture rather than smooth plaques. Nodularity can also be more prominent. And post-inflammatory pigment changes, both darkening and lightening, are far more common and more visible. Your exam note should describe the actual color you see rather than defaulting to “erythematous.” Phrases like “violaceous plaques” or “hyperpigmented patches with overlying scale” give a much more accurate picture.3Elsevier. Managing Atopic Dermatitis in Patients With Skin of Color
Associated Physical Stigmata
A thorough eczema exam goes beyond the active lesions. Several associated findings can support the diagnosis, help distinguish atopic dermatitis from other types of eczema, and give clues about chronicity. A study of minor diagnostic criteria in children found that the most common associated features were early onset of disease, xerosis, hyperlinearity of the palms, pityriasis alba (pale patches on the face), and Dennie-Morgan folds (extra creases under the lower eyelids).4PubMed Central. A Cross-Sectional Evaluation of the Usefulness of the Minor Features of Hanifin and Rajka Diagnostic Criteria for the Diagnosis of Atopic Dermatitis in the Pediatric Population
Dennie-Morgan folds and orbital darkening deserve special mention because they are easy to spot and frequently overlooked. Research in an Asian cohort found that these pigmentary changes around the eyes were more prevalent in patients with childhood-onset disease than in those whose atopic dermatitis began in adulthood.5PubMed. Evaluating and comparing the clinical characteristics between adult-onset and childhood-onset atopic dermatitis in an Asian clinical cohort When you see them, include them in your note. They help build a clinical picture that supports an atopic diagnosis even when the active lesions alone might be ambiguous.
Xerosis, or generalized dry skin surrounding the eczematous patches, is worth documenting separately from the active lesions. The dry skin of atopic dermatitis is not just cosmetically dry; it reflects a functionally impaired skin barrier with decreased hydration, increased water loss, and an elevated skin pH.6PubMed. Atopic xerosis: employment of noninvasive biophysical instrumentation for the functional analyses of the mildly abnormal stratum corneum and for the efficacy assessment of skin care products On exam, you can describe it by noting the texture (rough, scaly, flaky), whether it blanches or cracks on stretching, and how widespread it is relative to the active dermatitis.
Recognizing Subtypes by Their Signature Appearance
Eczema is an umbrella term, and the various subtypes each have physical exam features worth recognizing because the descriptors you use should reflect which pattern you are actually seeing.
Dyshidrotic eczema affects the palms, soles, and lateral fingers. Its hallmark is clusters of deep-seated vesicles that sit within the thick skin of those areas and have a characteristic appearance often compared to tapioca pudding.7PubMed Central. Dyshidrotic Eczema: A Common Cause of Palmar Dermatitis Document the location (palmar, plantar, or both), whether vesicles are intact or have ruptured into dry collarettes of scale, and whether there is background erythema. In chronic cases, the vesicles give way to peeling, fissuring, and thickened skin on the palms.
Nummular eczema presents as coin-shaped plaques, typically ranging from one to several centimeters in diameter. They are round to oval, well-demarcated, scaly, and sometimes crusted. The lesions tend to appear on the extremities and trunk. Document the shape explicitly, because it helps distinguish this pattern from the ill-defined patches of typical flexural eczema. Nummular morphology was specifically associated with adult-onset atopic dermatitis in at least one large comparison study.2PubMed Central. Phenotypical differences of child- and adult-onset atopic dermatitis
Asteatotic eczema, common in elderly patients and in dry climates, has a distinctive cracked appearance often described as “crazy paving,” resembling the surface of cracked porcelain.8Medical Profession Journal of Lampung. Asteatotic Eczema In 24 Years Old Female The fissures run in a network pattern over dry, erythematous skin, usually on the shins. When you see it, describe the cracking pattern, the depth of fissures, and whether any are bleeding or crusted.
Allergic contact dermatitis can mimic atopic eczema morphologically, with erythema, vesiculation, flaking, and lichenification all appearing depending on the stage. The key distinguishing feature on exam is the distribution: contact dermatitis conforms to the area of allergen exposure, so a sharply geometric or linear pattern, or involvement limited to a specific body part, should prompt you to describe the boundaries precisely and consider contact allergy.9Elsevier. Allergic Contact Dermatitis by Anatomical Regions: Diagnostic Clues
Signs of Complication
Part of examining eczema is looking for evidence that the disease has become complicated by infection, which changes both your description and your management. Two complications are common enough that you should actively look for them every time.
Bacterial superinfection, most often caused by Staphylococcus aureus, presents as honey-colored crusting over an erythematous base. This appearance is characteristic of impetigo developing on top of eczematous skin.10PubMed Central. The infectious complications of atopic dermatitis Other clues include increased oozing, pustules, regional lymphadenopathy, and a sudden worsening of previously stable disease. Describe the crust color and texture, note any purulent drainage, and document whether surrounding erythema extends beyond the usual eczema margins.
Eczema herpeticum is less common but far more dangerous. It occurs when herpes simplex virus infects eczematous skin and presents with clusters of monomorphic, punched-out erosions or dome-shaped vesicles, often with accompanying fever and malaise. Clinicians should keep a high index of suspicion when a patient with eczema develops vesicular lesions with punched-out erosions and systemic symptoms.11Pediatric Emergency Care. Eczema Herpeticum: Would You Know It If You Saw It? The punched-out quality of the erosions is the key descriptor to capture. Unlike the irregular, scratched-open erosions of excoriated eczema, these are uniform and look almost stamped into the skin.
Scoring Severity with EASI
Beyond narrative description, quantifying eczema severity gives your physical exam documentation a standardized anchor. The Eczema Area and Severity Index, or EASI, is the most widely used tool in clinical trials and increasingly in clinical practice. It divides the body into four regions (head and neck, upper extremities, trunk, and lower extremities), and in each region you estimate the percentage of surface area involved and grade four signs: erythema, edema or papulation, excoriation, and lichenification. Each sign is scored from 0 (absent) to 3 (severe), and the area involvement is scored on a scale from 0 to 6.12PubMed Central. The Eczema Area and Severity Index—A Practical Guide
The resulting total score ranges from 0 to 72. To make those numbers meaningful, severity strata have been established: scores from about 1 to 7 indicate mild disease, roughly 7 to 21 is moderate, 21 to 50 is severe, and above 50 is very severe.13PubMed. What the Eczema Area and Severity Index score tells us about the severity of atopic dermatitis: an interpretability study Including an EASI score in your exam note transforms a subjective description into something trackable over time and comparable across visits and providers. Even if you do not formally calculate the score every visit, framing your description around those four signs (erythema, edema/papulation, excoriation, lichenification) in each body region keeps your exam structured and thorough.
Dermoscopic Clues
If you use a dermatoscope during your exam, eczema has a recognizable pattern that can help confirm the diagnosis and distinguish it from look-alikes, especially psoriasis. Under dermoscopy, eczema typically shows clusters of red dots (dilated capillaries) in an irregular, patchy distribution, accompanied by yellow scales or yellow serocrust.14European Medical Journal. Dermoscopy of Inflammatory Conditions: The Journey So Far The irregularity of the vascular pattern is the distinguishing feature. Psoriasis also shows red dots, but they are arranged uniformly and regularly across the lesion, and the associated scales are white rather than yellow.
A study comparing dermoscopic features of palmoplantar eczema and palmoplantar psoriasis reinforced this distinction, finding that eczema was characterized by a pink background with yellow scales and atypically arranged blood vessels, while psoriasis showed a red background with white scales and regularly distributed vessels.15PubMed Central. Analysis of dermoscopic characteristic for the differential diagnosis of palmoplantar psoriasis and palmoplantar eczema When documenting dermoscopic findings, describe the vascular pattern (dotted, clustered or regular), the scale color, and the background hue.
Telling Eczema from Its Mimics on Exam
Several conditions look enough like eczema that your physical exam description needs to capture the features that distinguish them. Getting the description right often starts the differential diagnosis process before any lab work or biopsy results come back.
Psoriasis is the most common mimic. Both produce red, scaly plaques. The differences are in the details: psoriatic plaques are typically more sharply demarcated, with thick silvery-white scale and a predilection for extensor surfaces, the scalp, and the sacral area. Eczematous plaques tend to be less well defined, with finer scale, and favor flexural surfaces. The dermoscopic distinctions discussed above can help when the clinical picture is ambiguous.
Tinea corporis (ringworm) can produce annular, scaly patches that overlap with nummular eczema. The key exam finding is the active, raised, scaly border with central clearing in tinea, versus the more uniformly involved plaque in nummular eczema. A KOH scraping from the leading edge of the ring confirms fungal infection, but your narrative description of the border morphology is what signals the need for that test in the first place.
Seborrheic dermatitis overlaps with eczema on the face and scalp. It tends to favor the nasolabial folds, eyebrows, and retroauricular creases and produces greasy, yellowish scale rather than the dry, flaky scale of atopic eczema. Describing the quality of the scale (greasy versus dry) and its precise location helps separate the two.
Scabies can be confused with eczema because both cause intense itching and excoriated papules. Look for linear burrows, especially in the web spaces of fingers, wrists, and around the waistband. The presence of burrows is a distinctive physical exam finding that should always be documented when present, as it points strongly away from primary eczema.
Practical Tips for Writing the Exam Note
Putting all of this together into a coherent physical exam description does not require a checklist, but it does require a consistent approach. A well-structured eczema note typically covers the following elements in order: the overall distribution of disease (which body regions, symmetry), the morphology of individual lesions (type of primary lesion, secondary changes), the stage (acute, subacute, chronic), any associated features (xerosis, Dennie-Morgan folds, hyperlinear palms), and signs of complication (crusting pattern, punched-out erosions, lymphadenopathy).
Use color words that reflect what you actually see, not what textbooks assume you should see. If the inflammation looks dusky or brown rather than red, say so. If the lichenification is subtle, describe it as mild skin-line accentuation rather than reaching for the word “lichenified” when the finding barely qualifies. Quantify surface area when possible, even a rough percentage helps track changes over time. And note the patient’s itch behavior: visible excoriation marks, broken nails, and lichen simplex changes at sites of habitual scratching tell you something about disease burden that the appearance of individual lesions alone does not capture.
When recording findings for infants, keep in mind that the diagnostic criteria validated for adults and older children may not map perfectly. Work comparing criteria for diagnosing atopic eczema in infants found that multiple frameworks were used, but the combination of visible eczema with typical morphology and an atopic distribution pattern remained the practical backbone of clinical diagnosis even when formal criteria varied.16British Journal of Dermatology. A comparison between criteria for diagnosing atopic eczema in infants For infant exams, describe what you see on the cheeks, scalp, and extensor limbs, and note whether the diaper area is spared, since sparing of the diaper region is a classic clue pointing toward atopic dermatitis rather than other causes of infant rash.