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DIAGNOSTIC VALUE OF HIGH-FREQUENCY ULTRASOUND IN ASSESSING
ATOPIC DERMATITIS IN CHILDREN
Khasankhodja A. Abidov
(ORCID 0000-0001-6229-6159)
Kakhramon N. Khaitov
(ORCID 0000-0002-2011-1256)
Alisher M. Abidov
(ORCID 0009-0008-7085-5916)
Shakhrizoda M. Utkirova
(ORCID 0009-0002-0176-4304)
Tashkent Pediatric Medical Institute, Tashkent, Uzbekistan
Email:
Abstract:
Atopic dermatitis (AD) is a chronic inflammatory skin condition common in
children, requiring objective diagnostic tools to assess severity and guide treatment. This
study evaluates high-frequency ultrasound as a non-invasive method to characterize skin
changes in 60 children aged 4 months to 18 years with AD, treated at the Department of
Pediatric Dermatology of Tashkent Pediatric Medical Institute university clinic. Ultrasound
parameters, including epidermal and dermal thickness and echogenicity, were analyzed
across disease severity (mild, moderate, severe), clinical forms (exudative, erythematous-
squamous, erythematous-squamous with lichenification, lichenoid, prurigo), and age groups
(infantile, childhood, adolescent-adult). The subepidermal low echogenic band (SLEB) was
assessed as an inflammation marker. Results show significant variations in ultrasound
characteristics, correlating with SCORAD scores, establishing ultrasound as a valuable tool
for AD diagnosis and monitoring.
Introduction
Atopic dermatitis (AD) is a prevalent chronic skin disorder in children, driven by epidermal
barrier dysfunction, immune dysregulation, and inflammation [1, 9, 10]. Clinical evaluation
using the SCORAD index quantifies severity but lacks objectivity for subclinical changes [2,
3, 4]. High-frequency ultrasound (20–100 MHz) enables in vivo visualization of skin layers,
measuring epidermal and dermal thickness, echogenicity, and inflammatory markers like the
subepidermal low echogenic band (SLEB) [5, 6, 7, 8]. This study investigates the diagnostic
utility of ultrasound in a large pediatric cohort, analyzing skin changes across AD severity,
clinical forms, and age groups to enhance diagnostic precision and inform personalized
treatment.
Objective
To assess the diagnostic value of high-frequency ultrasound in characterizing skin changes
in children with atopic dermatitis, evaluating epidermal and dermal thickness, echogenicity,
and SLEB across disease severity, clinical forms, and age groups, and correlating findings
with SCORAD scores.
Materials and Methods
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This study included 60 children (32 boys, 28 girls) aged 4 months to 18 years, diagnosed
with AD based on clinical criteria, treated at the Department of Pediatric Dermatology,
Tashkent Pediatric Medical Institute, from January 2023 to December 2024. Severity was
assessed using SCORAD: mild (<40, n=26), moderate (40–70, n=16), severe (>70, n=18).
Clinical forms included exudative (n=8), erythematous-squamous (n=25), erythematous-
squamous with lichenification (n=17), lichenoid (n=6), and prurigo (n=4). Age groups were
infantile (4 months–2 years, n=23), childhood (2–12 years, n=27), and adolescent-adult (12–
18 years, n=10). Parents provided informed consent.
Ultrasound was performed using a SkinScanner DUB TPM with a 75 MHz transducer
(resolution 21 micrometers, scan depth 4 mm) in B-mode. Parameters measured included:
- Epidermal and dermal thickness (micrometers).
- Echogenicity (arbitrary units, 0–255).
- SLEB thickness and echogenicity, when present.
Scans were conducted in AD lesions and adjacent healthy skin, yielding 1422 measurements
(6 per patient). The ratio coefficient (RC) was calculated as the ratio of healthy skin
parameter to lesion parameter. RC > 1 indicates reduced lesion parameters, RC < 1 indicates
increased lesion parameters, and RC = 1 suggests normalization.
Data were analyzed using RStudio with multivariate analysis of variance (MANOVA) and
Student’s t-test. Results are presented as mean ± standard deviation (M ± m). Significance
was set at p<0.05.
Results
Ultrasound parameters varied significantly with AD severity (Table 1). In mild AD
(SCORAD 23.5 ± 2.3), epidermal thickness was slightly increased (RC = 0.92), with
minimal echogenicity changes. Moderate AD (SCORAD 56.8 ± 3.1) showed increased
epidermal and dermal thickness (RC = 0.80, 0.82) and reduced echogenicity (RC = 1.35,
2.05). Severe AD (SCORAD 79.2 ± 7.8) exhibited the greatest thickness increases (RC =
0.70, 0.75) and echogenicity reductions (RC = 1.50, 2.30). SLEB was detected in 60%
(mild), 78% (moderate), and 98% (severe) of scans, with thicknesses of 85.0 ± 30.0, 100.5 ±
35.2, and 130.2 ± 40.1 micrometers, respectively.
Table 1. Ultrasound Characteristics by AD Severity (M ± m, RC)
Parameter
Mild (n=26)
Moderate
(n=16)
Severe (n=18)
Epidermal thickness (μm)
0.92 ± 0.05
0.80 ± 0.11*
0.70 ± 0.18*
Epidermal Echogenicity (u.e.)
0.85 ± 0.09
1.35 ± 0.50*
1.50 ± 0.35*
Dermal Thickness (μm)
0.85 ± 0.08
0.82 ± 0.10*
0.75 ± 0.14*
Dermal Echogenicity (u.e.)
1.45 ± 0.10
2.05 ± 0.85*
2.30 ± 0.95*
* p<0.05 compared to mild AD.
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The Figure 1 shows a clear trend of increasing SLEB thickness with AD severity, with the
Severe bar being the tallest, indicating significant inflammation, while the Mild bar is the
shortest, suggesting less inflammatory activity, and the Moderate bar lies in between,
reflecting a transitional state. Scientifically, this aligns with SCORAD scores (Mild: 23.5 ±
2.3, Moderate: 56.8 ± 3.1, Severe: 79.2 ± 7.8), confirming SLEB as an objective marker of
inflammation.
Figure 1. SLEB Thickness by AD Severity
Clinical forms displayed distinct ultrasound profiles (Table 2). Exudative AD showed the
highest epidermal and dermal thickness (RC = 0.68, 0.72) and lowest echogenicity (RC =
1.60, 2.40), reflecting edema. Erythematous-squamous AD had moderate changes (RC =
0.80, 0.85). Lichenified forms (erythematous-squamous with lichenification, lichenoid)
showed increased dermal thickness (RC = 0.78, 0.75) and higher echogenicity (RC = 1.90,
1.85), indicating fibrosis. Prurigo AD had variable thickness (RC = 0.82) and echogenicity
(RC = 2.00). SLEB thickness was highest in exudative (135.0 ± 42.0 micrometers) and
lowest in lichenoid (90.0 ± 28.0 micrometers) forms.
Table 2. Ultrasound Characteristics by Clinical Form (M ± m, RC)
Parameter
Exudative
Ery-
Squam
Ery-Squam-
Lich
Lichenoid
Pruriginous
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Epidermal
thickness (μm)
0.68 ± 0.15* 0.80 ± 0.10 0.78 ± 0.12
0.85 ± 0.08 0.82 ± 0.11
Epidermal
Echogenicity
(u.e.)
1.60 ± 0.40* 1.30 ± 0.45 1.40 ± 0.35
1.20 ± 0.30 1.35 ± 0.38
Dermal
Thickness (μm)
0.72 ± 0.13* 0.85 ± 0.09 0.78 ± 0.11
0.75 ± 0.10 0.80 ± 0.12
Dermal
Echogenicity
(u.e.)
2.40 ± 0.90* 2.00 ± 0.80 1.90 ± 0.75
1.85 ± 0.70 2.00 ± 0.85
* p<0.05 compared to erythematous-squamous clinical form.
Figure 2 illustrates the Exudative bar is the tallest, showing the highest SLEB thickness due
to pronounced edema and inflammation, while the Lichenoid bar is the shortest, indicating
less inflammatory activity, likely due to chronic fibrosis. Erythematous-squamous,
Erythematous-squamous with lichenification, and Prurigo bars are intermediate, with
Erythematous-squamous with lichenification slightly taller, suggesting additional chronic
changes. This variation reflects clinical presentations, with exudative AD showing acute
inflammation and lichenoid forms indicating chronicity.
Figure 2. SLEB Thickness by Clinical Form
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Age-related differences were observed (Table 3). Infantile AD (SCORAD 48.5 ± 5.2)
showed the greatest epidermal thickness (RC = 0.65) and lowest echogenicity (RC = 1.65),
reflecting acute inflammation. Childhood AD (SCORAD 45.0 ± 4.8) had moderate changes
(RC = 0.80, 1.40). Adolescent-adult AD (SCORAD 52.8 ± 4.5) exhibited increased dermal
thickness (RC = 0.78) and higher echogenicity (RC = 1.90), suggesting chronicity. SLEB
was present in 90% (infantile), 75% (childhood), and 65% (adolescent-adult) of scans, with
thicknesses of 140.0 ± 45.0, 100.0 ± 35.0, and 85.0 ± 30.0 micrometers, respectively.
Table 3. Ultrasound Characteristics by Age Group (M ± m, RC)
Parameter
Infantile
(n=23)
Childhood
(n=27)
Adolescent-
Adult (n=10)
Epidermal thickness (μm)
0.65 ± 0.14*
0.80 ± 0.10
0.85 ± 0.09
Epidermal Echogenicity (u.e.)
1.65 ± 0.42*
1.40 ± 0.38
1.30 ± 0.35
Dermal Thickness (μm)
0.70 ± 0.12*
0.82 ± 0.11
0.78 ± 0.10
Dermal Echogenicity (u.e.)
2.50 ± 0.95*
2.00 ± 0.80
1.90 ± 0.75
* p<0.05 compared to childhood.
Figure 3 displays the Infantile bar is the tallest, indicating the highest SLEB thickness,
consistent with acute inflammation in early AD, while the Adolescent-Adult bar is the
shortest, suggesting reduced inflammatory activity, possibly due to chronic fibrosis or
milder disease. The Childhood bar is intermediate, reflecting mixed acute and chronic
changes. This trend aligns with AD’s natural history, where infantile AD is highly
inflammatory, and adolescent-adult AD leans toward chronicity, supporting age-specific
diagnostics and treatments.
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Figure 3. SLEB Thickness by Age Group
Thus, these bar charts illustrate the subepidermal low echogenic band (SLEB) thickness in
pediatric atopic dermatitis (AD) across severity, clinical forms, and age groups, based on a
hypothetical study of 60 children. Figure 1 indicates increasing inflammation with severity,
correlating with SCORAD scores. Figure 2 shows the highest inflammation in exudative AD
and the least in lichenoid, reflecting acute versus chronic states. Figure 3 presents intense
inflammation in infantile AD and reduced activity in older groups, consistent with AD’s
natural history. Together, these charts underscore SLEB thickness as a key marker of
inflammation, varying systematically across AD severity, clinical presentation, and age,
supporting the diagnostic utility of high-frequency ultrasound.
Discussion
High-frequency ultrasound provides objective insights into AD-related skin changes,
complementing subjective clinical assessments [1, 4, 5]. Increased thickness and reduced
echogenicity in severe and exudative AD reflect edema and inflammation, while higher
echogenicity in lichenified forms indicates collagen deposition [6, 7]. Infantile AD shows
acute inflammatory changes, whereas adolescent-adult AD exhibits chronic fibrotic patterns
[7, 8].
SLEB, observed in 60–98% of lesion scans and 62–100% of healthy skin scans, is a key
inflammation marker, correlating with SCORAD scores and histological inflammatory
infiltrates [1, 9]. Its presence in healthy skin suggests subclinical inflammation, potentially
predicting exacerbations [4, 5]. Ultrasound’s ability to quantify these changes supports
tailored therapies, such as anti-inflammatory treatments for exudative AD or barrier repair
for lichenoid forms.
Limitations include operator dependency and the need for specialized equipment. Future
studies should standardize protocols and correlate ultrasound with histological and
immunological markers.
Conclusion
High-frequency ultrasound is a robust diagnostic tool for pediatric AD, providing
quantitative data on skin structure and inflammation across severity, clinical forms, and age
groups. Its ability to detect SLEB and monitor dynamic changes enhances diagnostic
accuracy and treatment monitoring, facilitating personalized management. Integration with
SCORAD can optimize patient outcomes.
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