Pediatric Dermatology Vol. 14 No. 5 344-346, 1997

Infraorbital Crease and Atopic Dermatitis

Inderpal Singh, M.D., and Amrinder J. Kanwar, M.D.

Department of Dermatology & Venereology, Government Medical College Hospital, Chandigarh, India

Abstract: The usefulness of a prominent infraorbital skin crease as amarker of atopic dermatitis (AD) was examined in 500 consecutive schoolchildren 3 to 11 years of age. Infraorbital crease was recorded by twotrained observers according to a strict protocol, and AD was determinedby an independent dermatologist who was blinded to the study design. Aprominent Infraorbital crease was present in only 4 of 20 (20%) childrenwith AD, compared with 171 of 460 (35.6%) children who did not have AD(p > .05). While infraorbital crease may be of some use in diagnosingindividual cases of AD in a hospital setting, it appears to be less useful inpopulation-based studies because of Its poor validity and repeatability.

In 1948. D. B. Morgan described prominent infraor-bital skin creases in two patients with atopic dermatitis(.AD) and suggested that these crea,ses were a useful signof allergy (1). .Subsequent studies have demonstrated aninconsistent relationship between this sign and AD (2-4).This inconsistency could be attributable to a lack of aclear definition of infraorbital fold, differences in caseselection, observer bia.s, and small sample size. Sex andethnic group differences in relation to infraorbital creaseshave not been studied. Uehara (5) emphasized the non-specific nature of the infraorbital crea,se. He found that aprominent infraorbital crease was present in 2.5% of 300patients with AD and that it was present almost exclu-sively in those with concurrent eyelid dermatitis. An in-fraorbital fold was also seen in 8 of 11 patients withcontact dermatitis of the lower eyelid in Uehara's study,suggesting that such a fold may develop w ith eczematousdermatoses of diverse origins. De.spite these findings, thesign of the infraorbilal fold is still retained as a minorfeature in widely accepted diagno.stic criteria for AD (6).although Hanifin (7) emphasizes that it may be a non-specific feature of eyelid edema or dermatitis.

We examined the usefulness of a prominent infraor-bital crease as a marker for .AD in a [xipulation setting byconducting a cross-sectional study of school children.

We noted the prevalence of this sign, as it is our clinicalimpression that a prominent infraorbital fold is a com-mon finding among children, even in the absence of AD.

SUBJECTS AND METHODS

.All children present during an intensive 5-day visit to aprimar>' school were examined for the presetice or ab-sence of a prominent infraorbital crease and for .AD. Theschool was situated in an area with a large Hindu popu-lation and was chosen randomly from a li.st of 31 schoolsin Chandigarh, North India. Children 3 to 11 years of agewere seen by two dermatologists who independenth' re-corded the presence or absence of a prominent inftaor-bital crease for each child. \ prominent infraorbitalcrease was defined as a single or double prominent in-fraorbital skin fold affecting one or both eyes, extendingb>eyond the midline of the pupil when the gaze was di-tected anteriorly with the child at eye level and at arm'slength ftom the observer. Children were e.xamined innatural light, and no overhead lights that could have en-h;inced shadows were u.sed.

.All the children were then examined for the presenceor absence of active AD. Visible flexural dermatitis (er-ythema with surface change in the antecubital or popli-teal fo.ssae. iyound the neck or eye.s, or the anterior sur-

.Address torrespondcnce to Dr. Inderpal Singh. 160t (first floor).Sector 34-D. Chandigarh 160022. India.

344

Singh and Kanwar: Infraorbital Crease and ,AD 345

faces of the ankles) was recorded. Parental report offlexural dermatitis and self-reported "eczema" in thechild were also noted. The children's ethnic group andany personal histor\' of nasobronchial allergy and asthmawere recorded. Parents and siblings were questionedregarding family history of nasobronchial allergy,asthma, atopic dermatitis, allergic rhinitis, and wheez-ing. Data were analyzed by using the Z test of signifi-cance.

RESULTS

The overall prevalence of infraorbital crease v\'as 359<'(175 of .500). The crease was more common in girls(Table 1), affecting 36% (108 of 300) of girls and33.5% (67 of 200) of boys, but this difference was not.statistically significant (p > .05). This sex differencecould not Ix; explained by the AD status of the children.Regarding tbe ethnicity of tlie children, all were Indian;of these, 489 were Hindu, 7 were Sikh, and 4 were Mus-lim.

The presence of an infraorbital crease was not asso-ciated with the child's age (median age for those with aprominent crease was 6 years; for those with no crease,7 years). No association between infraorbital crease andAD was found in this study. Of the 20 children withactive .AD, only 4 (20%) were noted to have a promi-nent crea.se, compared with 171 of 480 (35.6%) childrenwho did not ha\e AD. Similarly, no association betweeninfraorbital crease and .AD was found using other uaysof defining AD. such as visible flexural dermatitis,parental history of flexutal dermatitis, or parental re-port of diagnosed eczema. Tliere was no association be-tween infraorbital fold and a history of hay fever orasthma alone or a.sthma or .AD when considered together(•fable 2).

DISCUSSION

Prominent infraorbital crease was not a useful marker ofAD in this study. In a dermatologic practice or hospitalsetting, infraorbital crease may continue to be of someuse in diagnosing individual cases of .AD if present (6,7).but our .study sugge.sts that it is not a useful discritninat-ing feature in a population survey because of its poor

T.'VBLE 1. Preiaience of Injruorhiral Crease 'ICl in a.Suney of 500 tndian School Children age .^-11 Years

T.ABLE 2. Predicwrs of Infraorhital Crease (IC) in aSun'ey of 500 Indian School Children age 3-11 Years

Sex

MaleFemaleTotal

Number ofSubjects

200300500

Subjects with IC.No. I %)

67 (33.5)108(36)17.5 (.351

Variable

Number of Subject.̂ with ICSubjects (n = 175)in - 500) No. (%) p

Atopic dermatitisPresent 20 4 (20)

171 (35.6)Absent 480Histor>' of asthma and/or hay fever

Present 30 12(40)

Absent 470 163 (.34.7)

validity. Some workers have maintained that a doubleinfraorbital crease is a far more specific marker of AD(7), but the verv- low frequency with which this doublecrease occurs makes it of little use as a marker of AD inpopulation surveys. Others have suggested that a promi-nent infraorbital crease may be a useful marker of respi-ratorv' allergy, even in the absence of AD (8), althoughlike Svensson et al. (9), we failed to find any asscKiationbetween infraorbital ciea,se and diagnosed asthma, hayfever, or permutations of a,sthma, hay fever, or AD in this.study. The sign is probably simply a reflection of recentor current eyelid dermatilis of diverse cau.se rather than aphenotypic marker for .AD (5).

One of the main difficulties in defining a prominentinfraorbital crease is reaching a consensus as to what ismeant by the term prominent (10). .Almo.st every personhas some degree of visible skin creasing beneath theireyes. Difficult borderline decisions are frequently en-countered when populations are examined. Other factorssuch as ethnic group, time of day, fatigue, lighting, andtone of facial muscles may contribute to further varia-tions in the recording of this sign.

This study suggests that prominent infraorbilalcreases may be a common finding in Indian Hindu chil-dren regardless of AD status. A prominent infraorbitalcrea,se was also more common in girls as compared toboys, although this was not statistically significant.Williams and Pembroke (10) found that black childrenwere twice as likely to have a prominent infraorbitalcrease when compared with their white counterparts,even in the absence of AD. In our study, the number ofchildren belonging to other ethnic groups (Muslim, Sikh)was too small to allow an\' comparisons to be made.Further population studies among Indian and other com-munities using identical methods ;u"e needed.

.As regards the prevalence of atopy in our population,we found only 6% of the children had a histor>' of atopicconditions. This may be because only a cross section wasexamined. It is, however, difficult to give exact figures

346 Pediatric Dennatology Vol. 14 No. 5 September/October 1997

for the prevalence of atopy in our population because ofthe lack of studies of this condition.

REFERENCES

1. Morgan DB. .A suggestive sign of allergy. Arcb Dermatol1948:57:1050.

2. Mecnan FOC. The significance of Morgan's fold in chil-dren with atopic dermatitis. .Acta Dermatol Venereol(Stockh) 1980;suppl 92:42-43.

3. Kim KH, Chung JH, Park KC. Clinical evaluation of minorclinical features of atopic dennatitis. Ann Dermatol 1993:5:9-12.

4. Kanwar AJ, Dhar S, Kaur S. Evaluation of minor clinicalfeatures of atopic dertnatitis. Pediatr Dermatol 1991;8:114-116.

5. Uehara M. Infraorbital fold in atopic dennatitis. .Arch Der-matol 1981:117:627-629.

6. Hanifin JM, Rajka G. Diagnostic features of atopic denna-titis. Acta Dermatol Venereol (Stockh) 1980;supp! 92:44-47.

7. Hanifm JM. Clinical and basic aspects of atopic dermatitis.Semin Dennatoi 1983:2:5-19.

8. Marks MB. Physical signs of allergy of the respiratory tractin children. Ann Allergy 1967;25:310-317.

9. Sven.sson A, Edman B, Mollcr H. A diagnostic tool foratopic dermatitis based on clinical criteria. Acta DermatolVenereol (Stockh) 1985;suppl 114:33^0.

10. Williams HC, Pembroke AC. Infraorbital ciea,se, ethnicgroup and atopic dermatitis. .Arch Dermatol 1996;132 51-54.