Dennie-Morgan Fold Plus Dark Circles: Suspect Atopy at First Sight
A
7-year-old girl was referred for evaluation of chronic
nasal obstruction. For 2 years, she had experienced
nasal obstruction associated with episodic sneezing,
itching, and purulent nasal discharge. She had a familial his-
tory of atopy with a mother presenting allergic rhinitis and
asthma and a father allergic to kiwi fruit.
At first sight, while entering the examination room, we
could observe several linear wrinkles beneath the lower eye-
lashes, associated with dark circles (Figure). Clinical
examination showed hypertrophy of the inferior nasal
turbinates and atopic dermatitis (AD) in the posterior
flexural region of the knees. Skin-prick tests were performed
showing sensitization to dust mites and cockroaches.
A diagnosis of persistent, moderate-severe allergic rhinitis
was made on the basis of positive skin-prick tests and a his-
tory of symptoms corresponding with exposure to the sensi-
tizing allergens. Avoidance of allergen was explained and a
treatment with antihistamine and nasal corticosteroids was
prescribed, leading to improvement of nasal symptoms.
Figure. Bilateral Dennie-Morgan folds: several linear wrinkles
beneath the lower eyelashes (white arrow) associated with
bilateral allergic shiners: dark circles beneath the lower eyelid
(arrowheads).
J Pediatr 2015;166:1541.
0022-3476/$ - see front matter. Copyright ª 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jpeds.2015.03.033
Dennie-Morgan infraorbital folds, first described in 1948,1
are secondary creases in the skin below the lower eyelids. They
are a minor criterion of AD2 and are present in up to 84% of
patients with AD, with a sensitivity of 78% and a specificity of
76%.3 They are also described in patients with allergic rhinitis
and/or asthma without AD. The pathophysiology is not
clearly established. They may be related to skin edema and
the continuous spasm of the Muller eyelid muscle resulting
from hypoxia linked to poor blood circulation.
Allergic shiners, or dark circles, first depicted by Marks in
1960,4 are blue-gray to purple discolorations beneath the
lower eyelid related to the accumulation of blood and other
fluids in the infraorbital groove, resulting from nasal conges-
tion. They have been correlated with the chronicity and
severity of allergic rhinitis.5 They are also described in AD
but with less sensitivity than for Dennie-Morgan folds.3
Although not pathognomonic, the presence of Dennie-
Morgan folds and/or dark circles in a child consulting for nasal
congestion is highly suggestive of allergic rhinitis and should
prompt the physician to perform an allergologic assessment. n
Sibylle Blanc, MD
Thierry Bourrier, MD
Pediatric Pulmonology and Allergology Department
H^opitaux Pediatriques de Nice CHU-Lenval
Marc Albertini, MD
Pediatric Pulmonology and Allergology Department
H^opitaux Pediatriques de Nice CHU-Lenval
Universite de Nice Sophia Antipolis
Christine Chiaverini, MD, PhD
Pediatric Consultations
H^opitaux Pediatriques de Nice CHU-Lenval
Dermatology Department
CHU de Nice
Lisa Giovannini-Chami, MD, PhD
Pediatric Pulmonology and Allergology Department
H^opitaux Pediatriques de Nice CHU-Lenval
Universite de Nice Sophia Antipolis
Nice, France
References
1. Morgan DB. A suggestive sign of allergy. Arch Derm Syphilol 1948;57:1050.
2. Hanifin JM, Rajka G. Diagnostic features of atopic dermatitis. Acta Derm
Venereol 1980;92:44-7.
3. Schram ME, Leeflang MM, Den Ottolander JPS, Spuls PI, Bos JD. Valida-
tion and refinement of the millennium criteria for atopic dermatitis. J
Dermatol 2011;38:850-8.
4. Marks MB. Nasal allergy in childhood. Observations in the south Florida
area. Ann Allergy 1960;18:1110-6.
5. Chen CH, Lin YT, Wen CY, Wang LC, Lin KH, Chiu SH, et al. Quantita-
tive assessment of allergic shiners in children with allergic rhinitis. J Al-
lergy Clin Immunol 2009;123:665-71. e661-6.
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