About Atopic Dermatitis (Eczema)
Atopic dermatitis, also known as atopic eczema, is a chronic inflammatory skin condition that causes dry, itchy skin and rashes that can come and go. It often begins in infancy or childhood, but it can continue into adulthood or start for the first time in adulthood. The rash can appear on any part of the body, and the pattern often changes with age.
In infants, affected areas commonly include the face, scalp, hands, and feet. In children, rashes often appear in the bends of the elbows and knees and on the front of the neck. In adolescents and adults, they may appear on the wrists, ankles, eyelids, and in the bends of the elbows and knees. Scratching can lead to oozing, crusting, bleeding, thickened skin, and skin infections. Atopic dermatitis is associated with other atopic conditions, such as asthma, allergic rhinitis, and food allergies, but allergies are not the cause of eczema for many people.
Atopic dermatitis develops from a mix of skin barrier, immune system, genetic, and environmental factors. Common contributors include:
- Genetic predisposition: A personal or family history of atopic dermatitis, asthma, allergic rhinitis, or food allergy can increase risk. Some people have gene changes that affect how well the skin barrier works.
- Immune system changes: The immune system may overreact to irritants, allergens, microbes, or other triggers, leading to inflammation and itching.
- Skin barrier impairment: A weakened skin barrier loses moisture more easily and allows irritants, allergens, and germs to enter, which can worsen dryness, itching, cracking, and inflammation.
Risk factors and associated environmental factors may include a family history of atopic disease, living in an urban area, dry climate, low ultraviolet light exposure, irritants, pollution or smoke exposure, and early-childhood antibiotic exposure. These factors may increase the likelihood of developing atopic dermatitis, but they do not guarantee that it will occur.
Common triggers for flares can include harsh soaps, fragranced skin care products or detergents, wool or rough fabrics, sweat, heat, cold dry weather, stress, scratching, saliva or drool in infants, and infections. Triggers vary from person to person, so it can help to track what seems to worsen symptoms and discuss patterns with a healthcare professional.
Common symptoms of atopic dermatitis include:
- Itching, which can be severe and may interfere with sleep.
- Dry, scaly, rough, or cracked patches of skin.
- Rashes that may look red, pink, purple, gray, dark brown, lighter, or darker than surrounding skin, depending on skin tone.
- Oozing, crusting, bleeding, or thickened skin, especially after scratching.
Symptoms can vary by age and from person to person. In infants, the rash may appear on the face, scalp, and areas around joints. In darker skin tones, eczema may be less visibly red and may leave lighter or darker patches after inflammation improves.
Atopic dermatitis can also be associated with other conditions or effects, such as asthma, allergic rhinitis, food allergy, very dry or thickened skin conditions, sleep loss, and emotional distress. These are not always symptoms of eczema itself, but they may occur along with it or result from ongoing itching and disrupted sleep.
Contact a healthcare professional if symptoms are persistent, worsening, painful, interfering with sleep or daily activities, or not improving with usual skin care. Seek prompt medical care for signs of infection, such as increasing pain, warmth, swelling, pus, honey-colored crusting, fever, or a rash that is rapidly worsening. Painful clustered blisters, fever, or rash near the eyes can be signs of a serious complication and need urgent medical attention.
Atopic dermatitis is usually diagnosed based on a medical history and physical examination of the skin. A healthcare professional will ask about symptoms, when they started, where the rash appears, personal or family history of atopic conditions, possible triggers, and signs of infection or other skin conditions.
- Medical history review: The clinician may ask about itching, flares, previous skin conditions, allergies, asthma, allergic rhinitis, family history, treatments used, and possible irritants or triggers.
- Skin examination: The clinician will examine the appearance, location, distribution, and severity of the rash and look for signs of infection or other diagnoses.
Additional tests are not always needed. They may be considered when the diagnosis is unclear, symptoms are severe or persistent, or a specific trigger or another condition is suspected.
- Skin prick testing or allergen-specific IgE blood testing: These tests may help identify a suspected allergy trigger, but they do not diagnose atopic dermatitis by themselves and should be interpreted in the context of symptoms.
- Biopsy: A skin biopsy is not routinely needed for typical atopic dermatitis. It may be used in atypical cases or when another condition needs to be ruled out.
- Severity tools: Tools such as SCORAD or the Eczema Area and Severity Index (EASI) may be used to assess disease severity and track response to treatment.
These examinations, tests, and procedures should be performed and interpreted by qualified healthcare professionals.
The goals of treatment for atopic dermatitis are to restore and protect the skin barrier, reduce inflammation and itching, promote healing, prevent infections, and reduce flares. Treatment depends on a person’s age, affected areas, symptom severity, other health conditions, and response to prior treatments.
Medications:
- Moisturizers and barrier creams: Used regularly to manage dryness and help repair the skin barrier.
- Topical corticosteroids: Creams or ointments that reduce inflammation during flares. Strength and duration should be guided by a healthcare professional, especially for sensitive areas such as the face, eyelids, skin folds, or genitals.
- Topical calcineurin inhibitors: Nonsteroid creams or ointments that may be used for certain body areas or longer-term control when appropriate.
- Topical phosphodiesterase inhibitors or topical JAK inhibitors: Nonsteroid prescription options that may be recommended for selected patients.
- Biologic injections or oral JAK inhibitors: Options for some people with moderate-to-severe atopic dermatitis when topical treatment is not enough. These medicines require medical supervision because eligibility, age limits, monitoring, and safety considerations vary.
- Antibiotic creams or oral antibiotics: Used when a bacterial skin infection is suspected or confirmed.
- Oral corticosteroids: Generally avoided for routine management because symptoms can rebound and side effects can occur. If used, they are usually reserved for short, carefully selected situations under clinician guidance.
- Antihistamines: These do not treat the underlying eczema inflammation. Sedating antihistamines may sometimes help with sleep during severe itching, but they are not the main treatment for eczema itch.
Therapies:
- Phototherapy: Narrowband ultraviolet B therapy may be used for some people with more widespread or persistent disease when topical treatments are not enough.
- Wet-wrap therapy: For selected moderate-to-severe flares, a clinician may recommend applying medication or moisturizer and covering the area with wet and dry layers to help calm inflammation and improve hydration.
Self-care and health behavior changes:
- Use fragrance-free moisturizers often, especially within a few minutes after bathing.
- Take short lukewarm baths or showers and use gentle, fragrance-free cleansers instead of harsh soaps.
- Avoid known triggers when possible, such as fragranced products, harsh detergents, wool or rough fabrics, overheating, sweat, smoke, and irritants.
- Keep nails short and consider strategies to reduce scratching, especially during sleep.
Specific medications and therapies should be recommended by a healthcare professional based on disease severity and individual factors. Medication dosing, side effects, monitoring needs, and safety warnings vary, so check with your healthcare professional or read the information provided with your medication.