Atopic dermatitis (AD), also known as atopic eczema, is a type of inflammation of the skin (dermatitis). It results in itchy, red, swollen, and cracked skin. Clear fluid may come from the affected areas, which often thicken over time. The condition typically starts in childhood with changing severity over the years. In children under one year of age much of the body may be affected. As children get older, the back of the knees and front of the elbows are the most common areas affected. In adults the hands and feet are the most commonly affected areas. Scratching worsens symptoms and affected people have an increased risk of skin infections. Many people with atopic dermatitis develop hay fever or asthma.
The cause is unknown but believed to involve genetics, immune system dysfunction, environmental exposures, and difficulties with the permeability of the skin. If one identical twin is affected, there is an 85% chance the other also has the condition. Those who live in cities and dry climates are more commonly affected. Exposure to certain chemicals or frequent hand washing makes symptoms worse. While emotional stress may make the symptoms worse it is not a cause. The disorder is not contagious. The diagnosis is typically based on the signs and symptoms. Other diseases that must be excluded before making a diagnosis include contact dermatitis, psoriasis, and seborrheic dermatitis.
Treatment involves avoiding things that make the condition worse, daily bathing with application of a moisturising cream afterwards, applying steroid creams when flares occur, and medications to help with itchiness. Things that commonly make it worse include wool clothing, soaps, perfumes, chlorine, dust, and cigarette smoke. Phototherapy may be useful in some people. Steroid pills or creams based on calcineurin inhibitors may occasionally be used if other measures are not effective. Antibiotics (either by mouth or topically) may be needed if a bacterial infection develops. Dietary changes are only needed if food allergies are suspected.
Atopic dermatitis affects about 20% of people at some point in their lives. It is more common in younger children. Males and females are equally affected. Many people outgrow the condition. Atopic dermatitis is sometimes called eczema, a term that also refers to a larger group of skin conditions. Other names include “infantile eczema”, “flexural eczema”, “prurigo Besnier”, “allergic eczema”, and “neurodermatitis”.
The exact cause of atopic dermatitis (eczema) is unknown. Healthy skin helps retain moisture and protects you from bacteria, irritants and allergens. Eczema is likely related to a mix of factors:
- Dry, irritable skin, which reduces the skin’s ability to be an effective barrier
- A gene variation that affects the skin’s barrier function
- Immune system dysfunction
- Bacteria, such as Staphylococcus aureus, on the skin that creates a film that blocks sweat glands
- Environmental conditions
Factors that put people at increased risk of developing the condition include:
- A personal or family history of eczema, allergies, hay fever or asthma
- Being a health care worker, which is linked to hand dermatitis
Risk factors for children include:
- Living in urban areas
- Being African-American
- Having parents with a high level of education
- Attending child care
- Having attention-deficit/hyperactivity disorder (ADHD)
Atopic dermatitis (eczema) signs and symptoms vary widely from person to person and include:
- Itching, which may be severe, especially at night
- Red to brownish-gray patches, especially on the hands, feet, ankles, wrists, neck, upper chest, eyelids, inside the bend of the elbows and knees, and, in infants, the face and scalp
- Small, raised bumps, which may leak fluid and crust over when scratched
- Thickened, cracked, dry, scaly skin
- Raw, sensitive, swollen skin from scratching
Atopic dermatitis most often begins before age 5 and may persist into adolescence and adulthood. For some people, it flares periodically and then clears up for a time, even for several years.
Factors that worsen atopic dermatitis
Most people with atopic dermatitis also have Staphylococcus aureus bacteria on their skin. The staph bacteria multiply rapidly when the skin barrier is broken and fluid is present on the skin. This in turn may worsen symptoms, particularly in young children.
Factors that can worsen atopic dermatitis signs and symptoms include:
- Dry skin, which can result from long, hot baths or showers
- Scratching, which causes further skin damage
- Bacteria and viruses
- Changes in heat and humidity
- Solvents, cleaners, soaps and detergents
- Wool in clothing, blankets and carpets
- Dust and pollen
- Tobacco smoke and air pollution
- Eggs, milk, peanuts, soybeans, fish and wheat, in infants and children
Atopic dermatitis is related to allergies. But eliminating allergens is rarely helpful in clearing the condition. Occasionally, items that trap dust — such as feather pillows, down comforters, mattresses, carpeting and drapes — can worsen the condition.
When to see a doctor
See your doctor if:
- You’re so uncomfortable that you are losing sleep or are distracted from your daily routines
- Your skin is painful
- You suspect your skin is infected (red streaks, pus, yellow scabs)
- You’ve tried self-care steps without success
- You think the condition is affecting your eyes or vision
Take your child to the doctor if you notice these signs and symptoms in your child or if you suspect your child has atopic dermatitis.
Seek immediate medical attention for your child if the rash looks infected and he or she has a fever.
Your doctor may recommend allergy testing to find out what might be causing your atopic dermatitis. Allergy testing is most helpful for people with atopic dermatitis who also have respiratory allergies or asthma.
Testing can also help find out if certain foods, such as eggs or nuts, are making the condition worse. Talk with your doctor about testing for allergies before making dietary changes.
If a specific allergen is thought to trigger your atopic dermatitis, you and your doctor will discuss how to remove it from your diet or environment while closely observing and recording your symptoms.
Atopic dermatitis can be persistent. You may need to try various treatments over months or years to control it. And even if you respond to treatment, your signs and symptoms may return (flare).
It’s important to recognize the condition early so you can start treatment. If regular moisturizing and other self-care steps don’t help, your doctor may suggest the following treatments and drugs:
- Creams that control itching and inflammation. Your doctor may prescribe a corticosteroid cream or ointment. Talk with your doctor before using any topical corticosteroid. Overuse of this drug may cause skin irritation or discoloration, thinning of the skin, infections, and stretch marks.
- Creams that help repair the skin. Drugs called calcineurin inhibitors — such as tacrolimus (Protopic) and pimecrolimus (Elidel) — affect your immune system. Applied to the skin, they help maintain normal skin, control itching and reduce flares of atopic dermatitis. Due to possible side effects, these prescription-only drugs are used only when other treatments have failed or if someone can’t tolerate other treatments. They are approved for children older than 2 and for adults.
- Drugs to fight infection. You may need antibiotics if you have a bacterial skin infection or an open sore or cracked skin caused by scratching. Your doctor may recommend taking oral antibiotics for a short time to treat an infection. Or he or she may suggest you take it for a longer time to reduce bacteria on your skin and to prevent another infection.
- Oral anti-itch drugs. If itching is severe, oral antihistamines may help. Diphenhydramine (Benadryl, others) can make you sleepy and may be especially helpful at bedtime.
- Oral or injected drugs that control inflammation. For more-severe cases, your doctor may prescribe oral corticosteroids — such as prednisone — or an injected corticosteroid. These drugs are effective but can’t be used long term because of potential serious side effects. Continue moisturizing and using other self-care remedies to prevent a flare-up after you stop taking the corticosteroids.
- Wet dressings. An effective, intensive treatment for severe atopic dermatitis involves wrapping the affected area with topical corticosteroids and wet bandages. It has proven to control signs and symptoms within hours to days. Sometimes it is done in a hospital because it’s labor intensive and requires nursing expertise. Or, ask your doctor about learning how to do this technique at home.
- Light therapy. The simplest form of light therapy (phototherapy) involves exposing your skin to controlled amounts of natural sunlight. Other forms use artificial ultraviolet A (UVA) and narrow band UVB either alone or with medications.
Though effective, long-term light therapy has harmful effects, including premature skin aging and an increased risk of skin cancer. For these reasons, phototherapy is not used for infants and young children. Talk with your doctor about the pros and cons of light therapy in your situation.
- Treatment for stress. Counseling may help children and young adults who are extremely embarrassed or frustrated by their skin condition.
- Relaxation, behavior modification or biofeedback. These approaches may help you with habitual scratching.
Treatment for infantile eczema includes:
- Identifying and avoiding skin irritations
- Avoiding extreme temperatures
- Lubricating your baby’s skin with bath oils, lotions, creams or ointments
See your baby’s doctor if these measures don’t improve the rash or if the rash looks infected. Your baby may need a prescription medication to control the rash or to treat an infection. Your doctor may recommend an oral antihistamine to help lessen the itch and to cause drowsiness, which may be helpful for nighttime itching and discomfort.
The following tips may help prevent bouts of dermatitis (flares) and minimize the drying effects of bathing:
- Try to identify and avoid triggers that worsen the inflammation. Reduce your exposure to your unique triggers.
- Take shorter baths or showers. Limit your baths and showers to 10 to 15 minutes. And use warm, rather than hot, water. Bath oil also may be helpful.
- Use only gentle soaps. Choose mild soaps that clean without removing too many natural oils. Deodorant and antibacterial soaps may be more drying to your skin. Use soap only on your face, underarms, genital areas, hands and feet. Use clear water elsewhere.
- Dry yourself carefully. After bathing, brush your skin rapidly with the palms of your hands, or gently pat your skin dry with a soft towel and apply moisturizer.
- Moisturize your skin at least twice a day. Creams or lotions seal in moisture. Thicker moisturizers work best — such as Cetaphil, Nutraderm and Eucerin. You may also want to use cosmetics that contain moisturizers. If your skin is extremely dry, try applying baby oil or a similar product while your skin is still moist. Oil has more staying power than moisturizers do
Home treatment for atopic dermatitis includes taking care of your skin and avoiding things that irritate it.
Take care of your skin
- Keep your skin hydrated through bathing in warm (not hot) water and applying moisturizer right afterwards.
Atopic Dermatitis: Taking Care of Your Skin
- Avoid things that irritate a rash or make it worse, such as soaps that dry the skin, perfumes, and scratchy clothing or bedding.
- Avoid possible allergens that cause a rash or make a rash worse, such as dust mites, animal dander, and certain foods.
Control itching and scratching
- Keep your fingernails trimmed and filed smooth to help prevent damaging the skin when you scratch it.
- Use protective dressings to keep from rubbing the affected area. Put mittens or cotton socks on your baby’s hands to help prevent him or her from scratching the area.
- Try coal tar preparations. When applied to the skin, they may help reduce itching. But if your itching gets worse after using coal tar, stop using it.
Avoid sun and stress
- Exposure to natural sunlight can be helpful for atopic dermatitis, but it is important to avoid sunburn. Too much sun, sweating, and/or getting too hot also can irritate the skin. When you use a sunscreen, choose one for sensitive skin.
- Reduce stress to help your skin and keep rashes from getting worse. Try relaxation techniques, behavior modification, or biofeedback. Massage therapy is also helpful, especially in children.
Although symptoms of atopic dermatitis can be very difficult and uncomfortable, the disease can be successfully managed. People with atopic dermatitis, as well as their families, can lead healthy, normal lives. Long-term management may include treatment with an allergist to control inhalant allergies and a dermatologist to monitor the skin-care component.
Complications of atopic dermatitis (eczema) include:
- Asthma and hayfever. Eczema sometimes precedes these conditions.
- Chronic itchy, scaly skin. A skin condition called neurodermatitis (lichen simplex chronicus) starts with a patch of itchy skin. You scratch the area, which makes it even itchier. Eventually, you may scratch simply out of habit. This condition can cause the affected skin to become discolored, thick and leathery.
- Skin infections. Repeated scratching that breaks the skin can cause open sores and cracks. These increase your risk of infection from bacteria and viruses, including the herpes simplex virus.
- Eye problems. Signs and symptoms of eye complications include severe itching around the eyelids, eye watering, inflammation of the eyelid (blepharitis) and inflammation of the eyelid (conjunctivitis).
- Irritant hand dermatitis. This especially affects people whose work requires that their hands are often wet and exposed to harsh soaps, detergents and disinfectants.
- Allergic contact dermatitis. This condition is common in patients with atopic dermatitis. Many substances can cause an allergic skin reaction, including corticosteroids, drugs often used to treat people with atopic dermatitis.
- Sleep problems. The itch-scratch cycle can cause you to awaken repeatedly and decrease the quality of your sleep.
- Behavioral problems. Studies show a link between atopic dermatitis and attention-deficit/hyperactivity disorder, especially if a child is also losing sleep.