Atopic Dermatitis (Eczema)

Topic Overview

What causes atopic dermatitis?

The cause of atopic dermatitis isn't clear, but it affects your skin's ability to hold moisture. Your skin becomes dry, itchy, and easily irritated.

Most people who have atopic dermatitis have a personal or family history of allergies, such as hay fever (allergic rhinitis) or asthma.

Things that may make atopic dermatitis worse include:

  • Allergens, such as dust mites or animal dander.
  • Harsh soaps or detergents.
  • Weather changes, especially dry and cold.
  • Stress.
  • An allergic reaction to certain foods, such as eggs, peanuts, milk, wheat, fish, or soy products.
  • Skin infection.

What are the symptoms?

Atopic dermatitis starts with dry skin that is often very itchy. Scratching causes the dry skin to become red and irritated (inflamed). Infection often occurs. Tiny bumps that look like little blisters may appear and ooze fluid or crust over. These symptoms—dryness, itchiness, scratching, and inflammation—may come and go. Over time, a recurring rash can lead to tough and thickened skin.

Mild atopic dermatitis affects a small area of skin, isn't very itchy, and usually goes away with moisturizer. Severe atopic dermatitis covers a large area of skin that is very itchy and doesn't go away with moisturizer.

People tend to get the rash on certain parts of the body, depending on their age. Common sites for babies include the scalp and face (especially on the cheeks), the front of the knees, and the back of the elbows. In children, common areas include the neck, wrists, legs, ankles, the creases of elbows or knees, and between the buttocks. In adults, the rash often appears in the creases of the elbows or knees and on the nape of the neck.

How is atopic dermatitis diagnosed?

A doctor can usually tell if you have atopic dermatitis by doing a physical exam and asking questions about your past health.

Your doctor may advise allergy testing to find the things that trigger the rash. Allergy tests can be done by an allergist (immunologist) or dermatologist.

How is it treated?

Mild atopic dermatitis can be treated at home.

  • Moisturize often to treat and prevent dry skin. Thicker creams and ointments, like petroleum jelly, work better than thinner lotions.
  • Avoid things that trigger rashes, such as harsh soaps and detergents, dander, and any other things you are allergic to.
  • Control scratching. You may want to cover the rash with a bandage to keep from rubbing it.
    • Putting mittens or cotton socks on your baby's hands may prevent him or her from scratching.
    • Wearing cotton gloves at night may help older children and adults. (Moisturize hands first before putting on the gloves.)
  • Use medicine prescribed by your doctor.
  • Bathe with lukewarm or warm (not hot) water. Soak for about 10 minutes. Use soap or shampoo at the end so that you aren't sitting in soapy water.

But if your symptoms are bothering you and aren't getting better, see your doctor. Getting medical treatment early may keep your symptoms from getting worse.

In severe cases, your doctor may prescribe pills or give you a shot to stop the itching. Or you may get ultraviolet (UV) light treatment at a clinic or doctor's office.

Frequently Asked Questions

Learning about atopic dermatitis:

Being diagnosed:

Getting treatment:

Living with atopic dermatitis:

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  Atopic Dermatitis: Taking Care of Your Skin
  Stress Management: Breathing Exercises for Relaxation

Cause

The cause of atopic dermatitis isn't known. But most people who have it have a personal or family history of allergies, such as hay fever (allergic rhinitis). The skin inflammation that causes the atopic dermatitis rash is considered a type of allergic response.

Itching and rash can be triggered by many things, including:

  • Allergens, such as dust mites, pollen, molds, or animal dander.
  • Harsh soaps or detergents, rubbing the skin, and wearing wool.
  • Workplace irritants, such as fumes and chemicals.
  • Weather changes, especially dry and cold.
  • Temperature changes, such as a suddenly higher temperature. This may bring on sweating, which can cause itching. Lying under blankets, entering a warm room, or going from a warm shower into colder air can all cause itching.
  • Stress. Emotions such as frustration or embarrassment may lead to more itching and scratching.
  • Certain foods, such as eggs, peanuts, milk, soy, or wheat products, if you are allergic to them. Up to 40% of children with moderate to severe atopic dermatitis also have some type of food allergy.1 But experts don't agree on whether foods can cause atopic dermatitis.
  • Excessive washing. Repeated washing dries out the top layer of skin. This can lead to drier skin and more itching, especially in the winter months when humidity is low.

Symptoms

The main symptom of atopic dermatitis is itching. The itching can be severe and persistent, especially at night. Scratching the affected area of skin usually causes a rash. The rash is red and patchy and may be long-lasting (chronic) or come and go (recurring). The rash may:

  • Develop fluid-filled sores that can ooze fluid or crust over. This can happen when the skin is rubbed or scratched or if a skin infection is present. This is known as an acute (sudden or of short duration), oozing rash.
  • Be scaly and dry, red, and itchy. This is known as a subacute (longer duration) rash.
  • Become tough and thick from constant scratching (lichenification).

How bad your symptoms are depends on how large an area of skin is affected, how much you scratch the rash, and whether the rash gets infected.

The areas most often affected are the face, scalp, neck, arms, and legs. The rash is also common in areas that bend, such as the back of the knees and inside of the elbows. Rashes in the groin or diaper area are rare. There may be age-related differences in the way the rash looks and behaves.

  • Babies (2 months to 2 years): The rash is often crusted or oozes fluid. It's most commonly seen during the winter months as dry, red patches on the cheeks.
  • Children (2 years to 11 years): The rash is usually dry. But it may go through stages from an oozing rash to a red, dry rash that causes the skin to thicken. This thickened skin is called lichenification. It often occurs after the rash goes away.

For adolescents and adults, atopic dermatitis often improves as you get older.

What Happens

Atopic dermatitis causes repeated attacks of itching and rash that can become quite severe. It is most common in babies and children. Some children outgrow it. But many people, especially teens and adults, continue to have relapses or to have the condition, although not as severely.2 Also, a person may get atopic dermatitis as an adult.

The condition may affect how children feel about themselves. A child may feel strange or different from other children because of the rash or restrictions in diet. The rash may make a child feel unattractive.

Complications

Some people who have atopic dermatitis get patches of lighter skin. This most often happens on the face, upper arms, or shoulders. Chronic scratching or rubbing of the skin can also lighten or darken skin color. When the condition has been successfully controlled, skin color returns to normal over time.

Skin infections can happen more often in people with atopic dermatitis. The skin may become red and warm, and a fever may develop. Skin infections are treated with antibiotics.

Eczema herpeticum results when atopic dermatitis is infected with the herpes simplex virus. This is the virus that causes cold sores and genital herpes. In this condition, the rash blisters and may begin to bleed and crust. You may also have a high fever. This is a serious infection, so contact your doctor right away.

What Increases Your Risk

The major risk factor for atopic dermatitis is having a family history of the condition. You are also at risk if family members have asthma, allergic rhinitis, or other allergies.

When To Call a Doctor

Call your doctor if you or your child has atopic dermatitis and:

  • Itching makes you or your child irritable.
  • Itching is interfering with daily activities or with sleep.
  • There are crusting or oozing sores, severe scratch marks, widespread rash, severe discoloration of the skin, or a fever that is accompanied by a rash.
  • Painful cracks form on the hands or fingers.
  • Atopic dermatitis on the hands interferes with daily school, work, or home activities.
  • Signs of bacterial infection develop. These include:
    • Increased pain, swelling, redness, tenderness, or heat.
    • Red streaks extending from the area.
    • A discharge of pus.
    • A fever of 100.4 °F (38 °C) or higher with no other cause.

Who to see

For the diagnosis and treatment of atopic dermatitis, consult with a:

If food or other allergies are suspected to be a factor in atopic dermatitis, you can see an allergist (immunologist) for specialized evaluation. For more information, see the topic Food Allergies.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

Most cases of atopic dermatitis can be diagnosed from a medical history and a physical exam.

Allergy testing

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.

Treatment Overview

Treatment for atopic dermatitis depends on the type of rash you have. Most mild cases can be treated at home with moisturizers—especially skin barrier repair moisturizers—and preventive care. Most of the time, rash and itching can be controlled within 3 weeks.

For more serious rashes, you will need to see your doctor for treatment. These rashes include:

  • An oozing rash, with fluid-filled sores that ooze fluid or crust over. You may have a skin infection.
  • A scaly, dry, red, and itchy rash.
  • Areas of thickened skin (lichenified skin).

For severe rashes, talk to your doctor about using bleach baths and wet wraps.

Getting medical treatment early may keep your symptoms from getting worse.

For rashes that don't get better with medicines or moisturizers, treatment may include:

For itching, treatment may include antihistamines. Also, taking baths with colloidal oatmeal (such as Aveeno) or applying wet dressings to the rash for 30 minutes several times a day may help.

In severe cases, hospitalization may be needed. A short stay in the hospital can quickly control the condition.

What to think about

Counseling may be helpful for children and adults with atopic dermatitis. Talking with a counselor can help reduce stress and anxiety caused by atopic dermatitis and can help a person cope with the condition.

Prevention

If your baby is at risk for atopic dermatitis because you or other family members have it or other allergies, these steps may help prevent a rash or reduce its severity:

  • If possible, breast-feed your baby for at least 6 months. Breast-feeding can boost your baby's immune system.
  • When you are ready to give your child solid foods, talk with your doctor. Ask if your child should avoid foods that often cause food allergies, such as eggs, peanuts, milk, soy, and wheat.

Home Treatment

Home treatment for atopic dermatitis includes taking care of your skin and avoiding things that irritate it.

Take care of your skin

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.
Click here to view an Actionset.Stress Management: Breathing Exercises for Relaxation

Medications

Medicines for atopic dermatitis are used to help control itching and heal the rash. If you or your child has a very mild itch and rash, you may be able to control it without medicine by using home treatment and preventive measures. But if symptoms are getting worse despite home treatment, you will need to use medical treatment to prevent the itch-scratch-rash cycle from getting out of control.

Medicine choices

Topical medicines, such as creams or ointments, are applied directly to the skin. Other medicines, such as oral corticosteroids or antihistamines, are taken as pills.

  • Topical corticosteroids are the most common and effective treatment for atopic dermatitis. They are used until the rash clears.
  • Calcineurin inhibitors are topical immunosuppressants—medicines that weaken your body's immune system. The U.S. Food and Drug Administration (FDA) recommends caution when prescribing or using Elidel (pimecrolimus) cream and Protopic (tacrolimus) ointment because of a potential cancer risk.3 The FDA also stresses that these medicines only be used as directed and only after trying other treatment options. These medicines aren't approved for children younger than 2 years of age.
  • Antihistamines are often used to treat atopic dermatitis itch. They can also help you sleep when severe night itching is a problem. But histamines aren't always involved in atopic dermatitis itch, so these medicines may not help all people. Don't give antihistamines to your child unless you've checked with the doctor first.
  • Oral corticosteroids are used in severe cases when the rash covers large areas of the body or when complications occur.
  • Cyclosporine or interferon is sometimes used in adults if other treatment doesn't help.
  • Antibiotic, antiviral, or antifungal medicines are used if the rash gets infected. Skin that has been broken down by scratching and inflammation can become infected.
  • Coal tar applied to the skin may help reduce itching. But this medicine should not be used on skin that is very irritated, because it can make your skin problem worse. Tar preparations are sometimes used to control the condition after a stronger medicine has successfully improved atopic dermatitis.

Other Treatment

Other treatment for atopic dermatitis includes light therapy and complementary therapies.

Light therapy

Severe atopic dermatitis may be treated by exposing affected skin to ultraviolet (UV) light. There are two types of ultraviolet light, called ultraviolet A (UVA) and ultraviolet B (UVB).

Too much sun exposure and light treatment (such as with UVA or UVB treatments) increases your risk of skin cancer.

Complementary or alternative treatments

Complementary or alternative treatments may be helpful for treating atopic dermatitis. Some small studies showed benefit from these treatments. But there isn't clear scientific evidence to show that they help. Examples of complementary and alternative treatments for atopic dermatitis include:

  • Dietary supplements of essential fatty acids (EFAs), such as fish oil or evening primrose oil.
  • Creams that are put on the skin. These creams contain St. John's wort or vitamin B12.
  • Chinese herbal therapy. But herbal therapies may also contain substances that may cause liver or heart problems.

If you are interested in these treatments, talk to your doctor. Ask about the treatments' use, their effectiveness, and any possible interactions related to other medicines you are taking.

Other Places To Get Help

Organizations

American Academy of Dermatology
Web Address: www.aad.org

National Eczema Association for Science and Education
Web Address: www.nationaleczema.org

References

Citations

  1. Leung DYM, et al. (2008). Atopic dermatitis (atopic eczema). In K Wolff et al., eds., Fitzpatrick's Dermatology in General Medicine, 7th ed., vol. 1, pp. 146–158. New York: McGraw-Hill.
  2. Boguniewicz M, Leung DYM (2009). Atopic dermatitis. In N Franklin Addison Jr et al., eds., Middleton's Allergy Principles and Practice, 7th ed., vol. 2, pp. 1083–1103. Philadelphia: Mosby Elsevier.
  3. U.S. Food and Drug Administration (2006). FDA approves updated labeling with boxed warning and medication guide for two eczema drugs, Elidel and Protopic. FDA News. Available online: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm153941.htm.

Other Works Consulted

  • Berger TG (2012). Dermatologic disorders. In SJ McPhee, MA Papadakis, eds., 2012 Current Medical Diagnosis and Treatment, 51st ed., pp. 93–163. New York: McGraw-Hill.
  • Bieber T (2008). Mechanisms of disease: Atopic dermatitis. New England Journal of Medicine, 358(14): 1483–1494.
  • Greer FR, et al. (2008). Effects of early nutritional interventions on the development of atopic disease in infants and children: The role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics, 121(1): 183–191. Also available online: http://pediatrics.aappublications.org/content/121/1/183.full.
  • Habif TP (2010). Atopic dermatitis. In Clinical Dermatology, A Color Guide to Diagnosis and Therapy, 5th ed., pp. 154–180. Edinburgh: Mosby Elsevier.
  • Habif TP, et al. (2011). Atopic dermatitis. In Skin Disease: Diagnosis and Treatment, 3rd ed., pp. 71–76. Edinburgh: Saunders.
  • Krakowski AC, et al. (2008). Management of atopic dermatitis in the pediatric population. Pediatrics, 122(4): 812–824.
  • Schmitt J, et al. (2011). Eczema, search date May 2009. Online version of BMJ Clinical Evidence: http://www.clinicalevidence.com.
  • Stevens SR, et al. (2008). Eczematous disorders, atopic dermatitis, and ichthyoses. In EG Nabel, ed., ACP Medicine, section 2, chap. 4. Hamilton, ON: BC Decker.

Credits

By Healthwise Staff
Adam Husney, MD - Family Medicine
Amy McMichael, MD - Dermatology
Last Revised October 8, 2013

Last Revised: October 8, 2013

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