Patient education: Atopic dermatitis (eczema) (Beyond the Basics)
- William L Weston, MD
William L Weston, MD
- Professor Emeritus of Dermatology
- University of Colorado Denver School of Medicine
- William Howe, MD
William Howe, MD
- Assistant Clinical Professor
- University of Colorado Denver School of Medicine
- Section Editor
- Robert P Dellavalle, MD, PhD, MSPH
Robert P Dellavalle, MD, PhD, MSPH
- Section Editor — General Dermatology
- Professor of Dermatology and Public Health
- University of Colorado School of Medicine
- Colorado School of Public Health
- Chief, Dermatology Service
- US Department of Veterans Affairs
- Eastern Colorado Health Care System
Atopic dermatitis, also known as eczema, is a skin problem that causes dry, itchy, scaly, red skin. It can occur in infants, children, and adults, and seems more common in certain families. Eczema can be treated with moisturizers and prescription ointments.
More detailed information about atopic dermatitis is available by subscription. (See "Treatment of atopic dermatitis (eczema)" and "Management of severe refractory atopic dermatitis (eczema)".)
The cause of eczema is not completely understood, although hereditary factors appear to play a strong role. In most people, atopic dermatitis is caused by a genetic dysfunction in the outermost layer of the skin (the epidermis). The epidermis is the first line of defense between the body and the environment. When the epidermis is intact, it keeps environmental irritants, allergens, and microbes from entering the body.
Despite popular belief, in children, eczema is rarely linked to food allergies. If a food allergy is suspected, the child should be evaluated by an allergy specialist. (See "Patient education: Food allergy symptoms and diagnosis (Beyond the Basics)" and "Role of allergy in atopic dermatitis (eczema)".)
Most people with eczema develop their first symptoms before age five. Intense itching of the skin, patches of redness, small bumps, and skin flaking are common. Scratching can cause additional skin inflammation, which can further worsen the itching. The itchiness may be more noticeable at nighttime.
Features of eczema vary from one individual to another, and can change over time. Although eczema is usually confined to specific areas of the body, it may affect multiple areas in severe cases:
●In infants, there may be red, scaly, and crusted areas on the front of the arms and legs, cheeks, or scalp. The diaper area is not usually affected.
●In children and adults, eczema commonly affects the back of the neck, the elbow creases, and the backs of the knees (picture 1). Other affected areas may include the face, wrists, and forearms (picture 2). The skin may become thickened and darkened, or even scarred, from repeated scratching.
The skin can also become infected as a result of scratching. Signs of infection include painful red bumps that sometimes contain pus; a healthcare provider should be consulted if this occurs.
Other findings in people with eczema can include:
●Dry, scaly skin
●Plugged hair follicles causing small bumps to develop, usually on the face, upper arms, and thighs
●Increased skin creasing on the palms and/or an extra fold of skin under the eye
●Darkening of the skin around the eyes
There is no specific test used to diagnose eczema. The diagnosis is usually based upon a person's medical history and physical examination.
Factors that strongly suggest eczema include long-standing and recurrent itching, a personal or family history of allergic conditions, and an early age when symptoms began. Other factors include worsened symptoms after exposure to certain triggers or any of the skin findings noted above.
Eczema is a chronic condition; it typically improves and then flares (worsens) periodically. Some people have no symptoms for several years. Eczema is not curable, although symptoms can be controlled with a variety of self-care measures and drug therapy.
Who treats eczema? — Many patients with atopic dermatitis can initially be treated by their primary care provider. However, a skin specialist (dermatologist) may be recommended in certain situations, such as if the condition does not improve with treatment, if certain areas of the body are affected (face or skin folds), and if another condition could be causing symptoms.
Eliminate aggravating factors — Eliminating factors that worsen eczema can help to control the symptoms. Aggravating factors may include:
●Heat, perspiration, dry environments
●Emotional stress or anxiety
●Rapid temperature changes
●Exposure to certain chemicals or cleaning solutions, including soaps and detergents, perfumes and cosmetics, wool or synthetic fibers, dust, sand, and cigarette smoke
Keep the skin hydrated
Emollients — Emollients are creams and ointments that moisturize the skin and prevent it from drying out. The best emollients for people with atopic dermatitis are thick creams (such as Eucerin, Cetaphil, and Nutraderm) or ointments (such as petroleum jelly, Aquaphor, and Vaseline), which contain little to no water. Emollients are most effective when applied immediately after bathing. Emollients can be applied twice a day or more often if needed. Lotions contain more water than creams and ointments and are less effective for moisturizing the skin.
Bathing — It is not clear if showers or baths are better for keeping the skin hydrated. Lukewarm baths or showers can hydrate and cool the skin, temporarily relieving the itching of eczema. An unscented, mild soap or nonsoap cleanser (such as Cetaphil) should be used sparingly. An emollient should be applied immediately after bathing or showering to prevent the skin from drying out as a result of water evaporation.
However, hot or long baths (greater than 10 to 15 minutes) and showers should be avoided since they can dry out the skin.
In some cases, healthcare providers may recommend dilute bleach baths for people with eczema. These baths help to decrease the number of bacteria on the skin that can cause infections or worsen symptoms. To prepare a bleach bath, ¼ to ½ cup of bleach is placed in a full bathtub (about 40 gallons) of water. Bleach baths are usually taken for five to ten minutes twice per week.
Treat skin irritation
Topical steroids — Prescription steroid (corticosteroid) creams and ointments may be recommended to control mild to moderate atopic dermatitis. Steroid creams and ointments are available in a variety of strengths (potencies); the least potent are available without a prescription (eg, hydrocortisone 1% cream). More potent formulations require a prescription.
Steroid creams or ointments are usually applied to the skin once or twice per day. These help to reduce symptoms and moisturize the skin. As the skin improves, a non-medicated emollient can be resumed. Strong topical steroids may be needed to control severe flares of eczema; however, these should be used for only short periods of time to prevent thinning of the skin.
Other skin treatments — Newer skin treatments for eczema include tacrolimus (Protopic) and pimecrolimus (Elidel). These are effective in controlling eczema, although they do not work as quickly as topical steroids. They are useful in sensitive areas such as the face and groin, and can be used in children over age two. Due to safety concerns, these treatments should only be used as instructed by a healthcare provider.
Oral steroids — Oral steroids (eg, prednisone) occasionally are used to treat a severe flare of eczema, although this treatment is not usually recommended on a regular basis because of potential side effects.
Ultraviolet light therapy (phototherapy) — Ultraviolet light therapy (phototherapy) can effectively control atopic dermatitis. However, this therapy is expensive, may increase a person's risk for skin cancer, and is therefore recommended only for people with severe eczema who do not respond to other treatments.
Immunosuppressive drugs — Drugs that weaken the immune system may be recommended for people with severe eczema who do not improve with other treatments. Treatment with these drugs can cause serious side effects, including an increased risk for infection.
Injectable medications — The injectable "biologic" medication dupilumab (brand name: Dupixent), which targets the immune system, may be beneficial for treating atopic dermatitis. Due to its high cost and potential side effects, this drug is reserved for adults with moderate to severe atopic dermatitis that has not responded to other treatments.
Oral antihistamines — Oral antihistamines sometimes help relieve the itching of eczema. The over-the-counter antihistamine diphenhydramine (Benadryl), and prescription antihistamines, such as hydroxyzine (Atarax) and cyproheptadine, are most effective for itching caused by eczema, although these drugs can cause drowsiness.
The nonsedating antihistamines such as cetirizine (Zyrtec) and loratadine (Claritin) may relieve symptoms, and both are available without a prescription in the United States.
Wet dressings — Wet dressings help soothe and hydrate the skin, reduce itching and redness, loosen crusted areas, and prevent skin injury from scratching. Dampened cotton garments may be worn over the affected area and covered with a dry garment. The person may wear these dressings overnight or change them every eight hours during the day.
Can eczema be prevented? — Babies who have a parent, brother, or sister with eczema have a high risk of developing atopic eczema. In these babies, the use of moisturizing creams or ointments from the first week of life may prevent eczema during the first year. However, it is uncertain whether this measure is effective in preventing eczema later in life.
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Eczema (atopic dermatitis) (The Basics)
Patient education: Seborrheic dermatitis (The Basics)
Patient education: Giving your child over-the-counter medicines (The Basics)
Patient education: Melasma (The Basics)
Patient education: Peanut allergy (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Approach to the patient with a scalp disorder
Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis
Introducing formula to infants at risk for allergic disease
Primary prevention of allergic disease: Maternal diet in pregnancy and lactation
The impact of breastfeeding on the development of allergic disease
Treatment of atopic dermatitis (eczema)
Management of severe refractory atopic dermatitis (eczema)
Role of allergy in atopic dermatitis (eczema)
The following organizations also provide reliable health information.
●National Library of Medicine
●National Institute on Arthritis and Musculoskeletal and Skin Diseases
●American Academy of Dermatology
●American Academy of Allergy, Asthma and Immunology
●National Eczema Association
- Brenninkmeijer EE, Schram ME, Leeflang MM, et al. Diagnostic criteria for atopic dermatitis: a systematic review. Br J Dermatol 2008; 158:754.
- Akdis CA, Akdis M, Bieber T, et al. Diagnosis and treatment of atopic dermatitis in children and adults: European Academy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL Consensus Report. J Allergy Clin Immunol 2006; 118:152.
- Fonacier L, Spergel J, Charlesworth EN, et al. Report of the Topical Calcineurin Inhibitor Task Force of the American College of Allergy, Asthma and Immunology and the American Academy of Allergy, Asthma and Immunology. J Allergy Clin Immunol 2005; 115:1249.
- Eichenfield LF, Tom WL, Chamlin SL, et al. Guidelines of care for the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol 2014; 70:338.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.