Atopic Dermatitis

Atopic dermatitis is a long-lasting skin condition that causes dry, itchy, and inflamed skin. While it most commonly begins in childhood, it can affect people at any age and requires ongoing care to manage symptoms and prevent flare-ups.

atopic eczema, eczema, infantile eczema

What is atopic dermatitis?
What causes this condition?
Signs and symptoms
How doctors diagnose atopic dermatitis
Treatment approaches
Daily care and lifestyle changes
Related health conditions

What is atopic dermatitis?

Atopic dermatitis is a chronic (long-lasting) skin condition that causes patches of skin to become dry, itchy, and inflamed. It is the most common type of eczema, a term used to describe a group of skin conditions that result from inflammation^[1]^[2].

The condition affects approximately 17.8 million people in the United States, including 9.6 million children under age 18 and about 16.5 million adults^[5]. It is extremely common worldwide, affecting about 10% to 30% of children and 2% to 10% of adults in developed countries^[6].

Atopic dermatitis typically begins in early childhood. About 60% of cases start before a child turns one year old, and 90% develop by five years of age^[3]^[13]. While many children outgrow the condition, others continue to experience symptoms throughout their lives. Some people also develop atopic dermatitis for the first time as adults^[1].

The condition is not contagious, meaning you cannot catch it from someone else or spread it to others^[1]^[4].

What causes this condition?

Atopic dermatitis develops due to a complex interaction of genetic factors, immune system problems, and environmental influences that affect how well the skin can protect the body^[6].

A key factor involves a change in a gene that produces a protein called filaggrin. This protein is essential for creating a strong protective barrier on the outermost layer of skin. When someone has only one working copy of the filaggrin gene instead of two, their skin has difficulty repairing itself when damaged. This makes the skin barrier weaker, allowing moisture to escape and irritants or allergens to enter more easily^[5]^[12].

When the skin barrier breaks down, the immune system becomes overactive and creates inflammation (redness, swelling, and irritation). This inflammation causes the characteristic itching and rash of atopic dermatitis^[2]^[12].

Genetics play a significant role in who develops atopic dermatitis. If one parent has the condition, there is more than a 50% chance their child will develop it. If both parents are affected, up to 80% of their children will have atopic symptoms^[6]. You are also more likely to develop atopic dermatitis if you or a close family member has asthma or hay fever (allergic rhinitis)^[4].

Common triggers

Certain factors can cause symptoms to worsen or trigger a flare-up (a period when symptoms get worse). Common triggers include^[2]^[4]:

Allergens or irritants such as soaps, detergents, pets, certain fabrics, pollen, house-dust mites, or particular foods
Changes in temperature or humidity, especially heat
Skin infections, particularly those caused by bacteria like Staphylococcus aureus
Stress and emotional factors
Hormonal changes, such as during pregnancy
Sweating
Rough fabrics like wool or clothing seams and labels

Signs and symptoms

The main symptom of atopic dermatitis is intense itchiness (also called pruritus). This itching can be so severe that it disrupts sleep and daily activities^[8]^[18].

The appearance of atopic dermatitis varies from person to person and can look different depending on your skin tone. Common features include^[1]^[2]:

Dry, cracked, or scaly skin
Skin discoloration that may appear red on light skin, or darker than the surrounding skin, brown, purple, or gray on darker skin tones
Rashes on swollen skin
Small, raised bumps that may leak fluid and crust over when scratched
Thickened skin from repeated scratching (called lichenification)
Darkening of the skin around the eyes
Raw, sensitive skin from scratching

The rash typically appears in different locations depending on age. In babies under one year old, atopic dermatitis often affects the face and then spreads to the neck, scalp, arms, and legs^[3]^[10]. As children grow older, the rash most commonly develops where the skin bends or folds, such as inside the elbows, behind the knees, and around the neck^[1]^[4]. In adults, the hands and feet are frequently affected^[10].

Symptoms typically come and go over time. There are usually periods when symptoms worsen (flare-ups) and times when they improve or even disappear temporarily^[2]^[4].

How doctors diagnose atopic dermatitis

A healthcare provider can usually diagnose atopic dermatitis by examining your skin, discussing your symptoms, and reviewing your medical and family health history^[2]^[11].

There is no single test for atopic dermatitis. However, your provider may recommend certain tests to rule out other skin conditions or identify specific triggers^[11]:

Patch testing: Small amounts of different substances are applied to your skin and covered. Over the next few days, your doctor checks for reactions to identify specific allergies that may be triggering your symptoms
Blood tests: These can help identify allergies or other conditions
Skin biopsy: In rare cases, a small sample of skin may be examined under a microscope to rule out other skin diseases

To make a diagnosis, doctors look for essential features that must be present: itchiness and a rash with typical appearance and location. They also consider supporting factors like early age when symptoms started, a personal or family history of allergies, and very dry skin^[8]^[18].

Treatment approaches

While there is no cure for atopic dermatitis, several treatments can effectively control symptoms and prevent flare-ups. Treatment usually involves a combination of approaches tailored to each person’s needs^[2]^[14].

Moisturizers and emollients

Moisturizers (also called emollients) are the foundation of atopic dermatitis care. Regular use helps restore the skin’s protective barrier, locks in moisture, and protects against irritants. They should be applied at least twice daily and anytime skin feels dry^[3]^[13]^[14].

Topical corticosteroids

Topical corticosteroids (steroid creams or ointments applied to the skin) are the first-line treatment for atopic dermatitis flare-ups. These medications reduce inflammation, itching, and redness. They come in various strengths, and your doctor will prescribe the appropriate strength based on the severity of your symptoms and where the rash appears on your body. Once-daily application is typically as effective as more frequent use^[3]^[13]^[14].

Topical calcineurin inhibitors

Medications like pimecrolimus and tacrolimus are recommended as second-line treatment for moderate to severe atopic dermatitis, especially for sensitive areas like the face and around the eyes where long-term use of strong corticosteroids can cause problems^[3]^[13]^[14].

Other treatments

Additional treatment options may include^[11]^[14]:

Phototherapy: Treatment with ultraviolet light can be effective for severe or difficult-to-treat atopic dermatitis in adults
Antibiotics: These are used only when there is clear evidence of a bacterial skin infection, not for prevention
Oral medications: For severe cases, doctors may prescribe immunosuppressive drugs or newer biologic medications that target specific parts of the immune system
Wet wrap therapy: Applying wet dressings over moisturizer and medication can help during severe flare-ups
Bleach baths: Diluted bleach baths may help reduce bacteria on the skin

Daily care and lifestyle changes

Self-care practices are essential for managing atopic dermatitis and preventing flare-ups^[14]^[20].

Bathing and skin care

Proper bathing techniques can help improve symptoms^[13]^[23]:

Bathe once daily in lukewarm water for 5 to 10 minutes
Use mild, fragrance-free cleansers or soap substitutes
Pat skin dry gently instead of rubbing
Apply moisturizer immediately after bathing while skin is still slightly damp
Apply prescribed medications before moisturizing

Avoiding triggers

Identifying and avoiding your personal triggers is crucial^[14]^[20]:

Use fragrance-free, hypoallergenic products
Wear soft, breathable fabrics like cotton; avoid wool and synthetic materials
Keep rooms cool to prevent overheating
Manage stress through relaxation techniques like meditation, yoga, or journaling
Keep fingernails short to minimize damage from scratching

Mental health support

Living with atopic dermatitis can affect emotional well-being. The condition can impact sleep, cause embarrassment, and lead to feelings of anxiety or depression. It’s important to address these emotional aspects by talking with healthcare providers, joining support groups, or working with a mental health professional^[19]^[20]^[23].

Sleep improvement

Since itching often disrupts sleep, establishing good sleep habits is important^[23]:

Go to bed and wake up at the same time daily
Create a consistent bedtime routine
Keep the bedroom cool, dark, and comfortable
Limit caffeine intake after lunch

People with atopic dermatitis have a higher risk of developing other health conditions. These often occur together in what is called the “atopic march”^[6]^[8]^[18]:

Food allergies: Children with atopic dermatitis are more likely to develop food allergies. About 10% to 30% of patients may have food hypersensitivity that can trigger or worsen their skin condition^[6].

Asthma: Approximately 30% of children with atopic dermatitis later develop asthma, compared to 12% of children without the skin condition^[3].

Allergic rhinitis (hay fever): About 34% of children with atopic dermatitis develop hay fever, compared to 14% of those without it^[3].

Skin infections: The damaged skin barrier makes people with atopic dermatitis more vulnerable to bacterial, viral, and fungal skin infections. These infections often cause the skin to weep clear fluid or develop crusting^[3].