What Is Eczema (Atopic Dermatitis)?

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Eczema, also known as atopic dermatitis, is an inflammatory skin condition that causes a scaly, inflamed, itchy rash. It can affect people of all ages, although it occurs more frequently in children (generally before the age of five) than adults.

Although the exact cause of eczema is unknown, it is believed to be the result of both genetic and environmental factors. Since there are no tests available to diagnose eczema, the disease will be confirmed based on a physical exam and whether the symptoms meet specific diagnostic criteria.

Treatments options include moisturizers, over-the-counter topical steroids, and prescription medications and therapies designed to alleviate skin inflammation.

Eczema Symptoms

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Eczema
Eczema on neck and chest.  DermNet / CC BY-NC-ND

This photo contains content that some people may find graphic or disturbing.

Eczema around eye
Eczema around eye. DermNet / CC BY-NC-ND

This photo contains content that some people may find graphic or disturbing.

Eczema on face
Eczema on face.  DermNet / CC BY-NC-ND

Itching (pruritus) is often the first symptom of eczema, which typically precedes the outbreak of a rash. The itching tends to get worse at night and can sometimes interfere with sleep.

Not all eczema rashes look the same and can vary by their location and eczema type (such as discoid eczema and dyshidrotic eczema). Still, there are classic signs and symptoms that characterize the disease, including.

  • Dry, scaly patches of skin
  • Areas of swelling and redness
  • Oozing bumps that crust over (particularly where the skin is scratched)
  • Skin discoloration, either lighter or darker, after the rash has healed
  • Areas of thick, leathery skin (most especially in adults)

Scratching only makes eczema worse. In some cases, scratching can cause breaks in the skin through which bacteria and other microbes can pass, causing infection.

Location by Age

The location and appearance of an eczema rash can differ by age group and help distinguish the disease in infants, children, and adults.

  • In infants, the rash typically appears on the cheeks and trunk as well as extensor surfaces (such as the front of a knee or back of the elbow or forearm).
  • In children, flares will less on the face and more on flexor areas (such as behind the knees or in the crook of the elbow).
  • In adolescents and adults, eczema tends to develop on the neck, face, and hands. Adults are also likely to experience lichenification in which affected areas of skin will begin to thicken and turn leathery.

A tell-tale sign of eczema in both adults and kids is that the armpits and groin are typically spared. though infants may sometimes have an affected groin region.

Stages of Eczema

Eczema has three distinct stages—acute, subacute, and chronic—each of which has different symptoms and treatment approaches.

Unlike other conditions, the stages don't necessarily confer to the disease severity or move in a linear fashion. It is not uncommon for eczema to move back and forth between stages or to suddenly go into low disease activity (remission).

  • Acute eczema is the sudden and severe onset of symptoms characterized by the development of weeping and crusting blisters.
  • Subacute eczema generally bridges the acute and chronic stages and manifests with dry, red, and scaly skin.
  • Chronic eczema is characterized by episodes lasting three months or more with frequent acute flares in which the skin will change and develop signs of long-term injury.

Dryness and itching are two hallmarks of eczema that occurs with all stages.

Causes

As of yet, the exact cause of atopic dermatitis isn't completely clear. It's believed to be caused by a combination of genetic and environmental factors that work in tandem to cause the inflammatory skin disease.

Genetics

Genetics is believed to play a central role in the development of eczema given that the disease tends to run in families.

In recent years, scientists have identified several genes that predispose patients to atopic dermatitis.

One of these mutations interferes with the production of a protein called filaggrin that provides skin cells structure and helps them retain moisture. The loss of filaggrin undermines the barrier function of the skin, allowing allergens and irritants to enter cells and trigger inflammation.

Environment

Scientists believe that environmental triggers may help instigate eczema in those genetically predisposed to the disease. Some have suggested that babies raised in a "too clean" environment may have impaired immunity and be less able to ward off allergens and irritants that cause inflammation at the cellular level.

Environmental triggers may also instigate acute flares. The triggers can vary from one person to the next and may include:

  • Extreme dry, cold temperatures
  • Extremely hot, humid weather
  • Food allergens
  • Dust mites, pollen, molds, and pet dander
  • Highly fragrance soap and skincare products
  • Rough fabrics, such as wool

Very dry skin, stress, and anxiety can also serve as triggers.

Diagnosis

There are no tests or imaging studies able to diagnose eczema. Uncomplicated cases are most often diagnosed with a combination of a physical exam and a review of one's medical history.

This is especially true in babies and children in whom eczema is common. Diagnosing eczema in adults can be more complicated since the disease is less likely to develop in adulthood and is easily mistaken for other skin conditions.

Your primary care physician or pediatrician can determine whether the features of the disease meet the diagnostic criteria in established guidelines. Atypical cases can be referred to an allergist, immunologist, or dermatologist for further examination.

Other tests (including patch testing, a KOH test, and skin biopsy) may be ordered to differentiate eczema from other possible causes.

Differential Diagnosis

If you have symptoms of atopic dermatitis, your physician will also consider other diagnoses that may look similar to atopic dermatitis. This is referred to as a differential diagnosis.

A differential diagnosis is used to differentiate eczema from other related conditions or those that simply look like eczema. Examples include:

Treatment

Eczema is a chronic condition with no known cure. When an eczema flare occurs, the appropriate treatment will vary based on the severity of the rash.

Over-the-Counter Treatments

Mild eczema can often be effectively controlled with a combination of over-the-counter (OTC) treatments, regular moisturizing, and other home remedies. Among them:

  • Skin barrier creams contain lipids and ceramides that can help restore moisture and improve the barrier function of the skin.
  • 1% hydrocortisone cream is typically applied before moisturizing to help reduce inflammation.
  • Wet wrap therapy involves wrapping lubricated skin (using skin barrier creams and/or topical steroids) in moist fabric strips for a couple of hours to help hydrate and cool dry, inflamed skin. Note that if wet wraps are used over topical steroids, treatment should be monitored by a physician.
  • Bleach baths are sometimes used to reduce inflammation and reduce the risk of bacterial skin infections.

Speak with your doctor before using any home remedy to ensure that it doesn't undermine standard treatments or worsen symptoms.

Prescription Medications and Procedures

Prescription medications are needed in cases where eczema does not clear up with over-the-counter hydrocortisone. These are not typically used on a continuous basis but rather when you have an acute flare. Among the options:

  • Prescription topical steroids like prednisolone or betamethasone
  • Topical calcineurin inhibitors such as Protopic (tacrolimus) and Elidel (pimecrolimus)
  • Dupixent (dupilumab), an injectable medication used to treat moderate to severe eczema in adults
  • Antibiotics or antifungals, if your rash has become infected
  • Phototherapy
  • Eucrisa (crisaborole), a topical formulation (non-corticosteroid) that is FDA-approved to be used in babies as young as 3 months old

Oral corticosteroids are not indicated for long-term care of atopic dermatitis. Occasionally they are used for short flares, but atopic dermatitis typically flares up again as soon as these drugs are tapered off.

Prevention

With conscientious care of your skin, you can greatly reduce your chance of an eczema flare-up by following some key strategies:

  • Use moisturizers liberally: Apply daily, ideally immediately after showering or bathing, and reapply when needed
  • Avoid harsh soaps, detergents or solvents: Opt for products that are unfragranced and dye-free.
  • Wear loose-fitting, light clothing: Avoid scratchy fabrics, tight belts and collars, and fabrics that don't breathe.
  • Know your triggers: Keep a diary to track which substance or events trigger a flare.
  • Manage your stress: Combining stress management with good sleep hygiene and regular exercise may go a long way toward preventing flares.

A Word From Verywell

Gentle skin care and the consistent application of moisturizers are the best steps to minimizing flares and reducing itchiness and irritation. If home treatment isn't enough, over-the-counter and prescription medications can help.

Although eczema can be difficult to manage for some people, a stepped approach to treatment—moving from topical to oral/injectable to combination therapies—can usually identify the best solution for you as an individual.

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