Atopic eczema

Atopic eczema, also known as atopic dermatitis, is the most common form of eczema.

Introduction

Atopic eczema, also known as atopic dermatitis, is the most common form of eczema. It mainly affects children, but can continue into adulthood.

Eczema is a condition that causes the skin to become itchy, red, dry and cracked. It is a long-term, or chronic, condition.

Atopic eczema commonly occurs in areas with folds of skin, such as:

  • behind the knees
  • the inside of the elbows
  • on the side of the neck
  • around the eyes and ears

Atopic eczema can vary in severity and most people are only mildly affected. Severe symptoms include cracked, sore and bleeding skin.

People with atopic eczema usually have periods when symptoms are less noticeable, as well as flare-ups when symptoms become more severe, needing additional treatment.

Read more about the symptoms of atopic eczema.

What causes atopic eczema?

The exact cause of atopic eczema is unknown. However, it often occurs in people who get allergies ("atopic" means sensitivity to allergens).

Atopic eczema can run in families and often occurs alongside other conditions, such as asthma and hay fever.

Read more information about the causes of atopic eczema.

Treating atopic eczema

Atopic eczema clears up or significantly improves in many children as they get older. In about 53% of cases, atopic eczema clears up by the time a child reaches 11 years of age, and in 65% of cases it clears up by 16 years of age.

However, severe eczema often has a significant impact on daily life and may be difficult to cope with physically and mentally. There is also an increased risk of infections.

Read more about complications of atopic eczema.

Many different types of treatment can be used to control symptoms and manage eczema, including medication and self-help techniques.

The main treatments are:

Read more about How atopic eczema is treated.

Who is affected?

Atopic eczema occurs before a child reaches five years of age. Many children develop it before their first birthday.

The number of people diagnosed with atopic eczema has increased in recent years. This could be because of changes in lifestyle or environmental factors that cause eczema, or because healthcare professionals are now more aware of the symptoms.

Males and females are affected equally.

Symptoms

The symptoms of atopic eczema may always be present. They can become worse during a flare-up, needing additional treatment.

Symptoms include itchy, dry and red skin that may be broken or cracked.

Atopic eczema can occur in small patches all over the body and is most common:

  • in infants – on the face and scalp, and on the arms and legs
  • in adults and children – on the hands or around joints on the arms and legs, such as the inside of the elbows or the backs of the knees

The symptoms of atopic eczema vary according to how severely you or your child are affected by the condition.

People with mild atopic eczema normally have only small areas of dry skin that are occasionally itchy. In more severe cases, atopic eczema can cause widespread dry skin, constant itching and oozing fluid.

Scratching can disrupt your sleep and make your skin bleed. It can also make itching worse, and a cycle of itching and regular scratching may develop. In children, this can lead to sleepless nights and difficulty concentrating at school.

During a flare-up

Symptoms become worse during a flare-up, and you or your child may need stronger treatment when this happens.

During a flare-up, your skin may be:

  • extremely itchy, red, hot, dry and scaly
  • wet, weeping and swollen
  • infected with bacteria (usually Staphylococcus aureus)

Read more about infections and other complications of atopic eczema.

Causes

There is no single cause of eczema. It probably has a mixture of inherited and environmental causes that act together at different times.

You may be born with an increased likelihood of developing eczema, which you inherit from your parents.

When you are exposed to environmental factors, such as dust or pollen, this causes eczema to appear. There are several triggers that can make your symptoms worse.

Genetics

Research suggests that atopic eczema is largely an inherited condition. This means that the cause lies in the genes that you inherit from your parents.

If a child's parents have atopic eczema, it is highly likely that the child will also develop the condition. Studies have shown that 60% of children who have a parent with atopic eczema will also have eczema. If both parents have atopic eczema, there is an 80% chance that a child will also have the condition.

It is not yet known exactly which genes are responsible for eczema.

The environment

If your genes make you more likely to develop atopic eczema, the condition will develop after you are exposed to certain environmental factors, such as allergens.

Allergens are substances that can cause the body to react abnormally. This is known as an allergic reaction. Some of the most common allergens that can cause atopic eczema include:

  • house dust mites
  • pet fur
  • pollen

Atopic eczema can sometimes be caused by food allergens, especially before the age of one. Foods that typically cause allergic reactions include:

  • cows' milk
  • eggs
  • nuts
  • soya
  • wheat

Some studies of children and young people with atopic eczema found that one-third to nearly two-thirds also had a food allergy. Having a food allergy increases the likelihood of your atopic eczema being severe.

Read more about food allergies.

Allergies do not always play a role. There are many other things likely to bring out eczema, including:

  • cold weather
  • dampness
  • harsh soaps
  • washing too much
  • rough clothing

Triggers

Triggers can make atopic eczema worse, although they do not necessarily cause the condition.

Hormonal changes in women

Hormones are powerful chemicals that are produced by the body and have a wide range of effects. Changes in the levels of certain hormones can affect the symptoms of atopic eczema in some women.

Many women's eczema is worse at certain times during their menstrual cycle. Some women have a flare-up of their eczema in the days before their period.

The hormonal changes during pregnancy can also affect atopic eczema:

  • more than half of all pregnant women find their symptoms get worse
  • one-quarter of pregnant women find their symptoms improve

Stress

While stress is known to be associated with atopic eczema, it is not fully understood how it affects the condition. Some people with eczema have worse symptoms when they are stressed. For other people, their symptoms cause them to feel stressed.

Read more about ways to manage stress.

Exercise

After vigorous exercise, sweating may make your eczema symptoms worse. Try to keep cool when you are exercising by drinking plenty of fluids and taking regular breaks.

Irritants

Irritants can make your symptoms worse. What irritates you may be different to what irritates someone else with the condition, but could include:

  • soaps and detergents, such as shampoo, washing-up liquid or bubble bath
  • some types of clothing, especially wool and nylon
  • overheating
  • very cold, dry weather
  • dust
  • unfamiliar pets

Other triggers

Other possible triggers include:

  • substances that touch your skin, such as perfume-based products or latex (a type of naturally occurring rubber)
  • environmental factors, such as tobacco smoke, living near a busy road or having water that contains lots of minerals (hard water)
  • the changing seasons – most people with atopic eczema find that their symptoms improve during the summer and get worse in the winter

Diagnosis

Your doctor will usually be able to diagnose atopic eczema by assessing the skin and asking questions about your symptoms.

These questions may include:

  • whether the rash is itchy and where it appears
  • when the symptoms first began
  • whether you have flare-ups of severe symptoms
  • whether there is a history of atopic eczema in your family
  • whether you have any other conditions, such as allergies or asthma

Tell your doctor if your condition is affecting your quality of life, for example if you have difficulty sleeping because of itching or it is limiting your daily activities.

Checklist for diagnosing atopic eczema

Typically, to be diagnosed with atopic eczema you must have had an itchy skin condition in the last 12 months, as well as three or more of the signs and symptoms described below:

  • You have itchiness and irritation in the creases of your skin, such as the inside of your elbows, behind your knees, your ankles, around your neck or around your eyes.
  • Your skin has been generally dry in the last 12 months.
  • You have or have had asthma or hay fever. For children under the age of four, they must have an immediate relative, such as a parent, brother or sister, who has asthma or hay fever.
  • There is eczema in the creases of your skin, or on the forehead, cheeks, arms or legs in children under the age of four.
  • In children over four and adults, the condition started at the age of two or before.

Establishing triggers

Your doctor should work with you to establish what triggers make your eczema worse. You may be asked about your diet and lifestyle to see if something obvious may be contributing to your symptoms. For example, you may have noticed that some soaps or shampoos make the eczema worse.

Read more about potential triggers and causes of atopic eczema.

You may also be asked to keep a food diary to try to determine whether a specific food makes your symptoms worse.

A food diary involves writing down everything you eat and making a record of any eczema flare-ups you have. Your doctor can then use the diary to see if there is a pattern between your symptoms and what you eat.

Treatment

Although there is no cure for atopic eczema, treatments can ease the symptoms.

Children with atopic eczema normally find their symptoms naturally improve over time.

Medications used to treat atopic eczema most commonly include:

Your doctor will prescribe emollients for dry skin and the weakest effective topical corticosteroid. Different strengths are needed for different parts of the body.

As long as the eczema is not infected, certain dressings or bandages – known as dry wraps, wet wraps and occlusive dressings – may also be applied by a healthcare professional.

They work by reducing itchiness, preventing scratching and helping to stop the skin from drying out.

Other medications

Other medicines used to ease the symptoms of eczema include:

Your doctor will prescribe additional medication as and when it is needed.

Self-care

As well as medication, there are things you can do yourself at home to help ease symptoms.

Scratching

Eczema is often itchy and scratching it can aggravate the skin, eventually causing it to thicken. Scratching your skin also increases the risk of your eczema becoming infected with bacteria.

Read more about complications of atopic eczema.

There may be times when you or your child cannot help scratching. Keeping nails short will minimise damage to the skin.

If your baby has atopic eczema, anti-scratch mittens may stop them scratching their skin. Tapping or pinching the skin until the itch has gone may also offer relief.

Avoiding triggers

Your doctor will work with you to establish what might trigger the eczema flare-ups, although it may get better or worse for no obvious reason.

Once you know what triggers a flare-up, you can try to avoid them. For example:

  • if certain fabrics irritate your skin, avoid wearing these and stick to natural materials such as cotton
  • if heat aggravates your eczema, keep the rooms in your home cool
  • avoid using soaps or detergents that may affect your skin

Although many people with eczema are allergic to house dust mites, it is not recommended that you try to get rid of them from your home. The process is time consuming and difficult to carry out effectively, and there is no clear evidence that it helps.

Similarly, although living in an area that has hard water is associated with slightly higher levels of eczema in younger children, installing a water softener does not seem to make any difference.

Diet

You should not make any significant dietary changes without first speaking to your doctor. Some foods, such as milk, eggs and nuts, have been shown to trigger eczema symptoms.

However, it may not be healthy to cut these from your diet without medical advice, especially in young children who need plenty of the calcium, calories and protein that are provided by these foods.

If your doctor suspects you have a food allergy, you may be referred to a dietitian (a specialist in diet and nutrition).

If you are breastfeeding a baby with atopic eczema, get medical advice before making any changes to your regular diet.

Emollients

Emollients are substances that help soften your skin to keep it moist. They reduce water loss from the skin by covering it with a protective film. They are the most important treatment for dry skin associated with atopic eczema.

It is important to keep skin moisturised to prevent it becoming dry and cracked.

Choosing an emollient

There are several different emollients available, some of which you can buy over-the-counter without a prescription. Your doctor or pharmacist can recommend a suitable one for you, although you may need to try a few before you find one that suits you.

You may also be prescribed different emollients for different uses, such as:

  • an ointment for very dry skin
  • a cream or lotion for less dry skin
  • an emollient to use on your face and hands
  • a different emollient to use on your body
  • an emollient to use instead of soap
  • an emollient to add to bath water or use in the shower

The difference between lotions, creams and ointments is the amount of oil and water they contain. Ointments contain the most oil so can be quite greasy, but they are the most effective at keeping moisture in the skin. Lotions contain the least oil so are not greasy, but can be less effective. Creams are in the middle.

If you have been using a particular emollient for some time, it may eventually become less effective or may start to irritate your skin. If this happens, speak to your doctor as another product can be prescribed instead.

If the skin is inflamed, emollients should be used along with an anti-inflammatory treatment, such as topical corticosteroids.

How to use emollients

Use your emollient all the time, especially between flare-ups, even when you do not have symptoms. Keeping separate supplies of emollients at work or at school can be a good idea.

To apply the emollient:

  • use a large amount
  • smooth the emollient into the skin in the same direction that the hair grows
  • do not rub the emollient in
  • for very dry skin, apply emollient every two to three hours
  • after a bath or shower, gently dry the skin and apply the emollient while the skin is still moist
  • do not share emollients with other people
  • do not put your fingers into an emollient pot – instead, use a spoon or pump dispenser as this reduces the risk of spreading infection

It is very important to keep using your emollients during a flare-up because this is when the skin needs the most moisture. During a flare-up, apply generous amounts frequently.

Topical corticosteroids

Topical corticosteroids are usually prescribed when the skin is inflamed. Topical means something applied directly to your skin. Corticosteroids work by quickly reducing inflammation.

You may be concerned about using medication that contains steroids. However, corticosteroids are not the same as anabolic steroids, sometimes used illegally by bodybuilders and athletes. When used correctly, corticosteroids are a safe and effective treatment for eczema.

Choosing a topical corticosteroid

Topical corticosteroids can be prescribed in different strengths, depending on the severity of your atopic eczema. They can be mild, such as hydrocortisone, moderate, such as clobetasone butyrate, strong or very strong. Severe cases of atopic eczema will require stronger corticosteroids. You may be prescribed:

  • a cream to be used on visible areas, such as the face and hands
  • an ointment to be used at night or for more severe flare-ups

If you need to use corticosteroids frequently, see your doctor regularly so they can check the treatment is working effectively and that you are using the right amount.

How to use topical corticosteroids

Apply the treatment sparingly to affected areas. Always follow the directions on the patient information leaflet that comes with the corticosteroid.

During an atopic eczema flare-up, do not apply the corticosteroid more than twice a day. Most people only have to apply it once a day. To apply the topical corticosteroid:

  • apply your emollient first and wait 30 minutes until the emollient has soaked into your skin
  • apply the recommended amount of the topical corticosteroid to the affected area
  • apply the treatment for 48 hours after the flare-up has cleared so the eczema under the skin is treated

If you or your child are using corticosteroids for a long time, they may need to be applied less frequently. Speak to your doctor for advice.

How much topical corticosteroid to use

Topical corticosteroids are measured in a standard unit called the fingertip unit (FTU).

  • one FTU is the amount of topical corticosteroid squeezed along an adult's fingertip
  • one FTU is enough to treat an area of skin twice the size of an adult's hand

Read more information about fingertip units and dosage of topical corticosteroids.

Side effects

Topical corticosteroids may cause a mild burning or stinging feeling as you apply them.

If strong topical corticosteroids are used for too long, they may also cause:

These side effects are rare.

Antihistamines

Antihistamines are a type of medicine that stops the effects of a substance in the blood called histamine. Your body often releases histamine when it comes into contact with an allergen.

Antihistamines can help you cope with the itching that atopic eczema causes. They can be sedating, which cause drowsiness, or non-sedating.

Non-sedating antihistamines

You may be prescribed a non-sedating antihistamine if you have severe itching or associated hay fever. If this helps, you may be advised to continue taking the non-sedating antihistamine in the long term. This should be reviewed every three months.

Sedating antihistamines

If itching affects your sleep, a sedating antihistamine may help. Sedating antihistamines are prescribed on a short-term basis, usually for a maximum of two weeks at a time, as they seem to lose their effect quickly.

These types of antihistimine can cause drowsiness the following day, so it's a good idea to let your child's school know that they may not be as alert as normal.

If you are taking sedating antihistamines, avoid driving the next day if you still feel drowsy. The sedative effect is likely to be stronger if you drink alcohol.

Corticosteroid tablets

In rare cases, if you have a severe flare-up your doctor may prescribe corticosteroid tablets. These are also used for flare-ups of asthma.

You may be prescribed [prednisolone] to take once a day, usually in the morning, for one to two weeks.

If oral corticosteroids are taken often or for a long time, they can cause side effects such as:

For this reason, your doctor is unlikely to prescribe corticosteroid tablets more than once a year without referring you to a specialist.

Infected eczema

Antibiotics are usually prescribed if eczema becomes infected.

Large areas of infected skin are usually treated with antibiotic tablets or capsules. The antibiotic most commonly prescribed is flucloxacillin, which is usually taken four times a day for seven days. If you are allergic to penicillin, you may be prescribed:

Small areas of infected eczema are usually treated with antibiotic creams or ointments applied directly to the infected area.

Topical antibiotics should not be used for longer than two weeks because the bacteria may become resistant to the medication. If your symptoms get worse, speak to your doctor.

Preventing infections

Once your infection has cleared, your doctor will prescribe new supplies of any creams and ointments you're using to avoid contamination. Old treatments should be disposed of.

During and after infection it's important to keep inflammation under control with corticosteroids.

If areas of your eczema are prone to infection, antiseptic cream or lotion can help kill any bacteria. Commonly prescribed topical antiseptics include chlorhexidine and triclosan.

Referral

In some cases of atopic eczema, your doctor may refer you to a specialist in treating skin conditions (dermatologist). You may be referred if:

  • your doctor is not sure what type of eczema you have
  • treatment is not controlling your eczema
  • the eczema is causing significant problems in your daily life
  • it is not clear what is causing your eczema

A dermatologist may offer the following treatments:

  • phototherapy – exposure to ultraviolet (UV) light
  • bandaging – medicated dressings or wet wraps are applied to your skin
  • an immunosuppressant medication – to suppress your immune system
  • very strong topical corticosteroids
  • additional support on using your treatments correctly – such as demonstrations from nurse specialists
  • psychological support
  • alitretinoin

Alitretinoin

Alitretinoin, sold under the brand name Toctino, is a medication for severe, long-term hand eczema that has not responded to other treatments. Treatment with alitretinoin must be supervised by a dermatologist and can only be used by people 18 years of age or over.

Alitretinoin is a type of medication called a retinoid. Retinoids reduce levels of irritation and itchiness associated with eczema. It comes as a capsule that most people are recommended to take once a day for 12-24 weeks.

Alitretinoin should never be taken during pregnancy because it can cause severe birth defects. Women who are breastfeeding should also avoid taking alitretinoin, because the medication can enter your breast milk and harm your baby.

Due to the risk of birth defects, alitretinoin is not recommended for women of child-bearing age.

Some common side effects of alitretinoin include:

  • headaches
  • dry mouth and eyes
  • a reduced number of red blood cells, known as anaemia
  • increased levels of fatty substances called cholesterol and triglyceride in the blood
  • joint pain or muscle pain

For a full list of side effects, see the patient information leaflet that comes with your medicine or alitretinoin medicines information.

Complications

Complications of atopic eczema can be physical and psychological, particularly in children.

Infection

As atopic eczema can cause your skin to become dry and cracked, there is an increased risk of skin infection. The risk is higher if you scratch your eczema and you do not use treatments correctly.

Bacterial infections can cause severe symptoms. The most common type of bacteria that infects atopic eczema is Staphylococcus aureus. A Staphylococcus aureus infection can cause:

  • redness
  • fluid that oozes out of the cracked skin and crusting where the fluid dries
  • a high temperature and a feeling of being unwell

Antibiotics will be needed to treat a Staph A infection (see How atopic eczema is treated).

Eczema herpeticum

It is possible for eczema to become infected with the herpes simplex virus, which normally causes cold sores. This can develop into a serious condition called eczema herpeticum. Symptoms of eczema herpeticum include:

  • areas of painful eczema that quickly get worse
  • groups of fluid-filled blisters that break open and leave open sores on the skin
  • a high temperature and generally feeling unwell, in some cases

Contact your doctor immediately if you think you or your child may have eczema herpeticum. If you cannot contact your doctor, go to your nearest hospital.

Psychological effects

As well as affecting you physically, atopic eczema may also affect you psychologically.

Preschool children with atopic eczema are more likely to have behavioural problems than children who do not have the condition. They are also more likely to be more dependent on their parents compared with children who do not have the condition.

Bullying

School children may experience teasing or bullying if they have atopic eczema. Any kind of bullying can be traumatic and difficult for a child to deal with. Your child may become quiet and withdrawn. Explain the situation to your child's teacher and encourage your child to tell you how they are feeling.

Sleep disturbance

Research suggests sleep-related problems are common among young children with eczema.

A lack of sleep may affect your child's mood and behaviour. It may also make it more difficult for them to concentrate at school, which may lead to them falling behind with their work.

Again, it is important to let your child's teacher know about their condition so it can be taken into consideration.

During an eczema flare-up, your child may need time off from school. This may also affect their ability to keep up with their studies.

Self-confidence

Atopic eczema can affect the self-confidence of both adults and children. Children may find it particularly difficult to deal with their condition, which may lead to them having a poor self-image.

If your child is severely lacking in confidence, it may affect their ability to develop social skills. Support and encouragement will help boost your child's self-confidence and give them a more positive attitude about their appearance.

Speak to your doctor if you are concerned your child's eczema is severely affecting their confidence.

Real stories

Battling against eczema for most of his life, John Fuller has tried just about every treatment option available.

John's eczema began when he was a baby. "It was always there as far back as I can remember," he says. "My skin would turn red raw and I would scratch and scratch. We tried everything from creams to salt baths. I have a very strong memory of sitting for ages in a salt bath because our doctor suggested it. Luckily, I wasn't bullied for having eczema like many children seem to be."

When John was 11, the family went to Barbados for a holiday. While they were there, they discovered the aloe vera plant.

"Someone suggested it might help my eczema and we were ready to try anything. Aloe vera is everywhere now, but back then nobody had heard of it. When we got back, we started growing it in our garden. I'd have to rub the plant juice all over me. Amazingly, the eczema cleared up for the next nine years."

John hoped he'd grown out of the condition. However, his eczema came back when he was finishing university. "The redness and the itching began again," he says. "Soon it was all over my arms and legs, and it's been there ever since."

John says he's tried every treatment going, including steroid pills and creams, and cyclosporin, a strong drug used mainly to stop transplant patients rejecting their new organs. It works by damping down the immune system.

"That was effective for a couple of years but it can damage your internal organs, so you can't stay on a high dose for too long," he explains. "I had to have regular blood tests to make sure everything was working properly, and eventually had to go on such a low dose that it wasn't worth it.

"I've been in hospital three times. In hospital you get the same treatment that you do at home, but it's more intensive and it's also cleaner."

He has also experimented with complementary therapies. "I went to a Chinese herbalist, who gave me some disgusting-tasting tea to drink every night," he says. "For a while, it seemed to work. Then the eczema came back. I found a lot of things work for a while but then lose their effectiveness."

John tries his best to live a normal life, but says it's not easy. "When the itching is really bad, it's very hard to concentrate at work," he says. "Sometimes I have to take time off. Employers don't like that, and it has an impact on everyone I work with. Sometimes sleeping is just impossible and that affects my daily life as well. I love playing cricket but direct sunlight turns me bright red. I look like a tomato."

John is resigned to living with his condition, but he still has hope. "Nobody knows why I have eczema and as yet there's no cure, but you never know. One day I could wake up and the eczema will be gone. Until then, I have to make do with the treatments we have."

Ruby's story

Ruby was diagnosed with eczema at six weeks old. Her mum, Daniella, explains how they've learned to cope with Ruby's condition.

"At only 10 days old, Ruby developed a rash all over her, a bit like teenage spots with white pimples.

"Doctors thought it was her sebaceous glands not working properly and said it would go away. It did. However, as there's a history of eczema in my husband's family and mine and it's a hereditary condition, I always thought she would develop it.

"Doctors tell me not to use any of the commonly marketed baby products, perfumed products or soap. Now, her treatment involves two baths daily using oil. Before the bath I also cover her body in aqueous cream. I wash her body with a flannel rather than a sponge because flannels can be washed daily.

"She doesn't sleep with many cuddly toys in her cot as they can carry dust, and I don't let her near animals as they can irritate and aggravate her skin.

"Some foods have had an effect on her skin too, so I have to make sure she doesn't eat them and other people don't give them to her. I also have to be careful with sun lotions and not to let her go in the sun too often.

"At its worst, the eczema on her right arm became infected and her skin went yellow and filled with pus. We quickly took her to the doctor and she was put on antibiotics. I spoke to the nurses at the hospital, who suggested trying a wet wrapping with some support, which is like a sports bandage, but I decided to cover the arm in moisturiser with a dry bandage over the top to try to stop her scratching in the night.

"You can't really stop a baby from scratching. You can distract them where possible and keep them occupied, keep their nails short by trimming them morning and night, and as a last resort I keep Ruby in long sleeves and cover her arms in a wet wrap.

"Once I was driving home in the evening after Ruby's normal bath time and she was tired and irritable. I noticed in my rear mirror that she was scratching and scratching, and her arm was bleeding. I was stuck in traffic and still far from home, so the best I could do was to sing songs to try to distract her. That was the hardest incident.

"I hope she will grow out of the eczema. I grew out of it and so did other members of my family. However, some of the people on my husband's side of the family still have it in their old age."

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