What is atopic eczema?
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
.What causes atopic eczema?
The exact cause of atopic eczema is unknown. However, it often occurs in people who get
("atopic" means sensitivity to allergens).Atopic eczema can run in families and often occurs alongside other conditions, such as
and .Read more information about the
.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.
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.Many different types of treatment can be used to control symptoms and manage eczema, including medication and self-help techniques.
The main treatments are:
- (moisturising treatments) – used all the time for dry skin
- – used to reduce swelling and redness during flare-ups
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.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.
Atopic eczema 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
.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
.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
Atopic eczema 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 or
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 . 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
.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.
Atopic eczema 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:
- – used all the time for dry skin
- – used to reduce swelling and redness during flare-ups
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:
- for severe itching
- for severe symptoms
- for infected eczema
- topical immunosuppresants, which reduce or suppress your body's immune system, such as pimecrolimus cream and tacrolimus ointment
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
.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
, 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
.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
.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:
- thinning of the skin, particularly in the crease of the elbow or knee joint
- visible blood vessels, particularly on the cheeks
- increased hair growth
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:
- (hypertension)
- brittle bones ()
- fluid retention
- affecting children's growth rate
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:
- four times a day for seven days
- clarithromycin twice a day for seven days
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
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
, 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
.Complications of atopic eczema
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
. 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
).Eczema herpeticum
It is possible for eczema to become infected with the herpes simplex virus, which normally causes
. 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.