Atopic Eczema: Symptoms, Causes & Treatment

What Is Atopic Eczema?

Atopic eczema (atopic dermatitis) is a chronic inflammatory skin condition characterized by dry, itchy skin and recurring flares of inflamed, red patches. It is caused by a combination of genetic factors affecting the skin barrier and immune system dysfunction. The condition affects 15-20% of children and 1-3% of adults, making it one of the most common skin diseases worldwide.

Atopic eczema is much more than just dry skin – it is a complex condition involving both the skin barrier and the immune system. The term "atopic" refers to the genetic tendency to develop allergic conditions, which is why atopic eczema often occurs alongside asthma and hay fever. This cluster of conditions is sometimes called the "atopic march" or "atopic triad," affecting individuals throughout their lives in different ways.

The skin of people with atopic eczema has structural abnormalities that affect its ability to retain moisture and protect against irritants, allergens, and bacteria. Research has shown that mutations in the filaggrin gene, which plays a crucial role in skin barrier function, are present in up to 50% of people with moderate-to-severe atopic eczema. This compromised skin barrier allows irritants to penetrate more easily and moisture to escape, creating a cycle of dryness, irritation, and inflammation.

The immune system in atopic eczema is also dysregulated, showing an overactive response to various triggers. This immune dysfunction leads to the chronic inflammation characteristic of the condition. The skin's defense system becomes imbalanced, producing too many inflammatory signals while failing to maintain proper antimicrobial defenses – which is why skin infections are more common in people with atopic eczema.

Different Types of Atopic Eczema

Atopic eczema can present in several distinct patterns, and understanding these variations helps in proper identification and treatment. While the underlying condition is the same, the appearance and location of symptoms can differ significantly between individuals and age groups.

Classic atopic eczema presents as dry, scaly patches that are intensely itchy. On light skin, the affected areas typically appear red and inflamed. On darker skin tones, the eczema may appear as darker or grayish-brown patches, and the redness may be less visible – this is important to recognize as it can sometimes lead to delayed diagnosis in people with darker skin.

Atopic winter feet (also called juvenile plantar dermatosis) affects the soles of the feet, causing scaling, cracking, and peeling of the skin. This variant is most common in children between 4 and 12 years old and tends to worsen in winter months when the contrast between warm indoor environments and cold outdoor temperatures stresses the skin.

Nummular eczema (also called discoid eczema) presents as coin-shaped patches of eczema, typically appearing on the arms and legs. While it can occur at any age, it is more common in adults over 50. These circular patches can be very itchy and may sometimes be mistaken for fungal infections.

Eyelid eczema affects the delicate skin around the eyes and is particularly common in teenagers and adults. This location can be especially troublesome because the thin skin is sensitive to treatments and the visibility of the condition can affect self-esteem.

What Are the Symptoms of Atopic Eczema?

The main symptoms of atopic eczema include intensely itchy, dry skin that flakes and scales; red or inflamed patches (or darker patches on dark skin); cracked and painful skin; and small blisters that may weep clear fluid. The location of symptoms varies by age: infants typically have rashes on the face and scalp, children develop eczema in skin folds, and adults often have hand, neck, and facial involvement.

Atopic eczema symptoms can range from mild to severe and typically follow a pattern of flares and remissions. During a flare, symptoms intensify significantly, while during remission periods, the skin may appear nearly normal. Understanding the full spectrum of symptoms helps in early recognition and appropriate management.

The cardinal symptom of atopic eczema is itching (pruritus), which can be incredibly intense and debilitating. The itching often worsens at night, leading to disturbed sleep for both patients and, in the case of children, their parents. This chronic sleep deprivation can significantly impact quality of life, affecting mood, concentration, and overall well-being. The "itch-scratch cycle" is a key concept – scratching provides temporary relief but damages the skin further, leading to more inflammation and more itching.

Dry skin (xerosis) is present virtually all the time in atopic eczema, not just during flares. The skin lacks the normal oils and natural moisturizing factors that keep healthy skin supple and hydrated. This dryness makes the skin feel rough, tight, and uncomfortable, and it predisposes to cracking and fissures that can be painful.

The inflammatory component of atopic eczema causes visible changes in the skin. On lighter skin, this typically appears as redness (erythema), but on darker skin tones, the affected areas may appear purple, brown, or grayish. The inflammation causes the skin to become swollen, warm to touch, and tender. During acute flares, small blisters (vesicles) containing clear fluid may develop; when these break, they weep and can form crusts.

Complications and Warning Signs

While atopic eczema itself is not dangerous, complications can arise that require prompt medical attention. The most common complication is secondary skin infection, which occurs when bacteria (most commonly Staphylococcus aureus) enter through the damaged skin barrier. Signs of infection include increased redness and warmth, yellow or green discharge, crusting that looks like honey-colored scabs, worsening pain, and sometimes fever.

Eczema herpeticum is a serious complication that occurs when the herpes simplex virus (the cold sore virus) infects eczematous skin. This causes clusters of painful blisters, often appearing like small punched-out erosions, and can spread rapidly. It requires urgent medical treatment with antiviral medications and should be treated as a medical emergency if affecting the eyes or if the person appears systemically unwell.

What Causes Atopic Eczema?

Atopic eczema is caused by a combination of genetic factors that weaken the skin barrier and dysregulate the immune system, combined with environmental triggers. Key factors include mutations in the filaggrin gene (affecting skin barrier function), family history of atopic conditions, and an overactive immune response. Environmental triggers such as irritants, allergens, climate, and stress can then precipitate flares.

Understanding the causes of atopic eczema requires looking at both the underlying predisposition and the triggers that cause flares. The condition results from a complex interplay between genetics, the immune system, the skin barrier, and environmental factors – no single cause can explain why some people develop atopic eczema while others do not.

Genetic Factors

Atopic eczema has a strong hereditary component. If one parent has an atopic condition (eczema, asthma, or hay fever), their child has approximately a 50% chance of developing one of these conditions. If both parents are affected, this risk increases to about 80%. Twin studies have confirmed this genetic link, showing that identical twins are much more likely to both have atopic eczema compared to non-identical twins.

The most significant genetic discovery in atopic eczema has been the identification of mutations in the filaggrin gene. Filaggrin is a protein essential for proper skin barrier formation – it helps create the "bricks and mortar" structure of the outer skin layer and contributes to the skin's natural moisturizing factors. When filaggrin is deficient or abnormal, the skin barrier is compromised, allowing moisture to escape and irritants to penetrate. Approximately 20-50% of people with moderate-to-severe atopic eczema carry filaggrin mutations.

Immune System Dysfunction

The immune system in atopic eczema is shifted toward a type of response called "Th2-dominated immunity." This means the immune system produces excess amounts of certain inflammatory chemicals (called cytokines, including interleukin-4, interleukin-13, and interleukin-31) that cause inflammation, itching, and further skin barrier disruption. This immune imbalance also explains why people with atopic eczema have a higher risk of skin infections – the immune response that normally fights bacteria and viruses is suppressed.

Environmental Triggers

While genetics and immune dysfunction create the predisposition for atopic eczema, environmental factors often trigger flares. Identifying and avoiding triggers is an important part of management, though it's worth noting that triggers vary considerably between individuals.

Skin irritants are among the most common triggers and include harsh soaps and detergents, fragranced products, wool and synthetic fabrics, dust, sand, and chlorinated water. The damaged skin barrier in atopic eczema is particularly susceptible to irritation from substances that would not bother normal skin.

Climate and humidity play significant roles. Cold, dry winter air can worsen eczema by increasing moisture loss from the skin. Central heating makes indoor air even drier. Conversely, hot, humid weather can trigger flares through sweating, which can irritate the skin. Sudden temperature changes – such as going from cold outdoor air to a warm heated building – can also trigger itching.

Stress and emotional factors are well-documented triggers for atopic eczema flares. The exact mechanism is not fully understood, but stress hormones are known to affect both the immune system and skin barrier function. Many people with eczema notice their symptoms worsen during stressful periods.

Infections can trigger flares – paradoxically, the same bacteria that colonize eczematous skin (Staphylococcus aureus) can also trigger increased inflammation. Viral infections like the common cold may also precipitate eczema flares in some people.

What Can I Do Myself to Manage Eczema?

The foundation of eczema self-care is regular, generous application of emollients (moisturizers) – at least twice daily, even when skin looks healthy. Additional measures include taking short, lukewarm baths or showers; avoiding known triggers like harsh soaps, wool, and extreme temperatures; wearing soft, breathable cotton clothing; keeping fingernails short to minimize scratching damage; and managing stress.

Self-care is the cornerstone of atopic eczema management. While medical treatments are important for controlling flares, the daily habits and routines you maintain have a profound impact on skin health and can significantly reduce the frequency and severity of flares. A proactive approach to skin care is essential – waiting until the skin is visibly dry or inflamed before starting care is like waiting until a fire has spread before reaching for the extinguisher.

Moisturizing: The Essential Foundation

Regular, generous application of emollients is the single most important thing you can do for atopic eczema. Emollients (also called moisturizers) work by trapping moisture in the skin, filling gaps in the damaged skin barrier, and protecting against irritants. They should be applied at least twice daily – and ideally more frequently during flares – to the entire body, not just visibly affected areas.

The best time to apply emollients is immediately after bathing, when the skin is still slightly damp. This "soak and seal" approach locks moisture into the skin. Apply the emollient within 3 minutes of getting out of the bath or shower for maximum benefit. During severe flares, emollients may need to be applied 4-6 times daily.

The amount of emollient needed is often underestimated. Adults typically need at least 500 grams per week for whole-body application, and children need proportionally less depending on their size. Think of covering the skin with a visible sheen – if it absorbs immediately without leaving any residue, you're probably not using enough. Apply in smooth, downward strokes in the direction of hair growth rather than rubbing in circles, as this reduces the risk of blocking hair follicles.

Bathing and Skin Cleansing

Bathing habits significantly impact eczema. While it might seem logical to avoid water to prevent drying the skin, regular bathing can actually help – if done correctly. The key is to use lukewarm (not hot) water, keep bathing time short (5-10 minutes), and always follow with immediate emollient application.

Hot water strips natural oils from the skin and triggers inflammation, so keep the temperature comfortable but not steamy. Long soaks may feel relaxing but they further impair the skin barrier. Think of bath time as treatment time, not relaxation time – you can find other ways to unwind that don't involve prolonged hot water exposure.

Choose cleansers carefully. Regular soaps are alkaline and strip the skin's natural protective acid mantle. Use soap-free cleansers, soap substitutes (many emollients can double as cleansers), or gentle syndets (synthetic detergent bars with a pH similar to skin). Avoid anything with fragrance, as these often contain potential irritants. Apply cleanser only where necessary – armpits, groin, hands, and feet – rather than all over.

Environmental and Lifestyle Modifications

Making changes to your environment and daily habits can reduce exposure to triggers and help maintain skin health. While individual triggers vary, several general principles apply to most people with atopic eczema.

Clothing choices matter more than you might think. Wear soft, breathable fabrics like cotton or silk next to the skin. Avoid wool and rough synthetic materials, which can irritate eczematous skin. New clothes should be washed before wearing to remove any finishing chemicals. Consider using fragrance-free, dye-free laundry detergent and skip fabric softeners, which often contain irritating fragrances and chemicals.

Indoor environment modifications can help. Keep indoor temperatures moderate and avoid overheating. Use a humidifier during dry winter months when heating systems reduce indoor humidity. Consider dust mite reduction measures if house dust mites seem to trigger your eczema – this includes using allergen-proof mattress and pillow covers, washing bedding weekly in hot water, and reducing soft furnishings that harbor dust mites.

Managing the itch-scratch cycle is crucial but challenging. Scratching provides momentary relief but damages the skin, triggers more inflammation, and perpetuates the cycle. Keep fingernails short and smooth to minimize damage from unconscious scratching. At night, consider cotton gloves or mittens, particularly for children. When the urge to scratch is overwhelming, try patting, pressing, or applying a cool compress instead. Keeping skin well-moisturized reduces itching significantly.

Sun Exposure

Many people with atopic eczema find that moderate sun exposure improves their symptoms. UV light has anti-inflammatory effects and can help reduce eczema activity. However, eczematous skin is often more sensitive, and sunburn will definitely make things worse. Sun exposure should be gradual and protective measures (appropriate clothing, shade during peak hours) should be used. Children under 1 year should be kept out of direct sunlight entirely, and older children should be protected from burning.

When Should You See a Doctor for Eczema?

See a doctor if your eczema is not improving after 1-2 weeks of consistent self-care with emollients and over-the-counter hydrocortisone, if there are signs of infection (yellow crusts, pus, spreading redness, fever), if eczema is severely affecting sleep or daily life, if it appears near the eyes, or if it is spreading rapidly. Children under 2 with persistent severe symptoms should always be evaluated by a healthcare provider.

While mild eczema can often be managed with good self-care and over-the-counter treatments, there are clear situations when professional medical evaluation is needed. Getting timely treatment prevents complications, improves quality of life, and can stop mild problems from becoming severe ones.

Schedule a routine appointment with your healthcare provider if your eczema is not improving despite consistent use of emollients and, if appropriate, over-the-counter hydrocortisone cream for 1-2 weeks. This suggests you may need stronger prescription treatments or that there may be an undiagnosed trigger or complicating factor.

Also seek care if your eczema is significantly affecting your quality of life – this includes sleep disturbance, difficulty with work or school, social isolation, or psychological distress. These impacts are valid reasons to seek more aggressive treatment, and effective therapies are available.

For children under 2 years with severe itching and symptoms that haven't improved with daily emollient use for 2 weeks, medical evaluation is recommended. Young children with eczema may also benefit from allergy testing, as food allergies can sometimes trigger or worsen eczema in this age group.

How Is Atopic Eczema Diagnosed?

Atopic eczema is diagnosed clinically based on characteristic symptoms and physical examination – there is no specific blood test or biopsy required. Doctors use established criteria including: chronic or relapsing itchy skin, typical location and appearance for age, personal or family history of atopic conditions, and early onset of symptoms. Allergy testing may be performed in some cases to identify potential triggers.

Diagnosis of atopic eczema is made by a healthcare provider based on clinical evaluation rather than laboratory tests. The diagnosis is established by recognizing the characteristic pattern of symptoms, examining the skin, and taking a detailed history. While this might seem straightforward, accurate diagnosis is important because several other conditions can mimic atopic eczema, and the treatment approaches differ.

Healthcare providers typically use established diagnostic criteria. The UK Working Party's criteria, widely used internationally, require the presence of an itchy skin condition in the last 12 months, plus at least three of the following: history of involvement of skin creases (elbow creases, behind knees, fronts of ankles, around neck, or around eyes); personal history of asthma or hay fever (or family history in children under 4); general dry skin in the past year; visible flexural eczema (or eczema on cheeks/forehead/outer limbs in children under 4); and onset before age 2 (this criterion is only applicable if the child is over 4).

When Allergy Testing May Be Helpful

Allergy testing is not routinely required for atopic eczema diagnosis but may be helpful in certain situations. In children under 5 with moderate-to-severe eczema that responds poorly to treatment, food allergies may be playing a role, and allergy testing can identify potential triggers. The most common food allergies associated with eczema in children are cow's milk, eggs, peanuts, tree nuts, wheat, soy, and fish.

It's important to note that having a positive allergy test doesn't always mean that food is making the eczema worse – it simply shows sensitization. Elimination diets should only be tried under medical supervision, and foods should only be permanently excluded if a clear connection to eczema flares is established through careful elimination and reintroduction.

How Is Atopic Eczema Treated?

Treatment follows a stepwise approach based on severity. All patients need daily emollients as the foundation. Mild eczema is treated with low-potency topical corticosteroids. Moderate-to-severe cases may require stronger corticosteroids, topical calcineurin inhibitors (tacrolimus, pimecrolimus), or newer treatments like crisaborole. Severe cases may need phototherapy or systemic medications including dupilumab (a biologic) or traditional immunosuppressants.

The treatment of atopic eczema aims to repair and maintain the skin barrier, reduce inflammation, relieve itching, and prevent infections. Treatment is tailored to the individual based on severity, age, location of eczema, previous treatment responses, and personal preferences. The approach is typically "stepwise" – starting with basic treatments and adding more powerful therapies as needed.

First-Line Treatment: Emollients

Emollients form the foundation of treatment for all patients with atopic eczema, regardless of severity. They should be used continuously, not just during flares, and should be continued even when using other treatments. The principles of emollient use have been covered in the self-care section – the key points are generous quantity, frequent application, and consistent daily use.

Topical Corticosteroids

Topical corticosteroids are the mainstay of anti-inflammatory treatment for atopic eczema flares. They work by suppressing the immune response in the skin, reducing inflammation, redness, and itching. They come in various strengths (potencies), from mild preparations suitable for long-term use on sensitive areas to very potent formulations reserved for short courses on thick, resistant eczema.

For mild eczema, low-potency corticosteroids like hydrocortisone 1% are often sufficient. These can be purchased over the counter in many countries and are generally safe for use on the face and in skin folds for short periods. Moderate-potency corticosteroids (like betamethasone valerate 0.025% or clobetasone butyrate) are used for more significant flares on the body. High-potency and very high-potency corticosteroids are reserved for thick, lichenified eczema and are used for short courses only.

When using topical corticosteroids, apply a thin layer to all affected areas once or twice daily (depending on the specific product) during flares. Continue until the eczema has completely cleared, not just improved – stopping too early often leads to rapid relapse. Once controlled, many people benefit from "weekend therapy" – applying topical corticosteroid to previously affected areas twice weekly to prevent flares.

Topical Calcineurin Inhibitors

Tacrolimus ointment and pimecrolimus cream are non-steroidal anti-inflammatory treatments that work by blocking calcineurin, a protein involved in the immune response. They are particularly useful for sensitive areas like the face and eyelids where long-term corticosteroid use is undesirable, and for people who need continuous anti-inflammatory treatment but want to minimize corticosteroid exposure.

A common side effect when starting these treatments is a burning or stinging sensation at the application site. This typically improves within a week of regular use. These medications should be applied to eczematous skin twice daily until clear, and can be used for long-term maintenance therapy.

Phototherapy (Light Treatment)

For moderate-to-severe atopic eczema that doesn't respond adequately to topical treatments, phototherapy can be very effective. This involves exposing the skin to controlled amounts of ultraviolet (UV) light, typically UVB (narrowband UVB is most commonly used). Phototherapy is given at specialized clinics, usually 2-3 times per week for several weeks. It works by reducing inflammation and slowing the overactive immune response in the skin.

Systemic Treatments for Severe Eczema

When atopic eczema is severe and not adequately controlled by topical treatments and phototherapy, systemic (whole-body) treatments may be needed. The most significant advance in this area has been the development of dupilumab, a biologic medication that blocks specific inflammatory pathways (IL-4 and IL-13) involved in atopic eczema. Given as an injection every two weeks, dupilumab has been shown to dramatically improve eczema in many patients with moderate-to-severe disease.

Other systemic options include traditional immunosuppressants like cyclosporine, methotrexate, and azathioprine. These are effective but require careful monitoring for side effects. Newer treatments including JAK inhibitors (such as upadacitinib, abrocitinib, and baricitinib) have also been approved for atopic eczema in many countries, offering additional options for severe disease.

How Does Atopic Eczema Affect Daily Life?

Atopic eczema can significantly impact quality of life through sleep disturbance, social and psychological effects, and limitations on activities and career choices. However, with proper management, most people can lead full, active lives. Support from healthcare providers, connecting with others who have eczema, and learning effective coping strategies all help manage the condition's broader impacts.

Living with atopic eczema extends far beyond skin symptoms. The condition can affect sleep, self-esteem, social relationships, work, and overall well-being. Acknowledging these broader impacts is important – they are valid concerns that deserve attention alongside the physical symptoms.

Sleep disturbance is one of the most significant quality-of-life impacts. The intense itching of atopic eczema often worsens at night, disrupting sleep and leading to daytime fatigue, difficulty concentrating, and mood disturbances. For parents of children with eczema, the disruption to family sleep can be exhausting. Addressing sleep problems often requires treating the underlying eczema more aggressively, and sometimes additional measures like sedating antihistamines at night may help.

Psychological effects are common and include anxiety, depression, low self-esteem, and social isolation. Visible skin conditions can attract unwanted attention, questions, or even discrimination. Children may experience bullying. Adults may avoid social situations or relationships. These psychological impacts should be taken seriously, and mental health support should be available alongside dermatological treatment.

Occupational Considerations

Career choices can be affected by atopic eczema, particularly regarding occupations involving wet work, irritant exposure, or hand use. Jobs that involve frequent hand washing, exposure to chemicals, or contact with irritants can be problematic. People with a history of eczema should consider these factors when choosing careers. Healthcare, hairdressing, cleaning, catering, and mechanical work are examples of occupations that may be challenging for people with eczema-prone skin.

If you develop eczema related to your work, seek medical advice promptly. Occupational dermatitis may be preventable with appropriate protective measures, or may indicate the need to modify your work activities or environment.

Eczema During Pregnancy

Atopic eczema can change during pregnancy – some women find it improves, while others experience worsening. Treatment decisions during pregnancy require balancing the risks of medications against the risks of uncontrolled eczema. Most topical treatments can be used safely during pregnancy when applied to limited areas. Emollients should be used liberally. Discuss any concerns with your healthcare provider, who can help you develop a safe treatment plan.