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Patient education: Eczema (atopic dermatitis) (Beyond the Basics)

Patient education: Eczema (atopic dermatitis) (Beyond the Basics)
Authors:
William L Weston, MD
William Howe, MD
Section Editor:
Robert P Dellavalle, MD, PhD, MSPH
Deputy Editor:
Rosamaria Corona, MD, DSc
Literature review current through: Sep 2022. | This topic last updated: Nov 23, 2021.

ECZEMA OVERVIEW — Eczema, also known as atopic dermatitis, is a skin problem that causes dry, itchy, scaly, red skin. It can affect infants, children, and adults and seems more common in certain families. Eczema can be treated with moisturizers and prescription ointments.

ECZEMA CAUSES — Although the cause of eczema is not completely understood, genetics appear to play a strong role, and people with a family history of eczema are at increased risk of developing the condition. In most people with eczema, there is a genetic abnormality in the outermost layer of the skin, called the epidermis. The epidermis is the first line of defense between the body and the environment. When the epidermis is intact, it keeps environmental irritants, allergens, and microbes from entering the body and prevents the skin from losing too much water. In people with eczema, this barrier is less strong and more permeable than it should be.

Despite popular belief, in children eczema is rarely linked to food allergies. If you think your child might have a food allergy, you should consult an allergy specialist for evaluation. (See "Patient education: Food allergy symptoms and diagnosis (Beyond the Basics)".)

ECZEMA SYMPTOMS — Most people with eczema develop their first symptoms as children, before the age of five. Intense itching of the skin, patches of inflamed skin, small bumps, and skin flaking are common. Scratching can further inflame the skin and worsen the itching. The itchiness may be more noticeable at nighttime.

Eczema symptoms vary from one person to another and can change over time. Although eczema is usually limited to specific areas of the body, it may affect multiple areas in severe cases:

In infants, there may be inflamed, scaly, and crusted areas on the front of the arms and legs, cheeks (picture 1), or scalp. The diaper area is not usually affected.

In children and adults, eczema commonly affects the back of the neck, the elbow creases, and the backs of the knees (picture 2). Other affected areas may include the face (picture 3), trunk (picture 4), wrists, and forearms. The skin may become thickened and darkened, or even scarred, from repeated scratching (picture 5).

Scratching can also lead to infection of the skin. Signs of infection include painful red bumps that sometimes contain pus; if you think you might have an infection, consult your doctor or nurse, as you may need treatment.

Other findings in people with eczema can include:

Dry, scaly skin

Plugged hair follicles causing small bumps, usually on the face, upper arms, and thighs (picture 6)

Increased skin creasing on the palms and/or an extra fold of skin under the eye

Darkening of the skin around the eyes

ECZEMA DIAGNOSIS — There is no specific test used to diagnose eczema. The diagnosis is usually based upon your medical history, symptoms, and physical examination.

Factors that strongly suggest eczema include long-term and recurrent itching, symptoms that began at a young age, and a personal or family history of certain allergic conditions (including asthma and seasonal allergies as well as eczema). Another factor to consider is symptoms that get worse after exposure to certain triggers. (See 'Identifying triggers' below.)

ECZEMA TREATMENT — Eczema is a chronic condition; it typically improves and then flares (gets worse) periodically. Some people have no symptoms for several years. Eczema is not curable, although it is possible to control your symptoms with a variety of self-care measures and medications.

Who treats eczema? — Many people with eczema can initially be treated by their primary care provider. However, you may need to see a dermatologist (skin specialist) in certain situations, such as if your condition does not improve with treatment, if certain areas of your body are affected (face or skin folds), or if another condition could be causing symptoms.

Identifying triggers — Eliminating factors that aggravate your eczema symptoms can help to control the symptoms. Possible triggers may include:

Cold or dry environments

Sweating

Emotional stress or anxiety

Rapid temperature changes

Exposure to certain chemicals or cleaning solutions, including soaps and detergents, perfumes and cosmetics, wool or synthetic fibers, dust, sand, and cigarette smoke

Keeping your skin hydrated

Emollients — Emollients are creams and ointments that moisturize the skin and prevent it from drying out. The best emollients for people with eczema are thick creams (such as Eucerin, Cetaphil, and Nutraderm) or ointments (such as petroleum jelly, Aquaphor, and Vaseline), which contain little to no water. Emollients are most effective when applied immediately after bathing. Emollients can be applied twice a day or more often if needed. Lotions contain more water than creams and ointments and are less effective for moisturizing the skin.

Bathing — It is not clear if showers or baths are better for keeping the skin hydrated. Lukewarm baths or showers can hydrate and cool the skin, temporarily relieving itching from eczema. An unscented, mild soap or non-soap cleanser (such as Cetaphil) should be used sparingly. Apply an emollient immediately after bathing or showering to prevent your skin from drying out as a result of water evaporation. Emollient bath additives (products you add to the bath water) have not been found to help relieve symptoms.

Hot or long baths (more than 10 to 15 minutes) and showers should be avoided since they can dry out the skin.

In some cases, health care providers may recommend dilute bleach baths for people with eczema. These baths help to decrease the number of bacteria on the skin that can cause infections or worsen symptoms. To prepare a bleach bath, one-fourth to one-half cup of bleach is placed in a full bathtub (about 40 gallons) of water. Bleach baths are usually taken for 5 to 10 minutes twice per week and should be followed by application of an emollient.

Treating skin irritation

Topical steroids — Your doctor may suggest a steroid (also called "corticosteroid") cream or ointment if you have mild to moderate eczema. Steroid creams and ointments are available in different strengths; the least potent are available without a prescription (eg, hydrocortisone 1% cream). Stronger versions require a prescription.

Steroid creams or ointments are usually applied to the skin once or twice per day. These help to reduce symptoms and moisturize your skin. As the skin improves, you can switch to a non-medicated emollient. Strong topical steroids may be needed to control severe flares of eczema; however, these should be used for only short periods of time to prevent thinning of the skin that can result from long-term use.

Other skin treatments — Newer skin treatments for eczema include tacrolimus ointment (brand name: Protopic) and pimecrolimus cream (brand name: Elidel). These are effective in controlling eczema, although they do not work as quickly as topical steroids. They are useful in sensitive areas such as the face and groin, and can be used in children over age two. Due to concerns about the long-term safety of these medications, it's important to carefully follow your health care provider's instructions about how and how long to use them.

Oral steroids — Oral steroids (eg, prednisone) occasionally are used for a short period of time to treat a severe flare of eczema, although this treatment is not usually recommended on a regular basis or for prolonged periods of time because of potential side effects.

Ultraviolet light therapy (phototherapy) — Ultraviolet light therapy (also called phototherapy) can effectively control eczema. However, this therapy is expensive and may increase your risk of skin cancer, and is therefore recommended only for people with severe eczema whose symptoms do not respond to other treatments.

Injectable medications — The injectable "biologic" medication dupilumab (brand name: Dupixent) may be beneficial for treating eczema. Due to its high cost and potential side effects, this drug is reserved for adults and children aged six years and older with moderate to severe eczema that has not responded to other treatments.

Other similar medications are also being studied.

Immunosuppressive drugs — Drugs that weaken the immune system may be recommended for people with severe eczema who do not improve with other treatments. However, treatment with these drugs can cause serious side effects, including an increased risk for infection. They are not recommended for use in infants or young children.

Relieving itching

Oral antihistamines — Oral antihistamines sometimes help relieve the itching of eczema. The over-the-counter antihistamine diphenhydramine (sample brand name: Benadryl) and prescription antihistamines, such as hydroxyzine (sample brand names: Vistaril, Atarax) and cyproheptadine, cause drowsiness; these may be especially beneficial for people who have trouble sleeping due to itching.

The nonsedating antihistamines such as cetirizine (brand name: Zyrtec) and loratadine (sample brand names: Alavert, Claritin) may relieve itching; both are available without a prescription in the United States and cause less drowsiness.

Wet dressings — Wet dressings (wet wraps) help soothe and hydrate the skin, reduce itching and redness, loosen crusted areas, and prevent skin injury due to scratching. Dampened cotton garments (eg, gauze) may be worn over the affected area and covered with a dry garment. You can wear these dressings for a few days, overnight, or during the day (change to a fresh dressing every eight hours).

Mood problems — Talk to your health care provider if your eczema is making you feel anxious or depressed. There are treatments that can help with this.

CAN ECZEMA BE PREVENTED? — Experts don't know if there is a way to prevent eczema. Babies who have a parent or sibling with eczema have a higher risk of developing eczema as well. For these babies, good skin care might be helpful, especially in cold or dry climates. Good skin care includes using moisturizing creams or ointments. However, doctors don't yet know if this actually helps prevent eczema later on.

If you do use cream or ointment on your newborn, it's important to wash your hands first. This helps lower the risk of getting germs on the baby's skin that could cause infection. It's also a good idea to use products that come in a tube instead of a jar that you dip your fingers in.

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Eczema (atopic dermatitis) (The Basics)
Patient education: Seborrheic dermatitis (The Basics)
Patient education: Giving your child over-the-counter medicines (The Basics)
Patient education: Melasma (The Basics)
Patient education: Peanut allergy (The Basics)
Patient education: Topical corticosteroid medicines (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Food allergy symptoms and diagnosis (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Approach to the patient with a scalp disorder
Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis
Introducing formula to infants at risk for allergic disease
Primary prevention of allergic disease: Maternal diet in pregnancy and lactation
The impact of breastfeeding on the development of allergic disease
Treatment of atopic dermatitis (eczema)
Management of severe atopic dermatitis (eczema) in children
Role of allergy in atopic dermatitis (eczema)

The following organizations also provide reliable health information.

National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

National Institute on Arthritis and Musculoskeletal and Skin Diseases

     (www.niams.nih.gov/health-topics/atopic-dermatitis)

American Academy of Dermatology

     (www.aad.org)

American Academy of Allergy, Asthma and Immunology

     (www.aaaai.org)

National Eczema Association

     (www.nationaleczema.org)

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This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2022 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.
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