Eczema – Atopic eczema
Atopic eczema, also known as atopic dermatitis, is the most common form of eczema. It mainly affects children, but can also affect adults.
Eczema is a condition that causes the skin to become itchy, red, dry and cracked. It is a long-term (chronic) condition in most people, although it can improve over time, especially in children.
Atopic eczema can affect any part of the body, but the most common areas to be affected are:
backs or fronts of the knees
outside or inside of the elbows
around the neck
People with atopic eczema usually have periods when symptoms are less noticeable, as well as periods when symptoms become more severe (flare-ups).
What causes atopic eczema?
The exact cause of atopic eczema is unknown, but it's clear it's not down to one single thing. It often occurs in people who get allergies – "atopic" means sensitivity to allergens.
It can run in families, and often develops alongside other conditions, such as asthma and hay fever.
The symptoms of atopic eczema often have certain triggers, such as soaps, detergents, stress and the weather. Sometimes food allergies can play a part, especially in young children with severe eczema.
Treating atopic eczema
There is currently no cure for atopic eczema, but treatment can help relieve the symptoms and many cases improve over time.
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 skin infections.
Many different treatments can be used to control symptoms and manage eczema, including:
self care techniques, such as reducing scratching and avoiding triggers
emollients (moisturising treatments) – used on a daily basis for dry skin
topical corticosteroids – used to reduce swelling, redness and itching during flare-ups
Who is affected?
About one in five children in the UK has atopic eczema. In 8 out of 10 cases, the condition develops before a child reaches the age of five. Many children develop it before their first birthday.
Atopic eczema can improve significantly, or even clear completely, in some children as they get older. About half of all cases improve a lot by the time a child reaches 11 years, and around two-thirds improve by the age of 16.
However, the condition can continue into adulthood and can sometimes develop for the first time in adults.
Other types of eczema
Eczema is the name for a group of skin conditions that cause dry, irritated skin. Other types of eczema include:
discoid eczema – a type of eczema that occurs in circular or oval patches on the skin
contact dermatitis – a type of eczema that occurs when the body comes into contact with a particular substance
varicose eczema – a type of eczema that most often affects the lower legs and is caused by problems with the flow of blood through the leg veins
seborrhoeic eczema – a type of eczema where red, scaly patches develop on the sides of the nose, eyebrows, ears and scalp
dyshidrotic eczema (pompholyx) – a type of eczema that causes tiny blisters to erupt across the palms of the hands
Symptoms of atopic eczema
Atopic eczema causes areas of skin to become itchy, dry, cracked, sore and red.
There will usually be periods where the symptoms improve, followed by periods where they get worse (flare-ups). Flare-ups may occur as often as two or three times a month.
Atopic eczema can occur all over the body, but is most common on the hands (especially fingers), the insides of the elbows or backs of the knees, and the face and scalp in children. The face is more commonly involved in adults.
The severity of atopic eczema can vary a lot from person to person. People with mild eczema may only have small areas of dry skin that are occasionally itchy. In more severe cases, atopic eczema can cause widespread red, inflamed skin all over the body and constant itching.
Scratching can disrupt your sleep, make your skin bleed, and cause secondary infections. It can also make itching worse, and a cycle of itching and regular scratching may develop. This can lead to sleepless nights and difficulty concentrating at school or work.
Areas of skin affected by eczema may also turn temporarily darker or lighter after the condition has improved. This is more noticeable in people with darker skin. It's not a result of scarring or a side effect of steroid creams, but more of a "footprint" of old inflammation and will eventually return to its normal colour.
Signs of an infection
Occasionally, areas of skin affected by atopic eczema can become infected. Signs of an infection can include:
See your doctor as soon as possible if you think your or your child's skin may have become infected.
your eczema getting a lot worse
fluid oozing from the skin
a yellow crust on the skin surface or small yellowish-white spots appearing in the eczema
the skin becoming swollen and sore
a high temperature (fever) and generally feeling unwell
Causes of atopic eczema
Atopic eczema is likely to be caused by a combination of things.
People with atopic eczema often have very dry skin because their skin is unable to retain much moisture.
This dryness may make the skin more likely to react to certain triggers, causing it to become red and itchy.
You may be born with an increased likelihood of developing atopic eczema because of the genes you inherit from your parents.
Research has shown children who have one or both parents with atopic eczema, or who have other siblings with eczema, are more likely to develop it themselves.
Atopic eczema is not infectious, so it cannot be passed on through close contact.
There are a number of things that may trigger your eczema symptoms. These can vary from person to person.
Common triggers include:
Some people also report their symptoms get worse when the air is dry or dusty, or when they are stressed, sweaty, or too hot or too cold.
If you are diagnosed with atopic eczema, your GP will work with you to try to identify any triggers for your symptoms.
irritants – such as soaps and detergents, including shampoo, washing-up liquid and bubble bath
environmental factors or allergens – such as cold and dry weather, dampness, and more specific things such as house dust mites, pet fur, pollen and moulds
food allergies – such as allergies to cows' milk, eggs, peanuts, soya or wheat
certain materials worn next to the skin – such as wool and synthetic fabrics
hormonal changes – women may find their symptoms get worse in the days before their period or during pregnancy
Diagnosing atopic eczema
Your GP will usually be able to diagnose atopic eczema by looking at your skin and asking questions about your symptoms.
These questions may include asking:
You should tell your GP if your condition is affecting your quality of life – for example, if you have difficulty sleeping because of itching, or your eczema limits your everyday activities.
Checklist for diagnosing atopic eczema
Typically, to be diagnosed with atopic eczema you should have had an itchy skin condition in the last 12 months and three or more of the following:
Your GP should work with you to establish if any 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 some soaps or shampoos make the eczema worse.
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 GP can then use the diary to see if there is a pattern between your symptoms and what you eat.
Allergy tests are not usually needed to identify triggers, although they are sometimes helpful in identifying food allergies that may be triggering symptoms in young children or in those where a food allergy is suspected.
whether the rash is itchy and where it appears
when the symptoms first began
whether it comes and goes over time
whether there is a history of atopic eczema in your family
whether you have any other conditions, such as allergiesor asthma
visibly irritated red skin in the creases of your skin, such as the insides of your elbows or behind your knees (or on the cheeks, outsides of elbows, or fronts of the knees in children aged 18 months or under) at the time of examination by a health professional
a history of skin irritation occurring in the same areas mentioned above
generally dry skin in the last 12 months
a history of asthma or hay fever – children under four must have an immediate relative, such as a parent, brother or sister, who has one of these conditions
the condition started before the age of two (this does not apply to children under the age of four)
Treating atopic eczema
There is no cure for atopic eczema, but treatments can ease the symptoms. Many children find their symptoms naturally improve as they get older.
The main treatments for atopic eczema are:
Other treatments include topical pimecrolimus or tacrolimus for eczema in sensitive sites not responding to simpler treatment, antihistaminesfor severe itching, bandages or special body suits to allow the body to heal underneath, or more powerful treatments offered by a dermatologist (skin specialist).
Read on to learn about the different treatments you may be offered. You can also read a summary of the pros and cons of these, allowing you to compare your treatment options.
As well as the treatments mentioned above, there are things you can do yourself to help ease your symptoms and prevent further problems.
Try to reduce the damage from scratching
Eczema is often itchy and it can be very tempting to scratch the affected areas of skin. But scratching usually damages the skin, which can itself cause more eczema to occur.
The skin eventually thickens into leathery areas as a result of chronic scratching. Deep scratching also causes bleeding and increases the risk of your skin becoming infected or scarred.
Try to reduce scratching whenever possible. You could try gently rubbing your skin with your fingers instead. If your baby has atopic eczema, anti-scratch mittens may stop them scratching their skin.
Keep your nails short and clean to minimise damage to the skin from unintentional scratching. Keep your skin covered with light clothing to reduce damage from habitual scratching.
Your GP 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 your triggers, you can try to avoid them. For example:
Although some people with eczema are allergic to house dust mites, trying to rid your home of them isn't recommended as it can be difficult and there is no clear evidence that it helps.
Some foods, such as eggs and cows' milk, can trigger eczema symptoms. However, you should not make significant changes to your diet without first speaking to your GP.
It may not be healthy to cut these foods from your diet, especially in young children who need the calcium, calories and protein from these foods.
If your GP suspects you have a food allergy, you may be referred to a dietitian (a specialist in diet and nutrition), who can help work out a way to avoid the food you're allergic to while ensuring you still get all the nutrition you need.
Alternatively, you may be referred to a hospital specialist such as an immunologist, dermatologist or paediatrician.
If you are breastfeeding a baby with atopic eczema, get medical advice before making any changes to your regular diet.
Emollients are moisturising treatments applied directly to the skin to reduce water loss and cover it with a protective film. They are often used to help manage dry or scaly skin conditions such as atopic eczema.
In addition to making the skin feel less dry, they may also have a mild anti-inflammatory role, and can help reduce the number of flare-ups you have.
Choosing an emollient
Several different emollients are available. You may need to try a few to find one that works for you. You may also be advised to use a mix of emollients, such as:
The difference between lotions, creams and ointments is the amount of oil they contain. Ointments contain the most oil so they can be quite greasy, but are the most effective at keeping moisture in the skin.
Lotions contain the least amount of oil so are not greasy, but can be less effective. Creams are somewhere in between.
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 is the case, your GP will be able to prescribe another product that suits you better. The best emollient is the one you feel happy using every day.
How to use emollients
Use your emollient all the time, even if you are not experiencing symptoms. Many people find it helpful to keep separate supplies of emollients at work or school, or a tub in the bathroom and one in a living area.
To apply the emollient
You should use an emollient at least twice a day if you can, or more often if you have very dry skin.
During a flare-up, apply generous amounts of emollient more frequently, but remember to treat inflamed skin with a topical corticosteroid as emollients used on their own are not enough to control it.
Don't put your fingers into an emollient pot – use a spoon or pump dispenser instead, as this reduces the risk of infection. And never share your emollient with other people.
If your skin is sore and inflamed, your GP may prescribe a topical corticosteroid (applied directly to your skin), which can reduce the inflammation within a few days.
Topical corticosteroids can be prescribed in different strengths, depending on the severity of your atopic eczema and the areas of skin affected.
They can be very mild (such as hydrocortisone), moderate (such as clobetasone butyrate), or even stronger (such as mometasone).
If you need to use corticosteroids frequently, see your GP regularly so they can check the treatment is working effectively and you are using the right amount.
How to use topical corticosteroids
Don't be afraid to apply the treatment to affected areas to control your eczema. Unless instructed otherwise by your doctor, follow the directions on the patient information leaflet that comes with your medication. This will give details of how much to apply.
Most people will only have to apply it once a day as there is no evidence there is any benefit to applying it more often.
When using a topical corticosteroid:
Occasionally, your doctor may suggest using a topical corticosteroid less frequently, but over a longer period of time. This is designed to help prevent flare-ups.
This is sometimes called "weekend treatment", where a person who has already gained control of their eczema uses the topical corticosteroid every weekend on the trouble sites to prevent them becoming active again.
Topical corticosteroids may cause a mild stinging sensation for less than a minute as you apply them.
In rare cases, they may also cause:
Most of these side effects will improve once treatment stops.
Generally, using a strong topical corticosteroid for many months, using them in sensitive areas such as the face, armpits or groin, or using a large amount will increase your risk of side effects. For this reason, you should be prescribed the weakest effective treatment to control your symptoms.
Antihistamines are a type of medicine that blocks the effects of a substance in the blood called histamine. They can help relieve the itching associated with atopic eczema.
They can either be sedating, which cause drowsiness, or non-sedating. If you have severe itching, your GP may suggest trying a non-sedating antihistamine.
If itching during a flare-up affects your sleep, your GP may suggest taking a sedating antihistamine. Sedating antihistamines can cause drowsiness into the following day, so it may be helpful to let your child's school know they may not be as alert as normal.
Bandages and wet wraps
In some cases, your GP may prescribe special medicated bandages, clothing or wet wraps to wear over areas of skin affected by eczema.
These can either be used over emollients or with topical corticosteroids to prevent scratching, allow the skin underneath to heal, and stop the skin drying out.
Corticosteroid tablets are rarely used to treat atopic eczema nowadays, but may occasionally be prescribed for short periods of five to seven days to help bring particularly severe flare-ups under control.
Longer courses of treatment are generally avoided because of the risk of potentially serious side effects.
If your GP thinks your condition may be severe enough to benefit from repeated or prolonged treatment with corticosteroid tablets, they will probably refer you to a specialist.
Seeing a specialist
In some cases, your GP may refer you to a specialist in treating skin conditions (dermatologist).
You may be referred if your GP is not sure what type of eczema you have, normal treatment is not controlling your eczema, your eczema is affecting your daily life, or it's not clear what is causing it.
A dermatologist may be able to offer the following:
A dermatologist may also offer additional support to help you use your treatments correctly, such as demonstrations from nurse specialists, and they may be able to refer you for psychological support if you feel you need it.
Some people may find complementary therapies such as herbal remedies helpful in treating their eczema, but there is little evidence to show these remedies are effective.
If you are thinking about using a complementary therapy, speak to your GP first to ensure the therapy is safe for you to use. Make sure you continue to use other treatments your GP has prescribed.
Complications of atopic eczema
People with atopic eczema can sometimes develop further physical and psychological problems.
Bacterial skin infections
As atopic eczema can cause your skin to become cracked and broken, there is a risk of the skin becoming infected with bacteria. The risk is higher if you scratch your eczema or do not use your treatments correctly.
Signs of a bacterial infection can include:
fluid oozing from the skin
a yellow crust on the skin surface
small yellowish-white spots appearing in the eczema
the skin becoming swollen and sore
a high temperature (fever) and generally feeling unwell
Your normal symptoms may also get rapidly worse and your eczema may not respond to your regular treatments.
You should see your doctor as soon as possible if you think your or your child's skin may have become infected.
They will usually prescribe antibiotic tablets, capsules or cream to treat the infection, as well as making sure the skin inflammation that led to the infection is well controlled.
Speak to your GP if these don't help or your symptoms get worse.
Once your infection has cleared, your GP will prescribe new supplies of any creams and ointments you're using to avoid contamination. Old treatments should be disposed of.
Viral skin infections
It's also 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 small, shallow 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 are diagnosed with eczema herpeticum, you will be given an antiviral medication called aciclovir.
As well as affecting you physically, atopic eczema may also affect you psychologically.
Preschool children with atopic eczema may be more likely to have behavioural problems such as hyperactivity than children who do not have the condition. They are also more likely to be more dependent on their parents.
Schoolchildren 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.
The National Eczema Society provides information about regional support groups, where you may be able to meet other people living with atopic eczema.
Sleep-related problems are common among people with eczema.
A lack of sleep may affect mood and behaviour. It may also make it more difficult to concentrate at school or work.
If your child has problems sleeping because of their eczema, they may fall behind with their schoolwork. It might help to let their teacher know about their condition so it can be taken into consideration.
During a severe eczema flare-up, your child may need time off from school. This may also affect their ability to keep up with their studies.
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 GP if you are concerned your child's eczema is severely affecting their confidence. They may benefit from specialist psychological support.
emollients (moisturisers) – used every day to stop the skin becoming dry
topical corticosteroids – creams and ointments used to reduce swelling and redness during flare-ups
if certain fabrics irritate your skin, avoid wearing these and stick to soft, fine-weave clothing or natural materials such as cotton
if heat aggravates your eczema, keep the rooms in your home cool, especially the bedroom
avoid using soaps or detergents that may affect your skin – use soap substitutes instead
an ointment for very dry skin
a cream or lotion for less dry skin
an emollient to use instead of soap
an emollient to add to bath water or use in the shower
one emollient to use on your face and hands, and a different one to use on your body
use a large amount
don't rub it in – smooth it into the skin in the same direction the hair grows instead
after a bath or shower, gently pat the skin dry and apply the emollient while the skin is still moist to keep the moisture in
apply your emollient first and ideally wait around 30 minutes until the emollient has soaked into your skin, or apply the corticosteroid at a different time of day (such as at night)
apply the recommended amount of the topical corticosteroid to the affected area
continue to use it until 48 hours after the flare-up has cleared so the inflammation under the skin surface is treated
thinning of the skin – especially if the strong steroids are used in the wrong places, such as the face, for too long (for example, several weeks)
changes in skin colour – usually, skin lightening after many months of using very strong steroids, but most lightening after eczema is a "footprint" of old inflammation and nothing to do with treatments
acne (spots) – especially when used on the face in teenagers
increased hair growth
a thorough review of your existing treatment – to make sure you are using enough of the right things at the right times
topical calcineurin inhibitors – creams and ointments that suppress your immune system, such as pimecrolimus andtacrolimus
very strong topical corticosteroids
bandages or wet wraps
phototherapy – ultraviolet (UV) light that reduces inflammation
immunosuppressant tablets – to suppress your immune system, such as azathioprine, ciclosporin and methotrexate
alitretinoin – medicine to treat severe eczema affecting the hands in adults
Eczema - Atopic eczema