Eczema (atopic dermatitis)

Eczema, or atopic dermatitis, is a chronic inflammatory skin condition that causes dry, itchy, and inflamed skin. It is common in children but can occur at any age and often follows a relapsing-remitting course. Eczema is linked to a skin-barrier defect and immune dysregulation and frequently coexists with asthma, allergic rhinitis, and food allergies (the “atopic march”).

Although eczema is not contagious, it can significantly affect sleep, comfort, and quality of life. Good daily skin care, trigger avoidance, and appropriate anti-inflammatory treatment keep most people well controlled. Newer targeted therapies have expanded options for moderate to severe disease.

Symptoms include:

• Dry, sensitive skin
• Intense itch (often worse at night)
• Red to brownish-gray patches, especially on the hands, feet, ankles, wrists, neck, upper chest, eyelids, and inside the bends of the elbows and knees
• Small, raised bumps that may leak fluid and crust when scratched
• Thickened, cracked, or scaly skin from chronic scratching (lichenification)
• Raw, sensitive skin from scratching

In infants, eczema often affects the face and extensor surfaces. In older children and adults, flexural areas are typical. Secondary bacterial or viral infection can cause sudden worsening, oozing, or crusting.

Atopic dermatitis results from a combination of genetic barrier defects (commonly filaggrin mutations), immune dysregulation (type 2 inflammation), and environmental triggers. A compromised barrier allows moisture loss and entry of irritants and allergens, which fuel itch and inflammation in a cycle.

Common triggers include dry air, harsh soaps, fragrances, wool, sweat, stress, infections, and allergens (dust mites, pollen, pet dander, certain foods in selected patients).

Risk factors include:

• Family history of eczema, asthma, or allergic rhinitis
• Personal history of asthma or allergies
• Living in urban or dry climates
• Young age (onset often in the first year of life)
• Belonging to certain ancestral groups with higher rates of filaggrin variants

Possible complications include:

• Skin infections (Staphylococcus aureus, herpes simplex — eczema herpeticum is an emergency)
• Neurodermatitis from chronic scratching
• Sleep disruption and impact on school or work
• Anxiety, depression, and social stigma
• Eye problems (conjunctivitis, keratitis) if the eyelids are chronically involved
• Contact dermatitis from topical products

Flares can often be reduced by:

• Daily moisturizing with fragrance-free creams or ointments
• Short, lukewarm baths or showers with gentle cleansers
• Immediate moisturizing after bathing
• Identifying and avoiding personal triggers
• Using a humidifier in dry environments
• Wearing soft, breathable fabrics (cotton)
• Managing stress and treating infections promptly

Diagnosis is clinical, based on history and appearance. Features that support atopic dermatitis include chronic or relapsing course, itch, typical distribution, early age of onset, and personal or family atopy. Skin biopsy or patch testing is sometimes used to exclude other conditions or identify contact allergens. Allergy testing is not routinely required for diagnosis but may help selected patients with suspected food or environmental triggers.

See a clinician if the rash is widespread, painful, infected-looking, interferes with sleep, or does not improve with consistent moisturizing and over-the-counter hydrocortisone used as directed. Infants with significant eczema and anyone with eye involvement or suspected infection need prompt care.

A stepwise approach is used:

Foundation — liberal emollients, gentle bathing, trigger avoidance.

Topical anti-inflammatory therapy

• Corticosteroids of appropriate potency for the site and severity
• Calcineurin inhibitors (tacrolimus, pimecrolimus)
• PDE4 inhibitor (crisaborole) and topical JAK inhibitors in selected cases

Phototherapy for widespread disease not controlled topically.

Systemic therapy for moderate to severe disease:

• Dupilumab and other biologics targeting type 2 inflammation
• Oral JAK inhibitors (with appropriate safety monitoring)
• Older immunosuppressants (cyclosporine, methotrexate, etc.) in some settings
• Short courses of oral corticosteroids only for severe acute flares (not for long-term use)

Treat secondary infection when present. Wet-wrap therapy can help severe flares under guidance.

Daily habits that help:

• Moisturize at least twice daily and after every bath
• Use prescribed topicals on active areas as directed (not just on “bad days” when proactive therapy is recommended)
• Keep nails short to reduce damage from scratching
• Choose fragrance-free laundry and skin products
• Manage itch with cool compresses, moisturizers, and medicines as prescribed
• Seek support for sleep and emotional impact

Bring:

• History of when the rash started, sites involved, and previous treatments
• List of all skin products and medicines
• Notes on suspected triggers
• Personal and family history of atopy
• Questions about topical potency, proactive therapy, and options if topical treatment is not enough