Atopic Eczema

Atopic eczema (atopic dermatitis) is the most common form of eczema, a condition that causes the skin to become itchy, red, dry and cracked.

Atopic eczema is more common in children, often developing before their first birthday. However, it may also develop for the first time in adults.

It's usually a long-term (chronic) condition, although it can improve significantly, or even clear completely, in some children as they get older.

Symptoms of atopic eczema

Atopic eczema causes areas of skin to become itchy, dry, cracked, sore and red.

There are usually 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 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 eventually returns to its normal colour.

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

Signs of an infection

Occasionally, areas of skin affected by atopic eczema can become infected. Signs of an infection can include:

• 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

See your doctor as soon as possible if you think your or your child's skin may have become infected.

When to seek medical advice

See your GP if you have symptoms of atopic eczema. They'll usually be able to diagnose atopic eczema by looking at your skin and asking questions such as:

• whether the rash is itchy and where it appears
• when the symptoms first began
• whether it comes and goes over time
• whether there's a history of atopic eczema in your family
• whether you have any other conditions, such as allergies or asthma
• whether something in your diet or lifestyle may be contributing to your symptoms

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:

• 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)

Causes of atopic eczema

The exact cause of atopic eczema is unknown, but it's clear it is not down to one single thing. Atopic eczema 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.

You may be asked to keep a food diary to try to determine whether a specific food makes your symptoms worse. Allergy tests aren't usually needed, although they're sometimes helpful in identifying whether a food allergy may be triggering symptoms.

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 isn't infectious, so it can't be passed on through close contact.

Eczema triggers

There are a number of things that may trigger your eczema symptoms. These can vary from person to person.

Common triggers include:

• 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
• skin infections

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're diagnosed with atopic eczema, your GP will work with you to try to identify any triggers for your symptoms.

Treating atopic eczema 

Treatment for atopic eczema can help to relieve the symptoms and many cases improve over time.

However, there's currently no cure and severe eczema often has a significant impact on daily life, which may be difficult to cope with physically and mentally. There's 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

Treatments for atopic eczema can help to ease the symptoms. There's no cure, but many children find their symptoms naturally improve as they get older.

The main treatments for atopic eczema are:

• 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

Other treatments include:

• topical pimecrolimus or tacrolimus for eczema in sensitive sites not responding to simpler treatment
• antihistamines for severe itching
• bandages or special body suits to allow the body to heal underneath
• more powerful treatments offered by a dermatologist (skin specialist)

The various treatments for atopic eczema are outlined below. You can also read a summary of the pros and cons of the treatments for atopic eczema, allowing you to compare your treatment options.

Self care

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.

Avoid triggers

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:

• 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

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's no clear evidence that it helps.

Read more about preventing allergies.

Dietary changes

Some foods, such as eggs and cows' milk, can trigger eczema symptoms. However, you shouldn't 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 a food allergy, you may be referred to a dietitian (a specialist in diet and nutrition). They can help to 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're breastfeeding a baby with atopic eczema, get medical advice before making any changes to your regular diet.

Emollients

Emollients are moisturising treatments applied directly to the skin to reduce water loss and cover it with a protective film. They're 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:

• 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

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've 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're 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:

• use a large amount
• don't rub it in – smooth it into the skin in the same direction the hair grows
• 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

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 aren't 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.

Topical corticosteroids

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)
• 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're 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 only have to apply it once a day as there's no evidence there is any benefit to applying it more often.

When using a topical corticosteroid:

• 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

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.

Side effects

Topical corticosteroids may cause a mild stinging sensation for less than a minute as you apply them.

In rare cases, they may also cause:

• 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

Most of these side effects will improve once treatment stops.

Your risk of side effects may be increased if you use a strong topical corticosteroid:

• for many months
• in sensitive areas such as the face, armpits or groin
• in large amounts

You should be prescribed the weakest effective treatment to control your symptoms.

Antihistamines 

Antihistamines are a type of medicine that block 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

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'll 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 isn't controlling your eczema
• your eczema is affecting your daily life
• it's not clear what's causing it

A dermatologist may be able to offer the following:

• allergy testing
• 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 and tacrolimus
• 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

A dermatologist may also offer additional support to help you use your treatments correctly, such as demonstrations from specialist nurses, and they may be able to refer you for psychological support if you feel you need it.

Complementary therapies

Some people may find complementary therapies such as herbal remedies helpful in treating their eczema, but there's little evidence to show these remedies are effective.

If you're 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

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's a risk of the skin becoming infected with bacteria. The risk is higher if you scratch your eczema or don't 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'll usually prescribe antibiotics 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 suspect eczema herpeticum. If you can't contact your GP, call NHS 111 or go to your nearest hospital.

If you're diagnosed with eczema herpeticum, you'll be given an antiviral medication called aciclovir.

Psychological effects

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 don't have the condition. They're also more likely to be more dependent on their parents.

Bullying

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're feeling.

The National Eczema Society provides information about regional support groups, where you may be able to meet other people living with atopic eczema.

You can also read more about bullying.

Problems sleeping

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.

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 GP if you're concerned your child's eczema is severely affecting their confidence. They may benefit from specialist psychological support.

Case Study 1 - 'I hope she'll grow out of the eczema'

Ruby was diagnosed with eczema at six weeks old. Her mum, Daniella, explains how they've learned to cope with Ruby's condition.

"At only 10 days old, Ruby developed a rash all over her, a bit like teenage spots with white pimples. Doctors thought it was her sebaceous glands not working properly and said it would go away. It did. 

"However, as there's a history of eczema in my husband's family and mine, and it's a hereditary condition, I always thought she would develop it.

"Doctors tell me not to use any of the commonly marketed baby products, perfumed products, or soap. Now, her treatment involves two baths daily using oil. Before the bath, I also cover her body in aqueous cream. I wash her body with a flannel rather than a sponge because flannels can be washed daily.

"She doesn't sleep with many cuddly toys in her cot as they can carry dust, and I don't let her near animals as they can irritate and aggravate her skin.

"Some foods have had an effect on her skin, too, so I have to make sure she doesn't eat them and other people don't give them to her. I also have to be careful with sun lotions and not to let her go in the sun too often.

"At its worst, the eczema on her right arm became infected, and her skin went yellow and filled with pus. We quickly took her to the GP and she was put on antibiotics.

"I spoke to the nurses at the hospital, who suggested trying a wet wrapping with some support, which is like a sports bandage, but I decided to cover the arm in moisturiser with a dry bandage over the top to try to stop her scratching in the night.

"You can't really stop a baby from scratching. You can distract them where possible and keep them occupied, keep their nails short by trimming them morning and night, and, as a last resort, I keep Ruby in long sleeves and cover her arms in a wet wrap.

"Once I was driving home in the evening after Ruby's normal bath time and she was tired and irritable. I noticed in my rear mirror that she was scratching and scratching, and her arm was bleeding. I was stuck in traffic and still far from home, so the best I could do was to sing songs to try to distract her. That was the hardest incident.

"I hope she will grow out of the eczema. I grew out of it and so did other members of my family. However, some of the people on my husband's side of the family still have it in their old age."

Case Study 2 - 'A lot of things work for a while, then lose their effectiveness'

Having battled against eczema for most of his life, John Fuller has tried just about every treatment option available.

John's eczema began when he was a baby. "It was always there as far back as I can remember," he says. "My skin would turn red raw and I would scratch and scratch. We tried everything from creams to salt baths. I have a very strong memory of sitting for ages in a salt bath because our GP suggested it. Luckily, I wasn't bullied for having eczema like many children seem to be."

When John was 11, the family went to Barbados for a holiday. While they were there, they discovered the aloe vera plant.

"Someone suggested it might help my eczema and we were ready to try anything. Aloe vera is everywhere now, but back then nobody had heard of it. When we got back, we started growing it in our garden. I'd have to rub the plant juice all over me. Amazingly, the eczema cleared up for the next nine years."

John hoped he'd grown out of the condition. However, his eczema came back when he was finishing university. "The redness and the itching began again," he says. "Soon it was all over my arms and legs, and it's been there ever since."

John says he's tried every treatment going, including steroid pills and creams, and cyclosporin, a strong drug used mainly to stop transplant patients rejecting their new organs. It works by damping down the immune system.

"That was effective for a couple of years but it can damage your internal organs, so you can't stay on a high dose for too long," he explains. "I had to have regular blood tests to make sure everything was working properly, and eventually had to go on such a low dose that it wasn't worth it.

"I've been in hospital three times. In hospital you get the same treatment that you do at home, but it's more intensive and it's also cleaner."

He has also experimented with complementary therapies. "I went to a Chinese herbalist, who gave me some disgusting-tasting tea to drink every night," he says. "For a while, it seemed to work. Then the eczema came back. I found a lot of things work for a while but then lose their effectiveness."

John tries his best to live a normal life, but says it's not easy. "When the itching is really bad, it's very hard to concentrate at work," he says. "Sometimes I have to take time off. Employers don't like that, and it has an impact on everyone I work with. Sometimes sleeping is just impossible and that affects my daily life as well. I love playing cricket but direct sunlight turns me bright red. I look like a tomato."

John is resigned to living with his condition, but he still has hope. "Nobody knows why I have eczema and as yet there's no cure, but you never know. One day I could wake up and the eczema will be gone. Until then, I have to make do with the treatments we have."