DefinitionAtopic dermatitis is a long-term (chronic) skin disorder that involves scaly and itchy rashes. See also:Contact dermatitisDyshidrotic eczemaNummular eczemaSeborrheic dermatitis
Alternative NamesInfantile eczema; Dermatitis - atopic; Eczema
Causes, incidence, and risk factorsAtopic dermatitis is due to a hypersensitivity reaction (similar to an allergy) in the skin, which leads to long-term swelling and redness (inflammation) of the skin. People with atopic dermititis may lack certain proteins in the skin, which leads to greater sensitivity.Atopic dermatitis is most common in infants. It may start as early as age 2 to 6 months. Many people outgrow it by early adulthood. People with atopic dermatitis often have asthma or seasonal allergies. There is often a family history of allergic conditions such as asthma, hay fever, or eczema. People with atopic dermatitis often test positive to allergy skin tests.However, atopic dermatitis is not caused by allergies. The condition tends to get worse when the person is exposed to certain triggers. The following can make atopic dermatitis symptoms worse:Allergies to pollen, mold, dust mites, or animalsCold and dry air in the winterColds or the fluContact with irritants and chemicalsContact with rough materials, such as woolDry skinEmotions and stress Exposure to too much water, such as taking too many baths or showers and swimming too oftenFeeling too hot or too cold, as well as sudden temperature changesFragrances or dyes added to skin lotions or soaps
SymptomsTypical skin changes may include:Blisters with oozing and crustingDry skin all over the body or areas of bumpy skin on the back of the arms and front of the thighsEar discharge or bleedingRaw areas of the skin from scratchingSkin coloring changes -- more or less color than the normal skin tone (See: Skin abnormally dark or light)Skin redness or inflammation around the blistersThickened or leather-like areas, called lichenification, which can occur after long-term irritation and scratchingBoth the type of rash and where the rash appears can depend on the age of the patient:In children younger than age 2, skin lesions begin on the face, scalp, hands, and feet. They are often crusting, bubbling, or oozing rashes that itch.In older children and adults, the rash is more commonly seen on the inside of the knees and elbows, as well as the neck, hands, and feet.During a severe outbreak, rashes may occur anywhere on the body.Itching, which is sometimes intense, almost always occurs. Itching may start even before the rash appears. Atopic dermatitis is often called the "itch that rashes" because the itching starts, and then the skin rash appears from the scratching.
Signs and testsA physical exam will be done. A skin biopsy can be done to confirm the diagnosis or rule out other causes of dry, itchy skin.Diagnosis is based on the:Appearance of the skinPersonal and family historyAllergy skin testing may be helpful for people with:Hard-to-treat atopic dermatitisOther allergy symptomsSkin rashes that form only on certain areas of the body after exposure to a specific chemical
TreatmentSKIN CARE AT HOMETaking care of your skin at home may reduce the need for medications.Avoid scratching the rash or skin:Relieve the itch by using a moisturizer, topical steroid cream, or other prescribed cream and taking antihistamines to reduce severe itching.Keep your child's fingernails cut short. Consider light gloves if nighttime scratching is a problem.Keep the skin moist (called lubricating or moisturizing the skin). Use ointments (such as petroleum jelly), creams, or lotions 2 - 3 times a day. Moisturizers should be free of alcohol, scents, dyes, fragrances, or other chemicals. A humidifier in the home will also help.Avoid anything that makes your symptoms worse. This may include:Foods such as eggs in a very young child (always discuss with your doctor first)Irritants such as wool and lanolinStrong soaps or detergents, as well as chemicals and solventsSudden changes in body temperature and stress, which may cause sweating and worsen the conditionTriggers that cause allergy symptomsWhen washing or bathing:Keep water contact as brief as possible and use gentle body washes and cleansers instead of regular soaps. Short, cooler baths are better then long, hot baths.Do not scrub or dry the skin too hard or for too long.After bathing, it is important to apply lubricating creams, lotions, or ointment on the skin while it is damp. This will help trap moisture in the skin.MEDICATIONSAt this time, allergy shots are not used to treat atopic dermatitis, although there is evidence that they may benefit certain adults with atopic dermatitis.Antihistamines taken by mouth may help with itching or if you have allergies. Often you can buy them without a prescription.Some antihistamines can cause sleepiness, but they may help with scratching while sleeping.Newer antihistamines cause little or no sleepiness. Some are available over the counter. These medications include fexofenadine (Allegra), loratadine (Claritin, Alavert), and cetirizine (Zyrtec).Most causes of atopic dermatitis are treated with medications that are placed directly on the skin or scalp (called topical medicines):At first, you will probably be prescribed a mild cortisone (or steroid) cream or ointment. If this doesn't work, you may need a stronger steroid medicine. You may need different strengths of steroids for different areas of skin.Medicines called topical immunomodulators (TIMs) may be prescribed for anyone over 2 years old. TIMs include tacrolimus (protopic) and pimecrolimus (Elidel). Ask your doctor about concerns over a possible cancer risk with the use of these medicines.Creams or ointments that contain coal tar or anthralin may be used for thickened areas.Barrier repair creams containing ceramidesWet-wrap treatment with topical corticosteroids has been shown effective for atopic dermatitis, although it can have side effects such as infection.Other treatments that may be used include:Antibiotic creams or pills if the skin is infectedDrugs that suppress the immune system, such as cyclosporine, methotrexate, or mycophenolate mofetilPhototherapy, a medical treatment in which your skin is carefully exposed to ultraviolet (UV) light
Expectations (prognosis)Atopic dermatitis is a long-term condition, but you can control it with treatment, by avoiding irritants, and by keeping the skin well-moisturized.In children, the condition often clears beginning at around age 5 - 6, but flare-ups will often occur. In adults, it is generally a long-term or returning condition.Atopic dermatitis may be harder to control if it:Began at an early ageInvolves a large amount of the bodyOccurs along with allergic rhinitis and asthmaOccurs in someone with a family history of eczema
ComplicationsInfections of the skin caused by bacteria, fungi, or virusesPermanent scars
Calling your health care providerCall for an appointment with your health care provider if:Atopic dermatitis does not respond to moisturizers or avoiding allergensSymptoms get worse or treatment does not workYou have signs of infection (such as fever, redness, or pain)
PreventionStudies have shown that children who are breast-fed until age 4 months are less likely to get atopic dermatitis.If the child is not breast-fed, using a formula that contains processed cow milk protein (called partially hydrolyzed formula) may decrease the chances of developing atopic dermatitis.
ReferencesExcema and hand dermatitis. In: Habif TP, ed. Clinical Dermatology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2009:chap 3.Atopic dermatitis. In: Habif TP, ed. Clinical Dermatology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2009:chap 5.Greer FR, Sicherer SH, Burks, W and the Committee on Nutrition and Section on Allergy and Immunology. Effects of early nutritional interventions on the development of atopic disease in infants and children: The role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008;121:183-191.Lewis-Jones S, Mugglestone MA; Guideline Development Group. Management of atopic eczema in children aged up to 12 years: summary of NICE guidance. BMJ. 2007;335:1263-1264.Ascroft DM, Chen LC, Garside R, Stein K, Williams HC. Topical pimecrolimus for eczema. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005500.Bath-Hextall FJ, Delamere FM, Williams HC. Dietary exclusions for established atopic eczema. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD005203.