Atopic Dermatitis or Eczema

What is atopic eczema?

Atopic eczema (sometimes called atopic dermatitis) is a frequent, long-lasting condition in which the skin becomes inflamed. Eczema is the term for dry, itchy, inflamed skin, which may crack, ooze or blister, or turn scaly, crusty and thick. The word atopic refers to a group of related conditions in which the immune system reacts more strongly than usual. These include eczema, asthma and hay fever.

Atopic eczema tends to come and go. Periods when the skin is calm are interrupted by flare-ups, sometimes with a clear trigger and sometimes without any obvious reason.

Who gets it?

Atopic eczema is very common. Around 20 in every 100 UK children have it at some stage, with boys and girls equally affected. It usually begins in the first few years of life. Many children improve as they grow up, and most are clear by their teenage years, but many continue to have dry, sensitive skin.

Eczema can also continue into adulthood, return after many years, or start for the first time as an adult. In adults it often affects the face, neck and hands, and it can be particularly troublesome for people whose work involves contact with water, cleaning products or other irritants.

What causes it?

Atopic eczema is caused by a combination of inherited and environmental factors. A key part of the problem is a weakened skin barrier. The outer layer of the skin normally acts like a wall, keeping water in and keeping irritants, allergens and germs out. In many people with eczema, a protein called filaggrin, which helps build this barrier, does not work properly because of changes in the gene that makes it.

A weaker barrier allows water to escape, so the skin becomes dry, and allows irritants and allergens to get in more easily, which triggers inflammation and itch. Scratching damages the barrier further, which makes the itch worse. This is often called the itch and scratch cycle.

What can make it worse?

Common triggers include soaps, shower gels, bubble baths and detergents; heat and sweating; woollen or rough clothing; dry or cold weather; dust and pets; being unwell, for example with a cold; and stress. In some people, allergens such as house dust mite, pollen or animal dander play a part. Food allergy can be a trigger in some young children but is a much less common factor in teenagers and adults.

Is it hereditary or contagious?

Atopic eczema runs in families, especially where other family members have eczema, asthma or hay fever. Roughly a third of children with atopic eczema go on to have asthma, hay fever, or both.

Eczema is not contagious. It cannot be caught from or passed on to another person.

What does it look and feel like?

The main symptom is itch, which can be intense. It is often worse at night and can disturb sleep, leading to tiredness, poor concentration and low mood. The skin usually feels dry, rough and sore, and scratching can cause bleeding and broken skin.

It can occur on any area of skin. It most commonly affects the creases of the elbows, behind the knees, the wrists, ankles and neck. It can also appear as coin-shaped patches (discoid eczema) or as many small bumps around hair follicles.

During a flare, the skin looks red on lighter skin tones. On brown and black skin, inflamed areas may look darker brown, purple or grey and the redness can be harder to see. After a flare settles, the skin can be left darker or lighter than the surrounding skin for some time. This is called post-inflammatory hyperpigmentation or hypopigmentation, and it usually fades gradually.

Active eczema can become wet and weepy. Small, itchy water blisters on the hands and feet are called pompholyx. When skin is scratched repeatedly over months or years, it can become thickened with exaggerated skin lines, which is called lichenification.

Complications

Eczema skin is more prone to infection. Bacterial infection, usually with Staphylococcus, can make the skin weepy, crusted with a golden or yellow crust, and more inflamed.

If the cold sore virus (herpes simplex) infects eczema, it can lead to a condition known as eczema herpeticum. This causes a sudden, painful flare with clusters of small, punched-out sores and sometimes fever and feeling unwell. Eczema herpeticum needs urgent medical assessment the same day.

Eczema can also have a significant effect on sleep, mood, confidence, work and relationships, and this deserves as much attention as the skin itself.

How is it diagnosed?

Atopic eczema is usually diagnosed from the history and the appearance of the skin. Blood tests and allergy tests are not usually needed. If eczema behaves unusually, for example affecting particular sites such as the eyelids or hands, or not responding as expected, an allergic contact dermatitis may be present as well, and patch testing can help identify the cause.

What are the treatment options?

Dr Mounsey has a special interest in eczema and its advanced treatment. He will assess how widespread and active your eczema is, look for triggers and infection, and consider patch testing if a contact allergy may be adding to the problem. Treatment usually starts with a tailored skin care routine using emollients and soap substitutes, alongside topical corticosteroids or calcineurin inhibitor creams such as tacrolimus, including a plan for using them proactively to keep flares at bay. For eczema that is not controlled with creams, options include phototherapy, immunosuppressant tablets such as ciclosporin or methotrexate, and advanced treatments, namely biologic injections and JAK inhibitor tablets. Dr Mounsey will explain the benefits and risks of each and arrange any monitoring needed.

What is the outlook?

There is no cure for atopic eczema, but it can be well controlled, and most people with eczema lead full, active lives. Understanding what makes your eczema worse is an important part of keeping it settled.

More information

British Association of Dermatologists patient leaflet: https://www.bad.org.uk/pils/atopic-eczema

This page gives general information only and is not a substitute for a consultation. Everyone's skin is different, and what is right for you will depend on your own circumstances. If you are worried about a skin problem, please book an appointment with Dr Mounsey or speak to your GP. If you have a mole or skin lesion that is changing, bleeding or growing quickly, please seek medical advice promptly.