One-liner#

Chronic, relapsing inflammatory skin disease characterized by intense pruritus and eczematous lesions, requiring a foundation of skin barrier repair with emollients, anti-inflammatory therapy for flares, and proactive maintenance to prevent recurrence.

Quick nav#

• Definition and epidemiology
• Pathophysiology
• Clinical presentation
• Diagnostic workup
• Treatment
• Patient education
• Prognosis and monitoring
• Special populations
• When to refer
• Smartphrase snippets
• Related pages

Definition and epidemiology#

Diagnostic criteria#

Clinical diagnosis based on Hanifin and Rajka criteria (simplified):

Must have:

• Pruritus (essential feature)
• Chronic or relapsing course

Plus 3 or more of:

• Personal or family history of atopy (asthma, allergic rhinitis, atopic dermatitis)
• Xerosis (dry skin)
• Flexural involvement (or facial/extensor in infants)
• Early age of onset
• Elevated IgE (not required for diagnosis)

UK Working Party criteria (practical):

• Itchy skin condition in last 12 months
• Plus 3 of: onset <2 years, history of flexural involvement, history of dry skin, personal history of atopy, visible flexural dermatitis

Epidemiology#

• Prevalence: 10-20% of children, 1-3% of adults
• 60% develop symptoms in first year of life; 90% by age 5
• Increasing prevalence in developed countries
• Strong genetic component: 70% have family history of atopy
• Part of “atopic march”: eczema → food allergies → asthma → allergic rhinitis
• Risk factors: family history, urban environment, higher socioeconomic status, smaller family size

Pathophysiology#

Mechanism (clinical understanding)#

Atopic dermatitis involves two key defects:

1. Skin barrier dysfunction:

• Filaggrin gene mutations in 30-50% of patients
• Filaggrin is essential for skin barrier integrity
• Defective barrier → increased water loss → dry skin
• Defective barrier → allergen/irritant penetration → inflammation

2. Immune dysregulation:

• Th2-dominant immune response
• Elevated IgE, IL-4, IL-13, IL-31 (itch cytokine)
• Reduced antimicrobial peptides → increased S. aureus colonization
• S. aureus colonizes 90% of AD skin (vs 5% of normal skin)
• Bacterial toxins act as superantigens → worsen inflammation

The itch-scratch cycle:

• Pruritus → scratching → skin damage → inflammation → more pruritus
• Breaking this cycle is essential for treatment success

Why this matters for treatment:

• Emollients restore barrier function (foundation of treatment)
• Anti-inflammatories (steroids, calcineurin inhibitors) address immune dysregulation
• Treating S. aureus colonization can improve flares
• Dupilumab blocks IL-4/IL-13 (targeted therapy for severe disease)

How to explain to patients#

“Eczema happens because of two problems: your skin barrier doesn’t hold moisture well, and your immune system overreacts to things that get through. Think of your skin like a brick wall—in eczema, the mortar between the bricks is weak, so water escapes and irritants get in. This triggers your immune system, causing redness and itching. The itching makes you scratch, which damages the skin more and makes everything worse.

That’s why moisturizing is so important—it’s like patching the mortar. The prescription creams calm down the immune reaction. Together, they break the cycle.”

Clinical presentation#

Characteristic symptoms#

Cardinal symptom: Pruritus

• Often severe, worse at night
• Disrupts sleep (major quality of life impact)
• “Itch that rashes” (scratching causes visible lesions)

Skin changes:

• Acute: erythema, papules, vesicles, weeping, crusting
• Subacute: erythema, scale, excoriations
• Chronic: lichenification (thickened skin), hyperpigmentation, fissures

Age-dependent distribution:

• Infants (0-2 years): face, scalp, extensor surfaces
• Children (2-12 years): flexural (antecubital, popliteal fossae), wrists, ankles
• Adolescents/adults: flexural, hands, face, neck

Associated features:

• Xerosis (dry skin)—nearly universal
• Keratosis pilaris (“chicken skin” on upper arms)
• Hyperlinear palms
• Dennie-Morgan folds (infraorbital creases)
• Allergic shiners (periorbital darkening)

Physical exam findings#

• Distribution: Age-appropriate pattern (flexural in older children/adults)
• Morphology: Erythematous patches/plaques, papules, scale, excoriations
• Lichenification: Thickened skin with accentuated skin lines (chronic rubbing)
• Xerosis: Generalized dry skin
• Secondary infection signs: Honey-colored crusting (impetigo), pustules, increased erythema/warmth

Severity assessment:

• Mild: Limited areas, minimal impact on sleep/daily activities
• Moderate: More widespread, moderate impact on sleep/activities
• Severe: Extensive involvement, significant sleep disruption, quality of life impact

Red flags#

• Eczema herpeticum: Widespread vesicles/punched-out erosions, fever—HSV superinfection, requires urgent antiviral therapy
• Severe secondary bacterial infection: Fever, spreading erythema, lymphangitis—may need systemic antibiotics, possible hospitalization
• Erythroderma: >90% BSA involvement—risk of fluid/electrolyte imbalance, infection
• Failure to thrive in infants: Consider food allergy evaluation
• Unilateral or unusual distribution: Consider contact dermatitis, tinea, other diagnoses

Diagnostic workup#

Initial evaluation#

Clinical diagnosis—no routine testing needed for typical atopic dermatitis.

Assess at initial visit:

• Severity and distribution
• Impact on sleep and quality of life
• Triggers identified by patient/family
• Current skin care routine
• Prior treatments and response
• Signs of secondary infection
• Atopic comorbidities (asthma, allergic rhinitis, food allergies)

Confirmatory testing#

Testing is NOT routinely needed. Consider in specific situations:

Food allergy testing:

• Only if clear history of immediate reaction to specific food
• NOT recommended as routine screening
• Positive IgE/skin prick tests common but often not clinically relevant
• Elimination diets only with allergist guidance

When to refer for specialist workup#

• Uncertain diagnosis
• Moderate-severe disease not responding to appropriate topical therapy
• Suspected allergic contact dermatitis (patch testing)
• Suspected food allergy contributing to eczema
• Need for systemic therapy
• Recurrent skin infections

What NOT to order#

• Routine IgE levels—elevated in most patients but doesn’t guide treatment
• Food allergy panels without clinical suspicion—high false positive rate, leads to unnecessary dietary restrictions
• Environmental allergy panels for eczema management—doesn’t change treatment approach
• Skin biopsy for typical presentation—clinical diagnosis is sufficient

Treatment#

Goals of therapy#

• Control pruritus and improve sleep
• Clear active inflammation
• Restore and maintain skin barrier
• Prevent flares through proactive management
• Minimize treatment side effects
• Improve quality of life

Realistic expectations:

• Chronic condition requiring ongoing management
• Goal is control, not cure
• Flares are expected; having a plan reduces severity
• Most patients achieve good control with topical therapy

Non-pharmacologic management#

Skin care routine (foundation of treatment):

Bathing:

• Daily lukewarm baths or showers (5-10 minutes)
• Use gentle, fragrance-free cleansers (Dove sensitive, Vanicream, CeraVe)
• Avoid hot water, harsh soaps, bubble baths
• Pat dry gently—don’t rub

“Soak and seal” technique:

• Bathe for 5-10 minutes
• Pat skin until slightly damp
• Apply medications to affected areas
• Apply emollient liberally to entire body within 3 minutes
• This traps moisture in the skin

Emollients:

• Apply liberally at least twice daily and after every hand washing
• Ointments > creams > lotions (thicker = better)
• Recommended: petrolatum (Vaseline), Aquaphor, CeraVe cream, Vanicream
• Use 1 pound per week for full-body application in adults
• Fragrance-free, dye-free products only

Trigger avoidance:

• Avoid known irritants: fragrances, dyes, harsh detergents
• Wear soft, breathable fabrics (cotton); avoid wool
• Keep nails short to minimize scratch damage
• Maintain cool, humid environment (humidifier in winter)
• Manage stress (can trigger flares)

Wet wrap therapy (for flares):

• Apply topical medication
• Cover with damp layer (wet pajamas, gauze)
• Cover with dry layer
• Leave on for 2-8 hours or overnight
• Very effective for severe flares; can use for 3-7 days

Pharmacologic management#

Mild disease:

Moderate disease:

Moderate-severe disease or flares:

Pruritus control:

Secondary infection:

Severe/refractory disease (specialist-initiated):

Patient counseling points#

For emollients: “Moisturizing is the most important thing you can do. Apply a thick cream or ointment at least twice a day and right after bathing while your skin is still damp. Use about a handful for your whole body. This is like medicine—it repairs your skin barrier and prevents flares.”

For topical steroids: “Apply a thin layer to the red, itchy areas only—not to normal skin. Use it twice a day until the area is clear, usually 1-2 weeks. Then stop or switch to a maintenance cream. Don’t use strong steroids on your face or skin folds. If you use them correctly, they’re very safe.”

For calcineurin inhibitors (tacrolimus, pimecrolimus): “This is a steroid-free cream that calms inflammation. It’s especially good for your face and for long-term use because it doesn’t thin the skin. It may burn or sting for the first few days—this gets better as your skin heals. Apply it twice a day.”

For flares: “When you feel a flare starting—increased itching, redness—start your steroid cream right away. Don’t wait until it gets bad. Treating early means shorter flares. Once it’s clear, you can stop the steroid and continue moisturizing.”

Monitoring and follow-up#

Initial visit:

• Establish diagnosis and severity
• Educate on skin care routine
• Start appropriate topical therapy
• Follow-up in 2-4 weeks

Follow-up visits:

• Assess response to treatment
• Adjust therapy as needed
• Reinforce skin care education
• Screen for complications (infection, side effects)

Maintenance phase:

• Follow-up every 3-6 months when stable
• Proactive therapy: tacrolimus 2-3x/week to previously affected areas prevents flares
• Continue daily emollients indefinitely

When to reassess:

• Not improving after 2-4 weeks of appropriate therapy
• Frequent flares despite maintenance therapy
• Signs of infection
• Significant quality of life impact

Patient education#

What is this condition?#

Eczema (atopic dermatitis) is a condition where your skin doesn’t hold moisture well and your immune system overreacts, causing red, itchy patches. It’s very common, especially in people with allergies or asthma.

Eczema is not contagious. You can’t catch it or give it to anyone. It tends to run in families. While there’s no cure, it can be very well controlled with proper skin care and treatment.

What you can do#

• Moisturize, moisturize, moisturize. Apply thick cream or ointment at least twice daily and after bathing.
• Take lukewarm baths or showers (not hot). Limit to 5-10 minutes.
• Use gentle, fragrance-free soaps and detergents.
• Apply moisturizer within 3 minutes of bathing while skin is still damp.
• Wear soft, breathable fabrics like cotton. Avoid wool and rough materials.
• Keep your nails short to reduce damage from scratching.
• Try to identify and avoid your triggers (certain soaps, stress, sweating).
• Use a humidifier in dry weather.
• When you feel a flare starting, use your prescription cream right away.

When to seek care#

• Your eczema is spreading or getting much worse
• You see signs of infection: oozing, crusting, increased redness, warmth, fever
• You develop small blisters that spread quickly (could be a viral infection)
• Your eczema is not improving with treatment after 2 weeks
• Your sleep is significantly affected
• Your eczema is affecting your daily life or mood

Questions to ask your doctor#

• How severe is my eczema?
• Am I using the right moisturizer?
• How long should I use the prescription cream?
• Is it safe to use on my face?
• What should I do when I have a flare?
• Could food allergies be making my eczema worse?
• Should I see a specialist?
• Are there any new treatments I should know about?

Prognosis and monitoring#

Expected course#

• Chronic, relapsing condition
• Many children “outgrow” eczema: 60% clear by adolescence, but may have dry skin or hand eczema as adults
• Adult-onset eczema tends to be more persistent
• Severity varies: some have rare mild flares, others have continuous moderate-severe disease
• Atopic march: 50-70% develop asthma or allergic rhinitis

With proper treatment:

• Most patients achieve good control
• Flares become less frequent and less severe
• Quality of life significantly improves

Monitoring parameters#

Complications to watch for#

• Secondary bacterial infection: Honey-colored crusting, increased redness, fever—treat with antibiotics
• Eczema herpeticum: Widespread vesicles, punched-out erosions, fever—HSV infection, urgent antiviral needed
• Steroid side effects: Skin atrophy, striae, telangiectasias—use lowest effective potency, steroid-sparing agents
• Sleep disruption: Major quality of life impact—address aggressively
• Psychological impact: Anxiety, depression, social isolation—screen and address
• Eye complications: Keratoconus, cataracts (with periorbital involvement)—ophthalmology referral if eye symptoms

Special populations#

Elderly/geriatric#

• Less common but can occur; consider other diagnoses (asteatotic eczema, drug reaction, cutaneous T-cell lymphoma)
• Skin more fragile—use lower potency steroids, shorter duration
• Increased infection risk
• Sedating antihistamines: use with caution (falls, confusion, urinary retention)
• Polypharmacy considerations
• Xerosis very common in elderly—aggressive moisturization

Chronic kidney disease#

• Uremic pruritus can mimic or coexist with atopic dermatitis
• Topical steroids: safe, no dose adjustment
• Oral antihistamines: cetirizine—reduce dose if eGFR <30
• Gabapentin for pruritus: reduce dose based on eGFR
• Dupilumab: no dose adjustment needed

Pregnancy and lactation#

• Eczema may improve, worsen, or stay same during pregnancy
• Safe in pregnancy: Emollients, low-to-mid potency topical steroids, tacrolimus (limited data but likely safe)
• Avoid: High-potency steroids over large areas, oral steroids if possible
• Limited data: Dupilumab—discuss risks/benefits with dermatology and OB
• Breastfeeding: topical steroids safe; avoid application to nipples before feeding

Infants and children#

• Most common age group for atopic dermatitis
• Distribution differs: face, scalp, extensor surfaces in infants
• Use low-potency steroids (hydrocortisone 1-2.5%) for face and folds
• Tacrolimus 0.03% approved for age ≥2 years
• Wet wrap therapy very effective for flares
• Food allergy evaluation if severe, early-onset, or not responding to treatment
• Dilute bleach baths safe and effective for reducing S. aureus

Other populations#

Polypharmacy considerations:

• Sedating antihistamines interact with other CNS depressants
• Topical steroids generally safe with other medications
• Dupilumab: no significant drug interactions

Immunocompromised patients:

• Higher risk of skin infections including eczema herpeticum
• May need more aggressive infection prevention (bleach baths)
• Biologics generally safe but monitor closely for infections

When to refer#

Specialist referral criteria#

Dermatology referral:

• Moderate-severe disease not controlled with appropriate topical therapy
• Uncertain diagnosis
• Need for systemic therapy
• Recurrent skin infections
• Suspected eczema herpeticum
• Significant quality of life impact despite treatment

Allergy referral:

• Suspected food allergy (immediate reactions to specific foods)
• Suspected allergic contact dermatitis (patch testing)
• Severe disease with possible environmental triggers

Urgency levels#

• Routine (weeks): Moderate disease not responding to topicals, need for systemic therapy evaluation
• Urgent (days): Widespread infection, rapidly worsening disease
• Emergent (same day): Suspected eczema herpeticum (widespread vesicles, fever), erythroderma

Smartphrase snippets#

Stable/controlled: Atopic dermatitis well-controlled, skin clear/near-clear with no signs of infection. Continue current emollient and topical regimen. Follow-up in [3-6 months] or sooner for flares.

Flare/worsening: Atopic dermatitis flare affecting [areas], no signs of secondary infection. Plan: [increase steroid potency / add wet wraps]. Reinforced skin care routine with follow-up in [2-4 weeks].

New diagnosis: New diagnosis of atopic dermatitis, [severity] disease affecting [distribution]. Starting [emollient regimen] with [topical steroid] BID to affected areas. Follow-up in [2-4 weeks] to assess response.

Related pages#

• Rash (Chronic/Recurrent) (complaint) — symptom-based approach to chronic rashes including eczema differential
• Pruritus (complaint) — evaluation of itching, which may reveal underlying atopic dermatitis
• Psoriasis (problem) — another common chronic inflammatory skin condition, sometimes confused with eczema