Atopic dermatitis (atopic eczema)

Atopic dermatitis is a chronic inflammatory skin condition that runs in flares. It has two foundations: a defective skin barrier that lets water out and irritants in, and an immune system inclined to over-react. It is not contagious and it is not "caused by nerves". It cannot be cured, but it can be controlled very well: with the right treatment most people spend most of their time with settled skin.

How it presents

• intense itching — often the hardest symptom to bear and the one that disrupts sleep;
• dry, rough skin all over the body, including between flares;
• red areas, sometimes with blisters and weeping in the acute phase;
• thickened skin with accentuated markings where it has been scratched over a long period;
• on brown and black skin, redness is less visible: grey or violet tones, papules and pigment changes predominate;
• sites vary with age: in infants, cheeks and scalp; in young children, the creases of elbows and knees; in adults, hands, eyelids, neck and flexures;
• it runs in flares with calmer periods between them.

What triggers flares

• dry air, central heating, cold, wind;
• harsh soaps, fragranced washes, detergents, fabric conditioners;
• heat and sweat;
• wool and rough synthetics against the skin;
• house dust mites, animal dander, pollen;
• infections, particularly viral respiratory ones;
• stress and lack of sleep;
• in some young children, certain foods — though less often than commonly believed;
• very hot water and long baths.

When to see a doctor

• itching is disturbing your sleep;
• flares keep recurring despite daily care;
• yellow crusts, weeping or pustules appear — added bacterial infection;
• grouped blisters, pain and fever appear — this can be a herpes infection on top of eczema, which is an emergency;
• a large area of skin is affected;
• the eczema involves the eyelids or eyes;
• it has begun in adulthood with no previous history;
• it is affecting school, work or mood.

Daily care, which is the foundation

Here the result depends more on consistency than on the particular product.

• emollients generously, several times a day, including when the skin looks fine. Consumption is measured in hundreds of grams a month;
• apply to damp skin within minutes of showering;
• short warm showers, not hot, with unfragranced cleansers instead of soap;
• pat dry rather than rubbing;
• cotton next to the skin, no wool and no stiff labels;
• unfragranced detergent with a double rinse and no fabric conditioner;
• short nails and, in young children, cotton mittens at night;
• a cool bedroom and a humidifier during the heating season.

Treating flares

• topical corticosteroids — the mainstay. Potency is chosen according to the site and the age, and they are used in short bursts until the skin settles. Fear of using them causes more harm than the steroids do: an undertreated flare lasts longer and needs more treatment in the end;
• topical calcineurin inhibitors — for face, eyelids and folds, and for maintenance;
• proactive treatment — applying treatment twice a week to the areas that always flare, to lengthen the gaps between flares;
• wet wraps for severe flares, on medical advice;
• antihistamines — mainly to help with sleep;
• antibiotics where bacterial infection is confirmed;
• phototherapy for widespread disease;
• systemic drugs and biologic therapy for severe disease — these have transformed the outlook for the most difficult cases.

About food allergy

This is the most common question and the source of the most mistakes. Atopic dermatitis is generally not caused by diet. Some infants with moderate or severe eczema do have an associated food allergy, but it is confirmed by testing, not by suspicion. Removing foods "just in case" impoverishes the diet, does not improve the skin and, in young children, can even make a genuine allergy more likely to develop.

Common questions

Is it contagious? No.

Will it go away? In many children it improves greatly or resolves by adolescence. In others it persists into adulthood, particularly on the hands.

Do steroids thin the skin? With prolonged and incorrect use, yes. Used in bursts at a potency appropriate to the site they are safe, and the alternative — a persistent flare — is worse.

Does the sea help? It helps many people, but rinse off the salt and apply an emollient afterwards.

Is it caused by nerves? Stress triggers flares, but the condition is not psychological: there is a genuine defect in the skin barrier.

Online consultation

In an online consultation the doctor reviews photographs, matches steroid potency to each area of the body, builds a realistic daily routine with you, recognises signs of added infection, and helps you decide whether food allergy testing makes sense in your case.

This material is for information only and does not replace a medical consultation.