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July 2016

Handout on Health: Atopic

Dermatitis (A type of eczema)

This publication is for people who have atopic

dermatitis (often called “eczema”), parents

and caregivers of children with atopic

dermatitis, and others interested in learning

more about the disease. The

publication describes the disease and its

symptoms and contains information about

diagnosis and treatment, as well as current

research efforts supported by the National

Institute of Arthritis and Musculoskeletal and

Skin Diseases (NIAMS) and other

components of the U.S. Department of

Health and Human Services’ National

Institutes of Health (NIH). It also discusses

issues such as skin care and quality of life for

people with atopic dermatitis. If you have

further questions after reading this

publication, you may wish to discuss them

with your doctor or your child’s pediatrician.

What Is Atopic Dermatitis?

Who Has Atopic Dermatitis?

Causes of Atopic Dermatitis

Symptoms of Atopic Dermatitis

Stages of Atopic Dermatitis

Diagnosing Atopic Dermatitis

Treatment of Atopic Dermatitis

Atopic Dermatitis and Vaccination

Against Smallpox

What Research Is Being Conducted

on Atopic Dermatitis?

Hope for the Future

Information Boxes

Skin Features Associated With Atopic

Dermatitis

Common Irritants

Treating Atopic Dermatitis in Infants

We want to hear from you

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and Children

Controlling Atopic Dermatitis

What Is Atopic Dermatitis?

Atopic dermatitis is a chronic (long-lasting)

disease that affects the skin. It is not

contagious; it cannot be passed from one

person to another. The word “dermatitis”

means inflammation of the skin. “Atopic”

refers to a group of diseases in which there is

often an inherited tendency to develop other

allergic conditions, such as asthma and hay

fever. In atopic dermatitis, the skin becomes

extremely itchy. Scratching leads to redness,

swelling, cracking, “weeping” clear fluid, and

finally, crusting and scaling. In most cases,

there are periods of time when the disease is

worse (called exacerbations or flares)

followed by periods when the skin improves

or clears up entirely (called remissions). As

some children with atopic dermatitis grow

older, their skin disease improves or

disappears altogether, although their skin

often remains dry and easily irritated. In

others, atopic dermatitis continues to be a

significant problem in adulthood.

Atopic dermatitis is often referred to as

“eczema,” which is a general term for the

several types of inflammation of the skin.

Atopic dermatitis is the most common of the

many types of eczema. Several have very

similar symptoms.

Who Has Atopic Dermatitis?

Atopic dermatitis is very common. It occurs

equally in males and females and affects an

estimated 30 percent of people in the United

States. Although atopic dermatitis may occur

at any age, it most often begins in infancy

and childhood. Onset after age 30 is less

common and is often caused by exposure of

the skin to harsh or wet conditions. People

who live in cities and in dry climates appear

more likely to develop this condition.

Causes of Atopic Dermatitis

The cause of atopic dermatitis is not known,

but the disease seems to result from a

combination of genetic (hereditary) and

environmental factors.

Children are more likely to develop this

disorder if a parent has had it or another

atopic disease like asthma or hay fever. If

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both parents have an atopic disease, the

likelihood increases. Although some people

outgrow skin symptoms, many children with

atopic dermatitis go on to develop hay fever

or asthma. Environmental factors can bring

on symptoms of atopic dermatitis at any time

in affected individuals.

Atopic dermatitis is also associated with

malfunction of the body’s immune system:

the system that recognizes and helps fight

bacteria and viruses that invade the body.

The immune system can become misguided

and create inflammation in the skin, even in

the absence of a major infection. This can be

viewed as a form of autoimmunity, where a

body reacts against its own tissues.

In the past, doctors thought that atopic

dermatitis was caused by an emotional

disorder. We now know that emotional

factors, such as stress, can make the

condition worse, but they do not cause the

disease.

Symptoms of Atopic Dermatitis

Symptoms (signs) vary from person to

person. The most common symptoms are

dry, itchy skin and rashes on the face, inside

the elbows and behind the knees, and on the

hands and feet. Itching is the most important

symptom of atopic dermatitis. Scratching and

rubbing in response to itching irritates the

skin, increases inflammation, and actually

increases itchiness. Itching is a particular

problem during sleep when conscious control

of scratching is lost.

The appearance of the skin that is affected

by atopic dermatitis depends on the amount

of scratching and the presence of secondary

skin infections. The skin may be red and

scaly or thick and leathery, contain small

raised bumps, or leak fluid and become

crusty and infected. The box below lists

common skin features of the disease. These

features can also be found in people who do

not have atopic dermatitis or who have other

types of skin disorders.

Skin Features Associated

With Atopic Dermatitis

Atopic pleat (DennieMorgan fold)—an extra

fold of skin that develops

under the eye

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Cheilitis—inflammation of

the skin on and around

the lips

Hyperlinear palms—

increased number of skin

creases on the palms

Hyperpigmented eyelids

—eyelids that have

become darker in color

from inflammation or hay

fever

Ichthyosis—dry,

rectangular scales on the

skin

Keratosis pilaris—small,

rough bumps, generally

on the face, upper arms,

and thighs

Lichenification—thick,

leathery skin resulting

from constant scratching

and rubbing

Papules—small raised

bumps that may open

when scratched and

become crusty and

infected

Urticaria—hives (red,

raised bumps) that may

occur after exposure to an

allergen, at the beginning

of flares, or after exercise

or a hot bath.

Atopic dermatitis may also affect the skin

around the eyes, the eyelids, and the

eyebrows and lashes. Scratching and

rubbing the eye area can cause the skin to

redden and swell. Some people with atopic

dermatitis develop an extra fold of skin under

their eyes. Patchy loss of eyebrows and

eyelashes may also result from scratching or

rubbing.

Researchers have noted differences in the

skin of people with atopic dermatitis that may

contribute to the symptoms of the disease.

The outer layer of skin, called the epidermis,

is divided into two parts: an inner part

containing moist, living cells, and an outer

part, known as the horny layer or stratum

corneum, containing dry, flattened, dead

cells. Under normal conditions the stratum

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corneum acts as a barrier, keeping the rest of

the skin from drying out and protecting other

layers of skin from damage caused by

irritants and infections. When this barrier is

damaged, irritants act more intensely on the

skin.

The skin of a person with atopic dermatitis

loses moisture from the epidermal layer,

allowing the skin to become very dry and

reducing its protective abilities. Thus, when

combined with the abnormal skin immune

system, the person’s skin is more likely to

become infected by bacteria or viruses.

Stages of Atopic Dermatitis

When atopic dermatitis occurs during infancy

and childhood, it affects each child differently

in terms of both onset and severity of

symptoms. In infants, atopic dermatitis

typically begins around 6 to 12 weeks of age.

It may first appear around the cheeks and

chin as a patchy facial rash, which can

progress to red, scaling, oozing skin. The

skin may become infected. Once the infant

becomes more mobile and begins crawling,

exposed areas, such as the inner and outer

parts of the arms and legs, may also be

affected. An infant with atopic dermatitis may

be restless and irritable because of the

itching and discomfort of the disease.

In childhood, the rash tends to occur behind

the knees and inside the elbows; on the sides

of the neck; around the mouth; and on the

wrists, ankles, and hands. Often, the rash

begins with papules that become hard and

scaly when scratched. The skin around the

lips may be inflamed, and constant licking of

the area may lead to small, painful cracks in

the skin around the mouth.

In some children, the disease goes into

remission for a long time, only to come back

at the onset of puberty when hormones,

stress, and the use of irritating skin care

products or cosmetics may cause the

disease to flare.

Although a number of people who developed

atopic dermatitis as children also experience

symptoms as adults, it is also possible for the

disease to show up first in adulthood. The

pattern in adults is similar to that seen in

children; that is, the disease may be

widespread or limited to only a few parts of

the body.

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Diagnosing Atopic Dermatitis

Each person with atopic dermatitis

experiences a unique combination of

symptoms, which may vary in severity over

time. The doctor will base a diagnosis on the

symptoms the patient experiences and may

need to see the patient several times to make

an accurate diagnosis and to rule out other

diseases and conditions that might cause

skin irritation. In some cases, the family

doctor or pediatrician may refer the patient to

a dermatologist (doctor specializing in skin

disorders) or allergist (allergy specialist) for

further evaluation.

A medical history may help the doctor better

understand the nature of a patient’s

symptoms, when they occur, and their

possible causes. The doctor may ask about

family history of allergic disease; whether the

patient also has diseases such as hay fever

or asthma; and about exposure to irritants,

sleep disturbances, any foods that seem to

be related to skin flares, previous treatments

for skin-related symptoms, and use of

steroids or other medications.

Currently, there is no single test to diagnose

atopic dermatitis. However, there are some

tests that can give the doctor an indication of

allergic sensitivity.

Pricking the skin with a needle that contains

a small amount of a suspected allergen may

be helpful in identifying factors that trigger

flares of atopic dermatitis. Negative results

on skin tests may help rule out the possibility

that certain substances cause skin

inflammation. Positive skin prick test results

are difficult to interpret in people with atopic

dermatitis because the skin is very sensitive

to many substances, and there can be many

positive test sites that are not meaningful to a

person’s disease at the time. Positive results

simply indicate that the individual has

immunoglobulin E or IgE (allergic) antibodies

to the substance tested. IgE controls the

immune system’s allergic response and is

often high in atopic dermatitis.

Common Irritants

Wool or synthetic fibers

Soaps and detergents

Some perfumes and

cosmetics

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Substances such as

chlorine, mineral oil, or

solvents

Dust or sand

Cigarette smoke.

Treatment of Atopic Dermatitis

The two main goals in treating atopic

dermatitis are healing the skin and preventing

flares. It is important for the patient and

family members to note any changes in the

skin’s condition in response to treatment, and

to be persistent in identifying the treatment

that seems to work best.

Medications: A variety of medications are

used to treat atopic dermatitis.

Corticosteroid creams and ointments have

been used for many years to treat atopic

dermatitis and other autoimmune diseases

affecting the skin.

When topical corticosteroids are not effective,

the doctor may prescribe a systemic

corticosteroid, which is taken by mouth or

injected instead of being applied directly to

the skin. Typically, these medications are

used only in resistant cases and only given

for short periods of time.

Certain antihistamines that cause drowsiness

can reduce nighttime scratching and allow

more restful sleep when taken at bedtime.

This effect can be particularly helpful for

patients whose nighttime scratching makes

the disease worse.

Topical calcineurin inhibitors decrease

inflammation in the skin and help prevent

flares. Barrier repair moisturizers reduce

water loss and work to rebuild the skin.

Phototherapy: Use of ultraviolet A or B light

waves, alone or combined, can be an

effective treatment for mild to moderate

dermatitis. If the doctor thinks that

phototherapy may be useful to treat the

symptoms of atopic dermatitis, he or she will

use the minimum exposure necessary and

monitor the skin carefully.

Treating Atopic Dermatitis in

Infants and Children

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Give lukewarm baths.

Apply moisturizer

immediately following the

bath.

Keep child’s fingernails

filed short.

Select soft cotton fabrics

when choosing clothing.

Consider using sedating

antihistamines to promote

sleep and reduce

scratching at night.

Keep the child cool; avoid

situations where

overheating occurs.

Learn to recognize skin

infections and seek

treatment promptly.

Attempt to distract the

child with activities to keep

him or her from

scratching.

Identify and remove

irritants and allergens.

Skin care: Healing the skin and keeping it

healthy are important to prevent further

damage and enhance quality of life.

Developing and sticking with a daily skin care

routine is critical to preventing flares.

A lukewarm bath helps to cleanse and

moisturize the skin without drying it

excessively. Because soaps can be drying to

the skin, the doctor may recommend use of a

mild bar soap or nonsoap cleanser. Bath oils

are not usually helpful.

After bathing, a person should air-dry the

skin, or pat it dry gently (avoiding rubbing or

brisk drying), and then apply a moisturizer to

seal in the water that has been absorbed into

the skin during bathing. A moisturizer

increases the rate of healing and establishes

a barrier against further drying and irritation.

Lotions that have a high water or alcohol

content evaporate more quickly, and alcohol

may cause stinging. Creams and ointments

work better at healing the skin.

Protection from allergen exposure: The

doctor may suggest reducing exposure to a

suspected allergen. For example, the

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presence of the house dust mite can be

limited by encasing mattresses and pillows in

special dust-proof covers, frequently washing

bedding in hot water, and removing

carpeting. However, there is no way to

completely rid the environment of airborne

allergens.

Changing the diet may not always relieve

symptoms of atopic dermatitis. A change may

be helpful, however, when the medical

history, laboratory studies, and specific

symptoms strongly suggest a food allergy. It

is up to the patient and his or her family and

physician to decide whether the dietary

restrictions are appropriate. Unless properly

monitored by a physician or dietitian, diets

with many restrictions can contribute to

serious nutritional problems, especially in

children.

Stress Management: Stress management

and relaxation techniques may help decrease

the likelihood of flares. Developing a network

of support that includes family, friends, health

professionals, and support groups or

organizations can be beneficial.

Atopic Dermatitis and Vaccination

Against Smallpox

Although scientists are working to develop

safer vaccines, individuals diagnosed with

atopic dermatitis (or eczema) should not

receive the current smallpox vaccine.

According to the Centers for Disease Control

and Prevention (CDC), a U.S. Government

organization, individuals who have ever been

diagnosed with atopic dermatitis, even if the

condition is mild or not presently active, are

more likely to develop a serious complication

if they are exposed to the virus from the

smallpox vaccine.

During a smallpox outbreak, these

vaccination recommendations may change.

People with atopic dermatitis who have been

exposed to smallpox should consult their

doctor about vaccination. They should also

find out what precautions to take if they have

close contact with someone who has recently

received the vaccine.

Additional information about atopic dermatitis

and smallpox vaccination is available from

the CDC. (See the For More Information

section.)

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What Research Is Being

Conducted on Atopic Dermatitis?

Researchers supported by the National

Institute of Arthritis and Musculoskeletal and

Skin Diseases (NIAMS) and other institutes

of the National Institutes of Health (NIH) are

gaining a better understanding of what

causes atopic dermatitis and how it can be

managed, treated, and, ultimately, prevented.

Some promising avenues of research are

described below.

Genetics: Although atopic dermatitis runs in

families, the role of genetics (inheritance)

remains unclear. It does appear that more

than one gene is involved in the disease.

Research has helped shed light on the way

atopic dermatitis is inherited. Studies show

that children are at increased risk for

developing the disorder if there is a family

history of other atopic disease, such as hay

fever or asthma. The risk is significantly

higher if both parents have an atopic disease.

In addition, a person whose fraternal

(nonidentical) twin has atopic dermatitis is

three times more likely to have atopic

dermatitis than someone in the general

population. Studies of identical twins show

that a person whose identical twin has atopic

dermatitis is even more likely to have atopic

dermatitis than someone in the general

population. These findings suggest that

genes play an important role in determining

who gets the disease.

Also, scientists have discovered mutations in

a certain gene that plays a role in the

production of a protein called filaggrin. The

filaggrin protein is normally found in the

outermost layer of the skin and functions as a

component of the skin barrier. The gene

mutation disrupts filaggrin’s ability to maintain

a normal skin barrier and appears to be a

genetic factor that predisposes people to

develop atopic dermatitis and other diseases

in which the skin barrier is compromised.

Researchers are hoping to answer more

questions about genetics and determine what

other genes are responsible for predisposing

people to develop atopic dermatitis.

Skin development and maintenance:

Discoveries about how the body creates and

maintains skin will be helpful in searching for

causes and treatments for diseases like

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atopic dermatitis in which the skin barrier

breaks down. Investigators are trying to find

out if drugs that are already on the market

can help repair the skin barrier.

For babies that may be at high risk for

developing atopic dermatitis, investigators

are trying to find out what effects moisturizers

may have if applied in infancy before

symptoms appear.

Understanding itch: One of the most

difficult symptoms of atopic dermatitis,

itching, is being studied to determine what

mechanisms trigger the sensation of itch.

Researchers are studying how the nervous

system and the immune system

communicate to cause the inflammation, itch,

and pain seen in atopic dermatitis.

Immune system imbalance: Researchers

are trying to see what factors play a role in

the immune response, causing inflammation

like that seen in atopic dermatitis. Also,

investigators are studying the skin

microbiome, the microorganisms that

normally live on the skin, to see how it plays

a role in keeping skin healthy or contributes

to atopic dematitis.

Controlling Atopic

Dermatitis

Prevent scratching or

rubbing whenever

possible.

Protect skin from

excessive moisture,

irritants, and rough

clothing.

Maintain a cool, stable

temperature and

consistent humidity levels.

Limit exposure to dust,

cigarette smoke, pollens,

and animal dander.

Recognize and limit

emotional stress.

More information on research is available

from the following websites:

NIH Clinical Research Trials and

You was designed to help people

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learn more about clinical trials, why

they matter, and how to participate.

Visitors to the website will find

information about the basics of

participating in a clinical trial,

first-hand stories from clinical trial

volunteers, explanations from

researchers, and links on how to

search for a trial or enroll in a

research-matching program.

ClinicalTrials.gov offers up-to-date

information for locating federally and

privately supported clinical trials for a

wide range of diseases and

conditions.

NIH RePORTER is an electronic tool

that allows users to search a

repository of both intramural and

extramural NIH-funded research

projects from the past 25 years and

access publications (since 1985) and

patents resulting from NIH funding.

PubMed is a free service of the U.S.

National Library of Medicine that lets

you search millions of journal citations

and abstracts in the fields of

medicine, nursing, dentistry,

veterinary medicine, the health care

system, and preclinical sciences.

Hope for the Future

Although the symptoms of atopic dermatitis

can be difficult and uncomfortable, the

disease can be successfully managed.

People with atopic dermatitis can lead

healthy, productive lives. As scientists learn

more about atopic dermatitis and what

causes it, they continue to move closer to

effective treatments, and perhaps, ultimately,

a cure.

For More Information

National Institute of Arthritis and

Musculoskeletal and Skin Diseases

(NIAMS)

Information Clearinghouse

National Institutes of Health

1 AMS Circle

Bethesda, MD 20892-3675

Phone: 301-495-4484

Toll free: 877-22-NIAMS (877-226-4267)

TTY: 301-565-2966

Fax: 301-718-6366

Email: NIAMSinfo@mail.nih.gov

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Website: https://www.niams.nih.gov

If you need more information about available

resources in your language or another

language, please visit our website or contact

the NIAMS Information Clearinghouse at

NIAMSinfo@mail.nih.gov.

Other Resources

National Institute of Allergy and Infectious

Diseases

Website: http://www.niaid.nih.gov/topics

/eczema/Pages/default.aspx

American Academy of Dermatology

Website: http://www.aad.org

American Academy of Allergy, Asthma,

and Immunology

Website: http://www.aaaai.org

National Eczema Association

Website: http://www.nationaleczema.org

Food Allergy Research & Education

Website: http://www.foodallergy.org

Acknowledgments

The NIAMS gratefully acknowledges the

assistance of the following individuals in the

preparation and review of the original version

of this publication: Joanne Cono, M.D.,

Sc.M., Centers for Disease Control and

Prevention, Atlanta, GA; Kevin Cooper, M.D.,

Case Western Reserve University, University

Hospitals of Cleveland, Cleveland, OH; Jon

Hanifin, M.D., Oregon Health & Science

University, Portland, OR; Donald Leung,

M.D., Ph.D., National Jewish Medical and

Research Center, Denver, CO; Alan Moshell,

M.D., NIAMS/NIH; Amy Paller, M.D.,

Children’s Hospital of Chicago, Chicago, IL;

Hugh Sampson, M.D., Mount Sinai School of

Medicine, New York, NY; Maria Turner, M.D.,

National Cancer Institute, NIH; and LaDonna

Williams, Inflammatory Skin Disease

Institute, Newport News, VA.

The mission of the National Institute of

Arthritis and Musculoskeletal and Skin

Diseases (NIAMS), a part of the U.S.

Department of Health and Human Services’

National Institutes of Health (NIH), is to

support research into the causes, treatment,

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and prevention of arthritis and

musculoskeletal and skin diseases; the

training of basic and clinical scientists to

carry out this research; and the dissemination

of information on research progress in these

diseases. The NIAMS Information

Clearinghouse is a public service sponsored

by NIAMS that provides health information

and information sources. Additional

information can be found on the NIAMS

website at www.niams.nih.gov.

For Your Information

This publication contains information about

medications used to treat the health condition

discussed here. When this publication was

developed, we included the most up-to-date

(accurate) information available.

Occasionally, new information on medication

is released.

For updates and for any questions about any

medications you are taking, please contact

U.S. Food and Drug Administration

Toll free: 888-INFO-FDA

(888-463-6332)

Website: http://www.fda.gov

For additional information on specific

medications, visit Drugs@FDA at

http://www.accessdata.fda.gov/scripts

/cder/daf/. Drugs@FDA is a searchable

catalog of FDA-approved drug products.

For updates and questions about statistics,

please contact

Centers for Disease Control and

Prevention, National Center for

Health Statistics

Toll free: 800-232-4636

Website: http://www.cdc.gov/nchs

This publication is not copyrighted. Readers

are encouraged to duplicate and distribute as

many copies as needed.

Additional copies of this publication are

available from:

National Institute of Arthritis and

Musculoskeletal and Skin Diseases

(NIAMS)

Information Clearinghouse

National Institutes of Health

1 AMS Circle

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Bethesda, MD 20892-3675

Phone: 301-495-4484

Toll free: 877-22-NIAMS

(877-226-4267)

TTY: 301-565-2966

Fax: 301-718-6366

Email: NIAMSinfo@mail.nih.gov

Website: https://www.niams.nih.gov

NIH Publication No. 16-4272

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