Atopic

Dermatitis

U.S. Department of Health and

Human Services

National Institutes of Health

National Institute of Arthritis and

Musculoskeletal and Skin Diseases

(A type of eczema)

HANDOUT ON HEAL T H
This booklet is not copyrighted. Readers are

encouraged to duplicate and distribute as many

copies as needed.

Additional copies of this booklet are available

from the National Institute of Arthritis and

Musculoskeletal and Skin Diseases, NIAMS/National

Institutes of Health, 1 AMS Circle, Bethesda, Maryland

20892-3675, and on the NIAMS Web site at http://

www.niams.nih.gov/hi/topics/dermatitis/index/html.
Table of Contents

Defining Atopic Dermatitis ............................................ 3

Incidence and Prevalence of Atopic Dermatitis ............. 4

Cost of Atopic Dermatitis............................................... 6

Causes of Atopic Dermatitis........................................... 6

Symptoms of Atopic Dermatitis..................................... 9

Stages of Atopic Dermatitis........................................... 11

Diagnosing Atopic Dermatitis ....................................... 12

Factors that Make Atopic Dermatitis Worse ................. 15

Treatment of Atopic Dermatitis..................................... 18

Atopic Dermatitis and Quality of Life .......................... 24

Atopic Dermatitis and Vaccination

Against Smallpox .......................................................... 25

Current Research ........................................................... 27

Hope for the Future ....................................................... 31

Additional Resources..................................................... 32
Types of Eczema (Dermatitis) ........................................ 5

Skin Features Associated With Atopic Dermatitis ......... 8

Major and Minor Features of Atopic Dermatitis........... 14

Common Irritants .......................................................... 16

Treating Atopic Dermatitis in Infants and Children...... 22

Tips for Working With Your Doctor..............................26

Controlling Atopic Dermatitis....................................... 28
3

Atopic Dermatitis

This booklet 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 booklet 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 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 booklet, you

may wish to discuss them with your doctor or your

child’s pediatrician.

A

topic 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 where 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
4

Although atopic

dermatitis may

occur at any age,

it most often

begins in infancy

and childhood.

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. Types of eczema are

described in the box on page 5.

A

topic dermatitis is very common.

It affects males and females and

accounts for 10 to 20 percent of all

visits to dermatologists (doctors who

specialize in the care and treatment of

skin diseases). Although atopic dermatitis may occur at

any age, it most often begins in infancy and childhood.

Scientists estimate that 65 percent of patients develop

symptoms in the first year of life, and 90 percent develop

symptoms before the age of 5. Onset after age 30 is less

common and is often due to exposure of the skin to harsh

or wet conditions. Atopic dermatitis is a common cause

of workplace disability. People who live in cities and in

dry climates appear more likely to develop this condition.
5

Types of Eczema (Dermatitis)

■ Allergic contact eczema (dermatitis): a red, itchy,

weepy reaction where the skin has come into

contact with a substance that the immune system

recognizes as foreign, such as poison ivy or

certain preservatives in creams and lotions

■ Atopic dermatitis: a chronic skin disease

characterized by itchy, inflamed skin

■ Contact eczema: a localized reaction that includes

redness, itching, and burning where the skin has

come into contact with an allergen (an allergycausing substance) or with an irritant such as an

acid, a cleaning agent, or other chemical

■ Dyshidrotic eczema: irritation of the skin on the

palms of hands and soles of the feet characterized

by clear, deep blisters that itch and burn

■ Neurodermatitis: scaly patches of the skin on the

head, lower legs, wrists, or forearms caused by a

localized itch (such as an insect bite) that become

intensely irritated when scratched

■ Nummular eczema: coin-shaped patches of

irritated skin—most common on the arms, back,

buttocks, and lower legs—that may be crusted,

scaling, and extremely itchy

■ Seborrheic eczema: yellowish, oily, scaly patches

of skin on the scalp, face, and occasionally other

parts of the body

■ Stasis dermatitis: a skin irritation on the lower

legs, generally related to circulatory problems
6

More than

15 million people

in the U.S. have

symptoms

of atopic

dermatitis.

Although it is difficult to identify exactly how many

people are affected by atopic dermatitis, an estimated 20

percent of infants and young children experience

symptoms of the disease. Roughly 60

percent of these infants continue to

have one or more symptoms of atopic

dermatitis in adulthood. This means

that more than 15 million people in the

United States have symptoms of the

disease.

I

n a recent analysis of the health

insurance records of 5 million

Americans under age 65, medical

researchers found that approximately

2.5 percent had atopic dermatitis.

Annual insurance payments for

medical care of atopic dermatitis

ranged from $580 to $1,250 per

patient. More than one-quarter of each

patient’s total health care costs were

for atopic dermatitis and related conditions. The

researchers project that U.S. health insurance companies

spend more than $1 billion per year on atopic dermatitis.

T

he 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 one or

both parents have had it or have had allergic conditions

like asthma or hay fever. While some people outgrow skin
7

Atopic dermatitis

is also

associated with

malfunction of

the body’s

immune system.

symptoms, approximately three-fourths of 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 individuals who have inherited

the atopic disease trait.

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.

Scientists have found that people with

atopic dermatitis have a low level of a

cytokine (a protein) that is essential to

the healthy function of the body’s

immune system and a high level of

other cytokines that lead to allergic

reactions. 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.
8

Skin Features Associated

With Atopic Dermatitis

■ Atopic pleat (Dennie-Morgan fold): an extra

fold of skin that develops under the eye

■ 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
9

S

ymptoms (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, be

thick and leathery, contain small

raised bumps, or leak fluid and

become crusty and infected. The box

on page 8 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.

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.

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.
10

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 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 (for example, Staphylococcus and Streptococcus) or viruses, such as those that

cause warts and cold sores.

Atopic dermatitis

may also affect

the skin around

the eyes, the

eyelids, and the

eyebrows

and lashes.
11

W

hen 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. The skin may

improve by 18 months of age, although the infant has a

greater than normal risk of developing dry skin or hand

eczema later in life.

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. For example,
12

It is also possible

for the disease to

show up first in

adulthood.

only the hands or feet may be affected and become dry,

itchy, red, and cracked. Sleep patterns and work

performance may be affected, and

long-term use of medications to treat

the atopic dermatitis may cause

complications. Adults with atopic

dermatitis also have a predisposition

toward irritant contact dermatitis,

where the skin becomes red and

inflamed from contact with

detergents, wool, friction from

clothing, or other potential irritants. It

is more likely to occur in occupations

involving frequent hand washing or

exposure to chemicals. Some people

develop a rash around their nipples.

These localized symptoms are

difficult to treat. Because adults may also develop

cataracts, the doctor may recommend regular eye exams.

E

ach person 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
13

Currently, there

is no single test

to diagnose

atopic dermatitis.

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. A preliminary

diagnosis of atopic dermatitis

can be made if the patient has

three or more features from each

of two categories: major features

and minor features. Some of

these features are listed in the

box on page 14.

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 IgE (allergic) antibodies

to the substance tested. IgE (immunoglobulin E) controls

the immune system’s allergic response and is often high

in atopic dermatitis.
14

Major and Minor Features of Atopic Dermatitis

■ Intense itching

■ Characteristic rash in locations typical of the

disease

■ Chronic or repeatedly occurring symptoms

■ Personal or family history of atopic disorders

(eczema, hay fever, asthma)

■ Early age of onset

■ Dry skin that may also have patchy scales or

rough bumps

■ High levels of immunoglobulin E (IgE), an

antibody, in the blood

■ Numerous skin creases on the palms

■ Hand or foot involvement

■ Inflammation around the lips

■ Nipple eczema

■ Susceptibility to skin infection

■ Positive allergy skin tests
15

Recently, it was shown that if the quantity of IgE

antibodies to a food in the blood is above a certain

level, it is diagnostic of a food allergy. If the level of

IgE to a specific food does not exceed the level needed

for diagnosis but a food allergy is suspected, a person

might be asked to record everything eaten and note any

reactions. Physician-supervised food challenges (that is,

the introduction of a food) following a period of food

elimination may be necessary to determine if

symptomatic food allergy is present. Identifying the

food allergen may be difficult when a person is also

being exposed to other possible allergens at the same

time or symptoms may be triggered by other factors,

such as infection, heat, and humidity.

M

any factors or conditions can make symptoms of

atopic dermatitis worse, further triggering the

already overactive immune system, aggravating the itchscratch cycle, and increasing damage to the skin. These

factors can be broken down into two main categories:

irritants and allergens. Emotional factors and some

infections and illnesses can also influence atopic

dermatitis.

Irritants are substances that directly affect the skin and,

when present in high enough concentrations with long

enough contact, cause the skin to become red and itchy

or to burn. Specific irritants affect people with atopic

dermatitis to different degrees. Over time, many patients

and their family members learn to identify the irritants

causing the most trouble. For example, frequent wetting

and drying of the skin may affect the skin barrier

function. Also, wool or synthetic fibers and rough or
16

poorly fitting clothing can rub the skin, trigger

inflammation, and cause the itch-scratch cycle to begin.

Soaps and detergents may have a drying effect and

worsen itching, and some perfumes and cosmetics may

irritate the skin. Exposure to certain substances, such as

solvents, dust, or sand, may also make the condition

worse. Cigarette smoke may irritate the eyelids. Because

the effects of irritants vary from one person to another,

each person can best determine what substances or

circumstances cause the disease to flare.

Allergens are substances from foods, plants, animals, or

the air that inflame the skin because the immune system

overreacts to the substance. Inflammation occurs even

when the person is exposed to small amounts of the

substance for a limited time. Although it is known that

allergens in the air, such as dust mites, pollens, molds,

and dander from animal hair or skin, may worsen the

symptoms of atopic dermatitis in some people, scientists

aren’t certain whether inhaling these allergens or their

Common Irritants

■ Wool or synthetic fibers

■ Soaps and detergents

■ Some perfumes and cosmetics

■ Substances such as chlorine, mineral oil,

or solvents

■ Dust or sand

■ Cigarette smoke
17

actual penetration of the skin causes the problems.

When people with atopic dermatitis come into contact

with an irritant or allergen they are sensitive to,

inflammation-producing cells become active. These cells

release chemicals that cause itching and redness. As the

person responds by scratching and rubbing the skin,

further damage occurs.

A number of studies have shown that foods may trigger

or worsen atopic dermatitis in some people, particularly

infants and children. In general, the worse the atopic

dermatitis and the younger the child, the more likely

food allergy is present. An allergic reaction to food can

cause skin inflammation (generally an itchy red rash),

gastrointestinal symptoms (abdominal pain, vomiting,

diarrhea), and/or upper respiratory tract symptoms

(congestion, sneezing, and wheezing). The most

common allergenic (allergy-causing) foods are eggs,

milk, peanuts, wheat, soy, and fish. A recent analysis of

a large number of studies on allergies and breastfeeding

indicated that breastfeeding an infant for at least 4

months may protect the child from developing allergies.

However, some studies suggest that mothers with a

family history of atopic diseases should avoid eating

common allergenic foods during late pregnancy and

breastfeeding.

In addition to irritants and allergens, emotional factors,

skin infections, and temperature and climate play a role

in atopic dermatitis. Although the disease itself is not

caused by emotional factors, it can be made worse by

stress, anger, and frustration. Interpersonal problems or

major life changes, such as divorce, job changes, or the

death of a loved one, can also make the disease worse.
18

Treatment is more

effective when a

partnership

develops that

includes the

patient, family

members, and

doctor.

Bathing without proper moisturizing afterward is a

common factor that triggers a flare of atopic dermatitis.

The low humidity of winter or the dry year-round

climate of some geographic areas can make the disease

worse, as can overheated indoor

areas and long or hot baths and

showers. Alternately sweating and

chilling can trigger a flare in some

people. Bacterial infections can also

trigger or increase the severity of

atopic dermatitis. If a patient

experiences a sudden flare of illness,

the doctor may check for infection.

T

reatment is more effective when a

partnership develops that includes

the patient, family members, and

doctor. The doctor will suggest a

treatment plan based on the patient’s

age, symptoms, and general health.

The patient or family member

providing care plays a large role in

the success of the treatment plan by

carefully following the doctor’s

instructions and paying attention to

what is or is not helpful. Most

patients will notice improvement with proper skin care

and lifestyle changes.

The doctor has two main goals in treating atopic

dermatitis: healing the skin and preventing flares.

These may be assisted by developing skin care routines
19

and avoiding substances that lead to skin irritation and

trigger the immune system and the itch-scratch cycle. 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: New medications known as immunomodulators have been developed that help control

inflammation and reduce immune system reactions

when applied to the skin. Examples of these medications

are tacrolimus ointment (Protopic*) and pimecrolimus

cream (Elidel). They can be used in patients older than 2

years of age and have few side effects (burning or

itching the first few days of application). They not only

reduce flares, but also maintain skin texture and reduce

the need for long-term use of corticosteroids.

Corticosteroid creams and ointments have been used for

many years to treat atopic dermatitis and other

autoimmune diseases affecting the skin. Sometimes

over-the-counter preparations are used, but in many

cases the doctor will prescribe a stronger corticosteroid

cream or ointment. When prescribing a medication, the

doctor will take into account the patient’s age, location

of the skin to be treated, severity of the symptoms, and

type of preparation (cream or ointment) that will be

most effective. Sometimes the base used in certain

brands of corticosteroid creams and ointments irritates

*Brand names included in this booklet are provided as examples only, and their inclusion does

not mean that these products are endorsed by the National Institutes of Health or any other

Government agency. Also, if a particular brand name is not mentioned, this does not mean or

imply that the product is unsatisfactory.
20

Corticosteroid

creams and ointments have been

used for many

years to treat

atopic dermatitis

and other autoimmune diseases affecting the skin.

the skin of a particular patient. Side effects of repeated or

long-term use of topical corticosteroids can include

thinning of the skin, infections, growth suppression (in

children), and stretch marks on 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.

An example of a commonly

prescribed corticosteroid is

prednisone. Typically, these

medications are used only in

resistant cases and only given for

short periods of time. The side

effects of systemic corticosteroids

can include skin damage, thinned or

weakened bones, high blood

pressure, high blood sugar,

infections, and cataracts. It can be

dangerous to suddenly stop taking

corticosteroids, so it is very

important that the doctor and patient

work together in changing the

corticosteroid dose.

Antibiotics to treat skin infections

may be applied directly to the skin

in an ointment, but are usually more

effective when taken by mouth. If

viral or fungal infections are present,

the doctor may also prescribe specific medications to

treat those infections.
21

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.

In adults, drugs that suppress the immune system, such

as cyclosporine, methotrexate, or azathioprine, may be

prescribed to treat severe cases of atopic dermatitis that

have failed to respond to other forms of therapy. These

drugs block the production of some immune cells and

curb the action of others. The side effects of drugs like

cyclosporine can include high blood pressure, nausea,

vomiting, kidney problems, headaches, tingling or

numbness, and a possible increased risk of cancer and

infections. There is also a risk of relapse after the drug is

stopped. Because of their toxic side effects, systemic

corticosteroids and immunosuppressive drugs are used

only in severe cases and then for as short a period of

time as possible. Patients requiring systemic

corticosteroids should be referred to dermatologists or

allergists specializing in the care of atopic dermatitis to

help identify trigger factors and alternative therapies.

In rare cases, when home-based treatments have been

unsuccessful, a patient may need a few days in the

hospital for intense treatment.

Phototherapy: Use of ultraviolet A or B light waves,

alone or combined, can be an effective treatment for mild

to moderate dermatitis in older children (over 12 years

old) and adults. A combination of ultraviolet light

therapy and a drug called psoralen can also be used in

cases that are resistant to ultraviolet light alone. Possible

long-term side effects of this treatment include premature
22

skin aging and skin cancer. 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.

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.

Treating Atopic Dermatitis

in Infants and Children

■ Give lukewarm baths.

■ Apply lubricant 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.
23

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 lubricant to seal in the water that has been

absorbed into the skin during bathing. In addition to

restoring the skin’s moisture, lubrication 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. Therefore, they generally are not

the best choice. Creams and ointments work better at

healing the skin.

Another key to protecting and restoring the skin is

taking steps to avoid repeated skin infections. Signs of

skin infection include tiny pustules (pus-filled bumps),

oozing cracks or sores, or crusty yellow blisters. If

symptoms of a skin infection develop, the doctor

should be consulted and treatment should begin as soon

as possible.

Protection from Allergen Exposure: The doctor may

suggest reducing exposure to a suspected allergen. For

example, the 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.
24

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.

D

espite the symptoms caused by atopic dermatitis, it

is possible for people with the disorder to maintain a

good quality of life. The keys to quality of life lie in

being well-informed; awareness of symptoms and their

possible cause; and developing a partnership involving

the patient or caregiving family member, medical doctor,

and other health professionals. Good communication is

essential. (See “Tips for Working With Your Doctor” on

page 26.)

When a child has atopic dermatitis, the entire family may

be affected. It is helpful if families have additional

support to help them cope with the stress and frustration

associated with the disease. A child may be fussy and

difficult and unable to keep from scratching and rubbing

the skin. Distracting the child and providing activities

that keep the hands busy are helpful but require much

effort on the part of the parents or caregivers. Another

issue families face is the social and emotional stress

associated with changes in appearance caused by atopic

dermatitis. The child may face difficulty in school or

with social relationships and may need additional support

and encouragement from family members.
25

Adults with atopic dermatitis can enhance their quality

of life by caring regularly for their skin and being

mindful of the effects of the disease and how to treat

them. Adults should develop a skin care regimen as part

of their daily routine, which can be adapted as

circumstances and skin conditions change. 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. Chronic anxiety and depression may be

relieved by short-term psychological therapy.

Recognizing the situations when scratching is most

likely to occur may also help. For example, many

patients find that they scratch more when they are idle,

and they do better when engaged in activities that keep

the hands occupied. Counseling also may be helpful to

identify or change career goals if a job involves contact

with irritants or involves frequent hand washing, such as

kitchen work or auto mechanics.

A

lthough scientists are working to develop safer

vaccines, persons 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,

persons 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.
26

People with atopic dermatitis should exercise caution

when coming into close physical contact with a person

who has been recently vaccinated, and make certain the

vaccinated person has covered the vaccination site or

taken other precautions until the scab falls off (about 3

weeks). Those who have had physical contact with a

vaccinated person’s unhealed vaccination site or to their

bedding or other items that might have touched that site

should notify their doctor, particularly if they develop a

new or unusual rash.

During a smallpox outbreak, these vaccination

recommendations may change. Persons with atopic

dermatitis who have been exposed to smallpox should

consult their doctor about vaccination.

Tips for Working With Your Doctor

■ Provide complete, accurate medical information.

■ Make a list of your questions and concerns in

advance.

■ Be honest and share your point of view with the

doctor.

■ Ask for clarification or further explanation if

you need it.

■ Talk to other members of the health care team,

such as nurses, therapists, or pharmacists.

■ Don’t hesitate to discuss sensitive subjects with

your doctor.

■ Discuss changes to medical treatment or

medications with your doctor.
27

Additional information about atopic dermatitis and

smallpox vaccination is available from CDC. (See

“Additional Resources” section of this booklet.)

R

esearchers supported by the National Institute of

Arthritis and Musculoskeletal and Skin Diseases and

other institutes of the National Institutes of Health 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, studies of identical

twins, who have the same genes, show that in an

estimated 80 to 90 percent of cases, atopic disease

appears in both twins. Fraternal (nonidentical) twins, who

have only some genes in common, are no more likely

than two other people in the general population to both

have an atopic disease. These findings suggest that genes

play an important role in determining who gets the

disease.

Biochemical Abnormalities: Scientists suspect that

changes in the skin’s protective barrier make people with

atopic dermatitis more sensitive to irritants. Such people

have lower levels of fatty acids (substances that provide
28

moisture and elasticity) in their skin, which causes dryness

and reduces the skin’s ability to control inflammation.

Other research points to a possible defect in a type of

white blood cell called a monocyte. In people with atopic

dermatitis, monocytes appear to play a role in the

decreased production of an immune system hormone

called interferon gamma (IFN-γ), which helps regulate

allergic reactions. This defect may cause exaggerated

immune and inflammatory responses in the blood and

tissues of people with atopic dermatitis.

Faulty Regulation of Immunoglobulin E (IgE): As

already described in the section on diagnosis, IgE is a type

of antibody that controls the immune system’s allergic

response. An antibody is a special protein produced by the

immune system that recognizes and helps fight and

destroy viruses, bacteria, and other foreign substances that

invade the body. Normally, IgE is present in very small

amounts, but levels are high in 80 to 90 percent of people

with atopic dermatitis.

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.
29

Researchers also

think that an imbalance in the immune system may

contribute to the

development of

atopic dermatitis.

In allergic diseases, IgE antibodies are produced in

response to different allergens. When an allergen comes

into contact with IgE on specialized immune cells, the cells

release various chemicals, including histamine. These

chemicals cause the symptoms of an

allergic reaction, such as wheezing,

sneezing, runny eyes, and itching.

The release of histamine and other

chemicals alone cannot explain the

typical long-term symptoms of the

disease. Research is underway to

identify factors that may explain why

too much IgE is produced and how it

plays a role in the disease.

Immune System Imbalance:

Researchers also think that an

imbalance in the immune system may

contribute to the development of

atopic dermatitis. It appears that the

part of the immune system

responsible for stimulating IgE is

overactive, and the part that handles

skin viral and fungal infections is

underactive. Indeed, the skin of

people with atopic dermatitis shows

increased susceptibility to skin

infections. This imbalance appears to result in the skin’s

inability to prevent inflammation, even in areas of skin

that appear normal. In one project, scientists are studying

the role of the infectious bacterium Staphylococcus aureus

(S. aureus) in atopic dermatitis.

Researchers believe that one type of immune cell in the

skin, called a Langerhans cell, may be involved in atopic

dermatitis. Langerhans cells pick up viruses, bacteria,
30

allergens, and other foreign substances that invade the

body and deliver them to other cells in the immune

defense system. Langerhans cells appear to be hyperactive in the skin of people with atopic diseases. Certain

Langerhans cells are particularly potent at activating

white blood cells called T cells in atopic skin, which

produce proteins that promote allergic response. This

function results in an exaggerated response of the skin to

tiny amounts of allergens.

Scientists have also developed mouse models to study

step-by-step changes in the immune system in atopic

dermatitis, which may eventually lead to a treatment that

effectively targets the immune system.

Drug Research: Some researchers are focusing on new

treatments for atopic dermatitis, including biologic agents,

fatty acid supplements, and new forms of phototherapy.

For example, they are studying how ultraviolet light

affects the skin’s immune system in healthy and diseased

skin. They are also investigating biologic agents,

including several aimed at modifying the response of the

immune system. A biologic agent is a new type of drug

based on molecules that occur naturally in the body. One

promising treatment is the use of thymopentin to

reestablish balance in the immune system.

Researchers also continue to look for drugs that suppress

the immune system. In this regard, they are studying the

effectiveness of cyclosporine A. Clinical trials are

underway with another drug called FK506, which is

applied to the skin rather than taken orally. Also, antiinflammatory drugs have been developed that affect

multiple cells and cell functions, and may prove to be an

effective alternative to corticosteroids in the treatment of

atopic dermatitis.
31

Several experimental treatments

are being evaluated that attempt

to replace substances that are

deficient in people

with atopic dermatitis.

Several experimental treatments are being evaluated that

attempt to replace substances that are deficient in people

with atopic dermatitis. Evening primrose oil is a

substance rich in gamma-linolenic acid, one of the fatty

acids that is decreased in the skin of

people with atopic dermatitis. Studies

to date using evening primrose oil have

yielded contradictory results. In

addition, dietary fatty acid supplements

have not proven highly effective. There

is also a great deal of interest in the

use of Chinese herbs and herbal teas to

treat the disease. Studies to date show

some benefit, but not without concerns

about toxicity and the risks involved in

suppressing the immune system

without close medical supervision.

A

lthough 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.
32

National Institute of Arthritis and Musculoskeletal

and Skin Diseases

NIAMS/National Institutes of Health

1 AMS Circle

Bethesda, MD 20892-3675

(301) 495-4484 or

(877) 22-NIAMS (226-4267) (free of charge)

TTY: (301) 565-2966

Fax: (301) 718-6366

niamsinfo@mail.nih.gov

www.niams.nih.gov

NIAMS provides information about various forms of

skin diseases; arthritis and rheumatic diseases; and

bone, muscle, and joint diseases. It distributes patient

and professional education materials and refers people

to other sources of information. Additional information

and updates can be found on the NIAMS Web site.

Listings of clinical trials recruiting patients who have or

are at risk of developing a skin disease can be found at

www.ClinicalTrials.gov.

Centers for Disease Control and Prevention

1600 Clifton Road

Atlanta, GA 30333

(888) 246-2675 (free of charge)

TTY: (866) 874-2646

E-mail: cdcresponse@ashastd.org

www.bt.cdc.gov/agent/smallpox/index.asp

This government organization is a focus for disease

prevention and control, environmental health, and

health promotion. It provides detailed information about

smallpox and vaccination against smallpox, including
those who should not receive the vaccine, precautions

vaccinated persons should take to prevent harm to those

with atopic dermatitis and certain other conditions, and

answers to frequently asked questions.

American Academy of Dermatology

P.O. Box 4014

Schaumburg, IL 60168

(847) 330-0230 or

(888) 462-DERM (3376) (free of charge)

Fax: (847) 330-0050

www.aad.org

This national professional association can provide

referrals to dermatologists. It has published a pamphlet

on atopic eczema/dermatitis, which is available on the

organization’s Web site or can be obtained by calling or

writing to the academy. Single copies are free.

American Academy of Allergy, Asthma,

and Immunology

611 East Wells Street

Milwaukee, WI 53202

(414) 272-6071 or (800) 822-2762 (free of charge)

E-mail: info@aaaai.org

www.aaaai.org

This national professional association representing

allergists and clinical immunologists publishes pamphlets

about allergies and atopic dermatitis. The academy can

also provide physician referrals for evaluation of

allergies.
34

National Eczema Association for

Science and Education

4460 Redwood Highway, Suite 16-D

San Rafael, CA 94903-1953

(415) 499-3474 or (800) 818-7546 (free of charge)

Fax: (415) 472-5345

info@nationaleczema.org

www.nationaleczema.org

This is a national patient-oriented association devoted to

eczema. It publishes a quarterly newsletter, provides

patient brochures and provider educational materials,

offers resource services to patients, and provides referrals

to atopic dermatitis/eczema research centers.

Inflammatory Skin Disease Institute

P.O. Box 1074

Newport News, VA 23601

(757) 223-0795 or

(800) 484-6800, Ext. 6321 (free of charge)

Fax: (757) 595-1842

This national organization provides educational

information and support and engages in advocacy. It is

dedicated to improving the lives of people with

inflammatory skin disease.
35

Food Allergy and Anaphylaxis Network (FAAN)

10400 Eaton Place

Fairfax, VA 22030

(703) 691-3179 or (800) 929-4040 (free of charge)

Fax: (703) 691-2713

faan@foodallergy.org

www.foodallergy.org

The organization provides education, emotional support,

and coping strategies to individuals with food allergies. It

publishes a bimonthly newsletter and has books, videos,

and other educational materials pertaining to food allergy

diets and to food-related issues in schools, daycare

centers, and camps. FAAN also makes physician referrals.
36

The NIAMS gratefully acknowledges the assistance of

the following people in the preparation and review of this

publication: Joanne Cono, M.D., Sc.M., Centers for

Disease Control and Prevention, Atlanta, Georgia; Kevin

Cooper, M.D., Case Western Reserve University,

University Hospitals of Cleveland, Cleveland, Ohio; Jon

Hanifin, M.D., Oregon Health & Science University,

Portland, Oregon; Donald Leung, M.D., Ph.D., National

Jewish Medical and Research Center, Denver, Colorado;

Alan Moshell, M.D., NIAMS, NIH; Amy Paller, M.D.,

Children’s Hospital of Chicago, Chicago, Illinois; Hugh

Sampson, M.D., Mount Sinai School of Medicine, New

York, New York; Maria Turner, M.D., National Cancer

Institute, NIH; and LaDonna Williams, Inflammatory

Skin Disease Institute, Newport News, Virginia.
The mission of the National Institute of Arthritis and

Musculoskeletal and Skin Diseases (NIAMS), a part of

the Department of Health and Human Services’ National

Institutes of Health (NIH), is to support research into the

causes, treatment, 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 National Institute of Arthritis and

Musculoskeletal and Skin Diseases Information

Clearinghouse is a public service sponsored by the

NIAMS that provides health information and information

sources. Additional information can be found on the

NIAMS Web site at www.niams.nih.gov
U.S. Department of Health and

Human Services

Public Health Service

National Institutes of Health

National Institute of Arthritis and

Musculoskeletal and Skin Diseases

NIH Publication No. 03-4272

January 1999

Revised April 2003