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Definition

Atopic dermatitis is a long-term (chronic) skin disorder that involves scaly and itchy rashes. It is a type of eczema.

Other forms of eczema include:

• Contact dermatitis
• Dyshidrotic eczema
• Nummular eczema
• Seborrheic dermatitis

Causes

Atopic dermatitis is due to a reaction in the skin. The reaction leads to ongoing itching, swelling and redness. People with atopic dermatitis may be more sensitive because their skin lacks specific proteins that maintain the skin's barrier to water.

Atopic dermatitis is most common in infants. It may start as early as age 2 to 6 months. Many people outgrow it by early adulthood.

People with atopic dermatitis often have asthma or seasonal allergies. There is often a family history of allergies such as asthma, hay fever, or eczema. People with atopic dermatitis often test positive for allergy skin tests. However, atopic dermatitis is not caused by allergies.

The following can make atopic dermatitis symptoms worse:

• Allergies to pollen, mold, dust mites, or animals
• Cold and dry air in the winter
• Colds or the flu
• Contact with irritants and chemicals
• Contact with rough materials, such as wool
• Dry skin
• Emotional stress
• Drying out of the skin from taking frequent baths or showers and swimming very often
• Getting too hot or too cold, as well as sudden changes in temperature
• Perfumes or dyes added to skin lotions or soaps

Symptoms

Skin changes may include:

• Blisters with oozing and crusting
• Dry skin all over the body, or areas of bumpy skin on the back of the arms and front of the thighs
• Ear discharge or bleeding
• Raw areas of the skin from scratching
• Skin color changes, such as more or less color than the normal skin tone
• Skin redness or inflammation around the blisters
• Thickened or leather-like areas, which can occur after long-term irritation and scratching

The type and location of the rash can depend on the age of the person:

• In children younger than age 2, the rash may begin on the face, scalp, hands, and feet. The rash is often itchy and forms blisters that ooze and crust over.
• In older children and adults, the rash is more often seen on the inside of the knees and elbow. It can also appear on the neck, hands, and feet.
• In adults, the rash may be limited to the hands, eyelids, or genitals.
  
• Rashes may occur anywhere on the body during a bad outbreak.

Intense itching is common. Itching may start even before the rash appears. Atopic dermatitis is often called the "itch that rashes" because the itching starts, and then the skin rash follows as a result of scratching.

Exams and Tests

Your health care provider will look at your skin and do a physical exam. You may need a skin biopsy to confirm the diagnosis or rule out other causes of dry, itchy skin.

Diagnosis is based on:

• How your skin looks
• Your personal and family history

Allergy skin testing may be helpful for people with:

• Hard-to-treat atopic dermatitis
• Other allergy symptoms
• Skin rashes that form only on certain areas of the body after exposure to a specific chemical

Your provider may order cultures for infection of the skin. If you have atopic dermatitis, you may get infections easily.

Treatment

SKIN CARE AT HOME

Daily skin care may cut down on the need for medicines.

To help you avoid scratching your rash or skin:

• Use a moisturizer, topical steroid cream, or other medicine your provider prescribes.
• Take antihistamine medicines by mouth to reduce severe itching.
• Keep your fingernails cut short. Wear light gloves during sleep if nighttime scratching is a problem.

Keep your skin moist by using ointments (such as petroleum jelly), creams, or lotions 2 to 3 times a day. Choose skin products that do not contain alcohol, scents, dyes, and other chemicals. A humidifier to keep home air moist will also help.

Avoid things that make symptoms worse, such as:

• Foods, such as eggs, that may cause an allergic reaction in a very young child (always talk to your provider first)
• Irritants, such as wool and lanolin
• Strong soaps or detergents, as well as chemicals and solvents
• Sudden changes in body temperature and stress, which may cause sweating
• Triggers that cause allergy symptoms

When washing or bathing:

• Expose your skin to water for as short a time as possible. Short, cooler baths are better than long, hot baths.
• Use gentle body washes and cleansers instead of regular soaps.
• Do not scrub or dry your skin too hard or for too long.
• Apply lubricating creams, lotions, or ointment to your skin while it is still damp after bathing. This will help trap moisture in your skin.

MEDICINES

At this time, allergy shots are not used to treat atopic dermatitis.

Antihistamines taken by mouth may help with itching or allergies. You can often buy these medicines without a prescription.

Atopic dermatitis is usually treated with medicines placed directly on the skin or scalp. These are called topical medicines:

• You will probably be prescribed a mild corticosteroid cream or ointment at first (such as hydrocortisone). You may need a stronger medicine if this does not work.
• Medicines called topical immunomodulators (TIMs) may be prescribed for anyone over 2 years old. Ask your provider about concerns over a possible cancer risk with the use of these medicines.
• Creams or ointments that contain coal tar or anthralin may be used for thickened areas.
• Barrier repair creams containing ceramides may be used.

Wet-wrap treatment with topical corticosteroids may help control the condition. But, it may lead to an infection.

Other treatments that may be used include:

• Antibiotic creams or pills if your skin is infected
• Drugs that suppress the immune system
• Targeted biologic medicines that are designed to affect parts of the immune system involved in atopic dermatitis
• Phototherapy, a treatment in which your skin is carefully exposed to ultraviolet (UV) light
• Short-term use of systemic steroids (steroids given by mouth or through a vein)

Outlook (Prognosis)

Atopic dermatitis lasts a long time. You can control it by treating it, avoiding irritants, and by keeping your skin well-moisturized.

In children, the condition often starts to go away around age 5 to 6, but flare-ups will often occur. In adults, the problem is generally a long-term or returning condition.

Atopic dermatitis may be harder to control if it:

• Begins at an early age
• Involves a large amount of the body
• Occurs along with allergies and asthma
• Occurs in someone with a family history of eczema

Possible Complications

Complications of atopic dermatitis include:

• Infections of the skin caused by bacteria, fungi, or viruses
• Permanent scars
• Side effects from long-term use of medicines to control eczema

When to Contact a Medical Professional

Contact your provider if:

• Atopic dermatitis does not get better with home care 
• Symptoms get worse or treatment does not work
• You have signs of infection (such as fever, redness, or pain)

Prevention

Children who are breastfed until age 4 months may be less likely to get atopic dermatitis.

If a child is not breastfed, using a formula that contains processed cow milk protein (called partially hydrolyzed formula) may cut down on the chances of developing atopic dermatitis.

References

American Academy of Dermatology Association website. Eczema types: atopic dermatitis overview. www.aad.org/public/diseases/eczema/types/atopic-dermatitis. Updated November 28, 2022. Accessed December 5, 2022.

Boguniewicz M, Leung DYM. Atopic dermatitis. In: Burks AW, Holgate ST, O'Hehir RE, et al, eds. Middleton's Allergy: Principles and Practice. 9th ed. Philadelphia, PA: Elsevier; 2020:chap 33.

Dinulos JGH. Atopic dermatitis. In: Dinulos JGH, ed. Habif's Clinical Dermatology. 7th ed. Philadelphia, PA: Elsevier; 2021:chap 5.

McAleer MA, O'Regan GM, Irvine AD. Atopic dermatitis. In: Bolognia JL, Schaffer JV, Cerroni L, eds. Dermatology. 4th ed. Philadelphia, PA: Elsevier; 2018:chap 12.

Moon M, Guerrero AM, Li X, Koch E, Gehris RP. Dermatology. In: Zitelli BJ, McIntire SC, Nowalk AJ, Garrison J, eds. Zitelli and Davis' Atlas of Pediatric Physical Diagnosis. 8th ed. Philadelphia, PA: Elsevier; 2023:chap 8.

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