Sometimes the terms “atopic dermatitis” and “eczema” are used interchangeably, but they are not identical: There are several different types of eczema, with atopic dermatitis the most prevalent form. Atopic dermatitis can begin in infancy and is most common in children and adolescents, but it affects adults as well, says Amy McMichael, MD, a dermatologist at Atrium Health Wake Forest Baptist in Winston Salem, North Carolina. People with atopic dermatitis often have other chronic conditions. “Atopic dermatitis can be associated with asthma, and environmental and food allergies,” says Dr. McMichael. An atopic dermatitis flare-up can include the following symptoms, according to Mayo Clinic:
Dry skinRash or patches of discolored skinItchy skinScaly patchesInflamed skin in affected areasOozing bumps on affected areas
Atopic dermatitis in white people typically looks pink or red, while in people of color, rashes may appear dark brown, purple, or ashen gray, says Shilpi Khetarpal, MD, a dermatologist at Cleveland Clinic in Ohio. Other atopic dermatitis symptoms are the same regardless of race or ethnicity. In adults with AD, the rash most often appears on the hands, neck, in the bend of the elbows and knees, the skin around the eyes, and the ankles and feet, says Dr. Wan. In infants, atopic dermatitis most often affects the face, scalp, and areas of skin where the joint bends. In older children, AD is most likely to show up in the bends of the elbows and knees, the neck, and the ankles. People with atopic dermatitis will typically experience periods where the disease is worse, called flares, followed by periods where the skin improves, called remissions. Genetics are a major influence. “People who have atopic dermatitis generally have a genetic predisposition towards it. That’s been supported by a lot of studies that have found shared immunologic or skin barrier impairment on a genetic level for a lot of patients,” says Wan. This impairment is related to a deficiency of a protein called filaggrin, per MedlinePlus. Without normal levels of this protein, the skin barrier changes and loses moisture, making the skin dry and more prone to damage and inflammation. Researchers believe that this inflammation triggers the itch-scratch cycle, leading to further skin damage as well as increased risk for bacterial infection. Although atopic dermatitis is not an autoimmune disease (a condition in which your immune system attacks your body), the immune system in someone with AD can malfunction and be overactive. This can create inflammation in the skin and contribute to atopic dermatitis. As for environmental causes, living in an area with a harsh climate raises the risk of developing atopic dermatitis, although there’s not as much evidence to show that environmental factors alone will cause AD, says Wan. Atopic dermatitis is not contagious, says McMichael. “Emotional stress may worsen the condition but does not cause it,” she adds. In some situations, atypical symptoms might make a physician uncertain about an atopic dermatitis diagnosis. In those cases the physician might request a skin biopsy to clarify or confirm a diagnosis, says Wan. A skin biopsy is a minor procedure that involves using a scalpel, sharp blade, or punch instrument to remove a very small section of the rash (after numbing the area with a local anesthetic), per NYU Langone Health. The physician sends the sample to a lab to be examined under a microscope to determine what is causing the rash. Many doctors aren’t adequately trained to recognize atopic dermatitis in skin of color, leading to delayed diagnosis or misdiagnosis. “Many people think of eczema as being red, dry, and itchy, which is how it appears in lighter skin individuals. However, in darker skin types the redness may be difficult to see because the eczema tends to look darker brown, purple, or ashen gray in color,” says Dr. Khetarpal. Common scales used to diagnose atopic dermatitis that include rating how red the patches are can underestimate the severity of AD in people with darker skin, notes research published in the Annals of Allergy, Asthma, and Immunology.
Prognosis of Atopic Dermatitis
Atopic dermatitis can affect different people in very different ways, and the prognosis (the course of the disease) can vary significantly from person to person as well, says Wan. “To generalize, there are a fair number of patients who ‘outgrow’ AD or at least have tremendous natural improvement over time. Some infants or children who have AD might not have many significant symptoms by late adolescent or adult years,” she says. Some people may have more of a waxing and waning AD experience. “For example, there are people who may only have flares in the winter and only need to use treatment then,” says Wan. Unfortunately, there are also people who have persistently severe atopic dermatitis throughout their adulthood and into their old age; some of those people need to remain on treatment throughout their entire life, says Wan. “The symptoms of a flare can go away in as little as a few days, especially if you start active treatment very quickly. But a flare can also extend for weeks or even months if you’re not treating or under-treating it,” she says. Generally speaking, with appropriate treatment, it’s reasonable to expect a flare to subside within a couple of weeks, says Wan. In addition to taking atopic dermatitis medications as directed, doing something as simple as using a daily moisturizer can help reduce the amount of time that a flare will last, Wan says. “For mild atopic dermatitis, topical steroids and other topical, nonsteroidal, anti-inflammatory medications may be used,” says McMichael. Over-the-counter oral antihistamines can help with itch. Corticosteroids. Also known as topical steroids, corticosteroids can take the form of ointment, cream, lotion or spray, according to the National Eczema Association. These medications can reduce inflammation and allow the skin to heal. “This is probably the most common topical treatment and can be used in adults and children,” says Wan. Topical steroids are classified by strength, ranging from “super potent” to “least potent.” Nonsteroid-Based Topical Treatments Dermatologists may prescribe nonsteroid-based topicals instead of corticosteroids for long-term use, or for cases involving sensitive areas like the face or genitals, says Wan. This group of medications includes:
Topical PDE4 Inhibitors These medications block PDE-4, an enzyme that’s involved in AD inflammation. Crisaborole (Eucrisa) ointment is approved to treat atopic dermatitis in children ages 3 months and older and adults.Topical Calcineurin Inhibitors (TCIs) TCIs reduce inflammation by preventing the immune system from activating certain cells. Medications include tacrolimus ointment (sold as a generic and under the brand name Protopic) and pimecrolimus cream (sold as a generic and under the brand name Elidel). Both can be used in people ages 2 and up.Topical JAK Inhibitor This type of medication works by blocking enzymes that contribute to inflammation in the skin and itch and affect skin barrier function. There’s currently one medication in this class, ruxolitinib (Opzelura), approved for adults and children 12 and older whose disease is not adequately controlled with other topical prescription therapies or who shouldn’t use those therapies. The U.S. Food and Drug Administration (FDA) requires that ruxolitinib carry a warning because of the small risk of potentially serious side effects.
Phototherapy Dermatologists often reserve medically regulated light therapy for more widespread or severe atopic dermatitis, says Wan. The most common type of phototherapy used to treat AD is narrowband ultraviolet B (NB-UVB) light, per the National Eczema Association, although your dermatologist may recommend other types. Systemic Treatments These therapies are taken by mouth (oral) or as an injection that treat the inflammation of the atopic dermatitis systemically, from the inside out, says Wan. Physicians will usually reserve these treatments for people with more severe AD. This group includes:
Biologics These injectable medications specifically target molecules in the body that are responsible for triggering inflammation. Dupilumab (Dupixent) is approved for atopic dermatitis in people ages 6 and older, and tralokinumab-Irdm (Adbry) is approved for adults ages 18 and older. Doctors can prescribe other biologics off-label (meaning they may work to control the inflammation, but they aren’t specifically approved for AD).Oral Immunosuppressants These medications can help suppress the immune system to reduce inflammation and lessen AD symptoms. Abrocitinib (Cibinqo) and Upadacitinib (Rinvoq) are oral JAK1 inhibitors for people who aren’t getting adequate symptom relief from biologics: Cibinqo is approved for adults, Rinvoq for people ages 12 and older. Both of these medications carry an FDA warning because of the small risk of potentially serious side effects.
Other immunosuppressive drugs are sometimes used to treat atopic dermatitis, per the National Eczema Association, but are not specifically approved for AD:
AzathioprineCyclosporineMethotrexateMycophenolate mofetil
Home Therapies for Atopic Dermatitis
Bleach Baths A diluted bleach bath can help with AD flares, especially when the skin is infected, says Wan. Wet Wrap Therapy This therapy involves applying moisturizer and medication to a flare-up, then wrapping the affected area with warm, damp fabric or gauze and then a second layer of dry cloth. Wet wrap therapy helps topic treatments work a bit more effectively, says Wan. The therapy can help rehydrate and calm the skin, too, according to the National Eczema Association. Moisturize. Something as simple as using an effective and unscented moisturizer twice a day can help prevent or improve atopic dermatitis flares, says Wan. Shower daily. Take a daily bath or shower but avoid hot water, which can dry out skin. Shorter is better — limit time in the bath or shower to 10 minutes or less, according to Mayo Clinic. Pat skin dry rather than toweling off vigorously. Avoid known triggers. These can include materials that can be abrasive to the skin such as wool; heat and sweat; cold and dry air; makeup or skin products; fragrances; harsh cleaning products; allergens such as dust mites, pet dander, mold, and pollen; smoke; and irritating chemicals or pollutants. Infants and children may have flares triggered by certain foods, such as eggs and dairy. But in adults, there is very limited evidence to strongly support that any one diet will help prevent AD or flares, says Wan. There is a connection between atopic dermatitis and sleep problems, but researchers are still trying to understand it. “We know that people with eczema [or] atopic dermatitis have sleep issues, which includes short sleep cycles sometimes and dysregulated sleep. It’s hard to know, is AD causing the sleep issues, or can sleep issues (in part) be one of the factors to cause or worsen AD, or both?” says Wan. Whatever the case, prioritizing sleep and addressing any underlying sleep issues may make AD less severe, she says. Finding healthy ways to manage and avoid stress can help as well, because emotional stress can make atopic dermatitis worse in some people, says Wan.
Asthma and Hay Fever It’s common for people with atopic dermatitis to develop asthma and hay fever.Food Allergies People with AD often have food allergies, and one of the main symptoms of this condition is hivesChronic Itchy, Scaly Skin A skin condition called neurodermatitis (lichen simplex chronicus) starts with a patch of itchy skin. Scratching the area can make it feel better at first, but can lead to more long-term itchiness. This condition can cause the affected skin to become discolored, thick, and leathery.Patches of Skin That Are Darker or Lighter Than the Surrounding Area After the initial rash heals, some patches of skin may remain a different color for months, a condition called post-inflammatory hyperpigmentation or hypopigmentation. Skin discoloration in AD is more likely in people of color, according to the Skin of Color Society.Skin Infections Repeated scratching that breaks the skin can cause open sores and cracks which can become infected. If untreated, these skin infections can spread and become life-threatening.Sleep Problems The itchiness of atopic dermatitis can interfere with sleep.Mental Health Conditions People with atopic dermatitis are more likely to have depression or anxiety.
It’s estimated that about 15 percent of children in the United States have atopic dermatitis, and about 16.5 million adults, according to the Allergy and Asthma Network. Women and girls are slightly more likely to develop atopic dermatitis compared with men and boys. Atopic dermatitis is more common in Black American children than in white children, affecting 19.3 percent of African American children compared with 16.1 percent of European American children, per the Annals of Allergy, Asthma, and Immunology research. “It’s unclear what’s driving those differences,” says Wan. “It could be genetic, but it’s also likely to be caused by social determinants of health, such as a person’s ability to access treatments.” Because of the differences in the way atopic dermatitis appears in different races and ethnicities, many experts believe it’s unlikely that a “one-size-fits-all” treatment approach will work for everyone. More clinical trials are needed that evaluate how effective different medications are in treating AD in different types of skin. Depression and Anxiety Depression and anxiety symptoms are more common in adults with atopic dermatitis than in the general population. A study published in 2020 in the Journal of Allergy and Clinical Immunology in Practice found that people with AD were 14 percent more likely to develop new depression and 17 percent more likely to develop new anxiety. The authors also found that the more severe a person’s atopic dermatitis was, the more likely they were to develop depression. The AAD represents most practicing dermatologists in the United States, but the organization also provides lots of resources and information for people living with skin conditions, including atopic dermatitis. The website includes a tool that allows you to search its database to find a dermatologist in your area. Asthma and Allergy Foundation of America (AAFA) Managing allergies and triggers is an important part of minimizing atopic dermatitis flares. The AAFA’s site has a wealth of information about allergies, for both adults and kids. The organization has partnered with the National Eczema Association to study atopic dermatitis in America. National Eczema Association (NEA) The NEA is the most prominent U.S. organization devoted solely to education, research, patient support, and advocacy related to atopic dermatitis and other forms of eczema. The organization also has a searchable product directory, called the Seal of Acceptance, that screens products that have been created or intended for use by people with eczema or severe sensitive skin conditions.
