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Eczema (atopic)

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Eczema is a chronic skin condition that causes the skin to become itchy, reddened, dry and cracked.
Brought to you by NHS Choices

Overview

Introduction

Atopic eczema is the most common form of eczema, and mainly affects children. The exact cause of atopic eczema is unknown, but it often occurs in people who are prone to allergies ('atopic' means sensitivity to allergens).

Approximately three in 10 people who visit their GP with a skin problem are diagnosed with atopic eczema. The number of people who are diagnosed with it has increased in recent years. Males and females are affected equally, as are people from different ethnic backgrounds.

About eight in 10 atopic eczema cases occur before a child reaches five years of age. Many children develop it before their first birthday.

How will atopic eczema affect me or my child?

Atopic eczema can vary in severity. Some people are only mildly affected and have small areas of dry skin, which are occasionally itchy. Others may experience more severe symptoms, such as cracked, sore and bleeding skin.

For most children with atopic eczema, it clears up or significantly improves as they get older. In approximately 53% of young children with atopic eczema, it clears up by the time they reach 11, and in 65% of cases it clears up by the age of 16.

Fast facts

  • Eczema is a group of skin conditions that can affect all age groups.
  • Eczema affects around one in 12 adults and one in five children in the UK.
  • There are several different types of eczema, from mild to severe, including atopic, contact and varicose.
  • Cases of eczema have increased three-fold over the past 30 years.
  • Eczema can cause huge emotional and physical effects, especially if not treated properly.
  • Eczema can run in families and often accompanies asthma and hayfever.

    Source: National Eczema Society

Symptoms

Symptoms of atopic eczema

The symptoms of atopic eczema may always be present, but during a flare-up they will worsen and you or your child may need more intense treatment.

Atopic eczema can cause your skin to become:

  • dry,
  • itchy,
  • red,
  • broken,
  • thickened and
  • cracked.

During a flare-up, your skin may be:

  • extremely itchy, red, hot, dry and scaly,
  • wet, weeping and swollen, and
  • infected with bacteria (usually staphylococcus).


The symptoms of atopic eczema will vary according to how severely you or your child are affected by the condition.

People with mild atopic eczema will normally only experience small areas of dry skin, which are occasionally itchy. However, in more severe cases, atopic eczema can cause widespread dry skin, constant itching and oozing fluid.
Scratching can disrupt your sleep and make your skin bleed. It can also make an itch worse and an itch-scratch cycle may develop, with regular scratching. In children, this can lead to sleepless nights and difficulty concentrating at school.

Can eczema lead to more serious problems?

Broken skin can commonly lead to secondary infections, which are unpleasant and in severe cases may be difficult to treat. Eye complications of atopic eczema include conjunctival irritation, and less commonly, conjunctivitis and cataracts.

Causes

Causes of atopic eczema

Atopic eczema is an inherited condition, which means that you are born with it. It may be made worse by 'external' factors, such as pet fur and pollen, or 'internal' factors, such as stress and hormone levels.

Genetic factors

Research suggests that atopic eczema is primarily caused by a genetic problem. However, the exact genetic cause is not yet known.

If a child's parents have atopic eczema, there is a high probability that the child will also develop the condition. For example, studies have shown that 60% of children who have a parent with atopic eczema also have the condition. And, in cases where both parents have atopic eczema, 80% of children also have the condition.

Environmental factors

There are a number of environmental factors that can make atopic eczema worse.

Allergens are substances that can cause the body to react abnormally. This is known as an allergic reaction. Some of the most common allergens that can worsen atopic eczema include:

  • house dust-mites,
  • pet fur, and
  • pollen.

Atopic eczema can also sometimes be aggravated by food allergens. Foods that typically cause allergic reactions include:

  • cow's milk,
  • eggs,
  • nuts,
  • soya, and
  • wheat.

Approximately 10% of children with atopic eczema are affected by the food allergens listed above. It is relatively rare for food allergens to trigger atopic eczema in adults.

Hormonal changes

Many women find that their eczema is worse at certain times during their menstrual cycle. This is because hormonal changes in the body can affect the symptoms of atopic eczema.

Approximately 30% of women experience a flare-up of their eczema in the days before their period. Pregnancy can also have an adverse affect on those who have atopic eczema, with up to 50% of pregnant women finding that their eczema symptoms worsen during pregnancy.

Stress

Although it is known that stress is associated with atopic eczema, precisely how it affects the condition is not yet fully understood. Some people with eczema feel that their symptoms are worse when they are stressed. Others find that it is their symptoms that cause them to feel stressed.

Seasons

Most people with atopic eczema find that their symptoms improve during the summer months and get worse in the winter.

Exercise

After vigorous exercise, you may find that sweating makes your eczema symptoms worse. You should therefore try to keep cool when you are exercising by drinking plenty of fluids and taking regular breaks.

Diagnosis

Diagnosing atopic eczema

Your GP will usually be able to diagnose atopic eczema by assessing your or your child's skin and asking some questions about the symptoms.

You will be asked whether there is any history of atopic eczema in your family, or any other conditions that may be related to your eczema, such as allergies or asthma.

Diagnostic criteria

To help confirm a diagnosis of atopic eczema, your GP will assess the appearance of your skin against a number of diagnostic criteria.

In order to be diagnosed with atopic eczema, you must have had an itchy skin condition in the last 12 months plus three or more of the criteria outlined below.

  • Itchiness and irritation in the creases of your skin, such as the front of your elbows, behind your knees, at the front of your ankles, around your neck or around your eyes.
  • You currently have asthma or hayfever, or you have had them in the past. In the case of a child who is less than four years of age, they must have an immediate relative, such as a parent, brother or sister, who has asthma or hayfever.
  • Your skin has been dry within the last 12 months.
  • Your condition started when you were two years of age or younger (this criteria is not used if your child is less than four years of age).
  • There is eczema on the skin covering your joints, or the parts of your body that flex, such as your elbow, knees and wrists.

If your symptoms meet these diagnostic criteria, your GP will probably not need to carry out any formal kind of testing in order to confirm the diagnosis.

Establishing trigger factors

Your GP will work with you to try to establish what factors worsen your eczema. They may ask you some questions about your diet and lifestyle to see if there are any obvious factors that may be contributing to your symptoms. For example, if you have recently changed the type of soap or detergent that you use, it may be a trigger factor.

Your GP may also use other methods to try to determine what is triggering your eczema. For example, they may ask you to keep a food diary, to establish whether a specific food is causing your symptoms to worsen.

A food diary involves you noting down everything that you eat, while at the same time making a record of any eczema flares that you have. In this way, your GP can see if there are any patterns between your symptoms and what you eat.

Treatment

Treating eczema

Although there is no simple cure for atopic eczema, the symptoms during an eczema flare can usually be eased using a variety of treatments. Children with atopic eczema normally find that their symptoms naturally improve with time.

Self-care

There are a number of self-care treatments that you can use at home to help manage your or your child's eczema symptoms.

Avoid scratching:
Although eczema is often itchy, scratching it will further aggravate the skin. If you scratch your skin, the risk of your eczema becoming infected with bacteria will be increased (see the 'complications' section).

However, there may be times when you or your child will not be able to help scratching your eczema. Keeping nails short will help to minimise any damage to the skin. If your baby has atopic eczema, anti-scratch mittens will help prevent them scratching their skin.

Avoid trigger factors:
Your GP will work with you to try to establish what factors or foods trigger your or your child's eczema flares (see the 'diagnosis' section). If you are able to establish which factors trigger flares, you can try to avoid contact with them.

For example, if some man-made materials irritate your skin, avoid wearing synthetic fibres and stick to natural materials, such as cotton. Or, if heat aggravates your eczema, keep the rooms in your home cool. Also, avoid using any soaps or detergents that you think may affect the skin.

Although house dust mites have been shown to trigger eczema flares, it is not recommended that you try to eradicate dust mites from your home. The process is very time consuming and difficult to carry out effectively. Studies have also shown that dust mite avoidance techniques are rarely effective.

Diet:
If you or your child have atopic eczema, you should not make any significant dietary changes without first consulting your GP. Some foods, such as milk, eggs and nuts, have been shown to trigger eczema symptoms. If you are breastfeeding a baby who has atopic eczema, you should also seek medical advice before making any changes to your regular diet.

Complementary therapies

Some people choose to use complementary therapies to treat atopic eczema, such as aromatherapy (using essential oils for a therapeutic effect).

Although some people find these therapies helpful, it is important to remember that there is often a lack of evidence to show that they are effective in treating conditions such as atopic eczema. Therefore, if you are thinking about using a complementary therapy, you should speak to your GP first, to ensure that the therapy is safe for you to use.

Emollients

Emollients are substances that help to soften and smooth your skin in order to keep it supple and moist. They are one of the most important forms of treatment for atopic eczema.

As atopic eczema can cause your skin to become dry and cracked, it is important to keep it moisturised to prevent it from becoming further irritated.

What emollients will be prescribed?
If you have recently been diagnosed with atopic eczema, and you or your child is receiving treatment for the first time, a number of different emollients may have to be tried before a suitable one is found.

Most people will need to be prescribed a number of different emollients for long-term use. For example, you may need to use one type of emollient on your face and hands and a different one for the rest of your body.

There are a number of different emollients that are designed for use on different skin types. For example, for very dry skin, ointments are often prescribed, and for skin that is less dry, creams and lotions are usually recommended.

If you have been using a particular emollient for some time, it may eventually become less effective, or it may start to irritate your skin. If this is the case, you should speak to your GP.

How should I use them?
Emollients should be applied by smoothing them into the skin in the same direction that the hair grows (see box). You should avoid rubbing emollients in, because doing so can irritate the skin.

After washing, make sure that you gently dry the skin. Apply the emollient as soon as the skin is dry. Do not share emollients with other people.

Creams and lotions tend to be more suitable for red, inflamed areas of skin. Ointments are more suitable for areas of dry skin that are not inflamed.

When should I use them?
Emollients should be used frequently, even when the skin appears to be clear. This should help to reduce the number of eczema flares that you or your child has. If the skin is very dry, emollients should be applied every two to three hours.

You may wish to consider keeping separate supplies of emollients at work or at school.

It is very important to keep using your emollients during a flare-up because this is when the skin needs the most moisture. During a flare-up, you should apply emollients very frequently and in generous amounts.

Emollient treatments should be used instead of soap. This is because most normal soaps irritate atopic eczema. Replacing soaps with emollients should help to reduce the risk of experiencing a flare-up. You can also get emollient bath and shower additives, which can help to prevent your skin from becoming aggravated.

Can they cause any side effects?
The most common side effect of using emollients is a rash. If you have atopic eczema, your skin is very sensitive and can sometimes react to certain ingredients within an emollient. If your or your child's skin reacts to the emollient, you should speak to your GP, who will be able to prescribe an alternative product.

It is important to be aware that some emollients contain paraffin and can be a fire hazard. As some emollient products are highly flammable, they should not be used near a naked flame.

Emollients that are added to your bath can also be easy to slip on. As long as you are aware of these hazards, you should be able to use emollients safely.

Topical corticosteroids

If your or your child's skin is red and inflamed from an atopic eczema flare, your GP may prescribe a topical corticosteroid (one that is applied directly to your skin) to help ease your symptoms. Corticosteroids work by quickly reducing inflammation.

You may be concerned about using medication that contains steroids. However, corticosteroids are not the same as anabolic steroids (which are sometimes used by bodybuilders to build muscle). When used correctly, corticosteroids are a safe and effective treatment for eczema.

The strength of corticosteroid that is prescribed will depend on the severity of your atopic eczema. Severe cases of atopic eczema will require a stronger corticosteroid than milder cases.

If your atopic eczema is moderate to severe, you may need to apply topical corticosteroids in between flare-ups, as well as during them.

If you need to use corticosteroids frequently, you should visit your GP regularly so they can check that the treatment is working effectively.

How should I use them?
When using corticosteroids, you should apply the treatment sparingly to the affected areas (see box). Always follow the directions on the patient information leaflet that comes with the corticosteroid, which will provide details about how much you should apply.

During an atopic eczema flare, you should not apply the corticosteroid more than twice a day. Most people will only have to apply it once a day. You should continue to apply the treatment for 48 hours after the flare-up has cleared up.

If you or your child are using corticosteroids on a long-term basis, you may be able to apply them less frequently. Your GP will advise you about how often you should be applying them.

Speak to your GP if you have been using a topical corticosteroid and your symptoms have not improved.

Antihistamines

Antihistamines are a type of medicine that work by stopping the effects of a substance in the blood, known as histamine. Your body often releases histamine when it comes into contact with an allergen. It can cause a wide range of symptoms, including sneezing, watery eyes and itching.

Antihistamines can either be sedating or non-sedating. Sedating anti-histamines can make people feel drowsy. They are normally prescribed during a flare to help ease itchiness at night, helping you or your child to get a good night's sleep. Sedating antihistamines are prescribed on a short-term basis, usually for a maximum of two weeks at a time.

Sedating antihistamines should usually be taken about one hour before going to bed. Drowsiness may persist the following day, so make sure you let your child's school know that they may not be as alert as normal. If you are taking sedating antihistamines, avoid driving the next day if you still feel drowsy.

Non-sedating antihistamines also help to ease itching, but will not make you feel drowsy. You can therefore use this type of medicine on a long-term basis.

Infected eczema

If you or your child's eczema has become infected with bacteria (see the 'complications' section), you will usually be prescribed antibiotic treatment.

If you have an extensive area of infected eczema, an oral antibiotic (taken by mouth) you will normally be prescribed. The antibiotic most commonly prescribed is flucloxacillin, which is usually taken for seven days. However, if you are allergic to penicillin, you will be prescribed a different antibiotic - either erythromycin or clarithomycin.

If you have a small amount of infected eczema, you will normally be prescribed a topical antibiotic. This means that the medicine is applied directly to the affected area of skin, in the form of an ointment or cream. They should not be used for longer than two weeks.

Reducing the risk of re-infection

Once your infection has cleared, your GP may have to prescribe new supplies of any topical medication or treatments that you use, such as emoillents or corticosteroids. This is in case your old ones are infected. Once you have received the new supplies, you should throw your old treatments away.

If there are areas of your eczema that are prone to infection, you may be prescribed a topical antiseptic. This type of treatment is also applied directly to your affected skin, and works by helping to kill bacteria. Commonly prescribed topical antiseptics include chlorhexidine and triclosan.

Referral

In some severe cases of atopic eczema, your GP may have to refer you for assessment and treatment by a dermatologist (a specialist in treating skin conditions). For example, your GP may refer you if you fail to respond to prescribed treatment, or if they are uncertain about what is causing your eczema.

Some of the treatments a dermatologist may be able to offer you include phototherapy, where your eczema is exposed to ultraviolet (UV) light, bandaging (where treatments such as medicated dressings or wet wraps are applied to your skin) and topical calcineurin inhibitors (a type of medicine that helps to reduce inflammation).

However, these types of treatments are not be suitable for everyone, and can only be carried out by experienced skin-care specialists.

How to apply an emollient

  • Stroke the cream onto your skin following the direction of your hair, to avoid irritating the hair follicles.
  • Don't apply just before bedtime, as the skin may become sweaty and itchy under the bedclothes.
  • Leave 30 mins between appying an emollient and applying a steroid cream, as one may dilute the other.

How to apply a topical steroid

  • It's important to get the dose right, so use a standard measure - the fingertip unit (FTU)
  • One FTU is the amount of topical steroid squeezed along an adult's fingertip.
  • One FTU is enough to treat an area of skin twice the size of an adult's hand
  • Click here for a guide on fingertip units for treating different areas of the body (links to external site)

Complications

Complications of atopic eczema

Infection

As atopic eczema can cause your skin to become dry and cracked, the risk of getting a skin infection is increased. If you scratch your eczema, the likelihood of it becoming infected is also increased.

Bacterial infections can cause more severe symptoms. The most common type of bacteria that infects atopic eczema is Staphylococcus aureus. If your skin becomes infected with S. aureus, it can make your eczema worse, with increased redness, oozing of fluid and crusting of the skin. Your skin will be unable to heal naturally from this type of infection.

Psychological effects

As well as affecting you physically, atopic eczema may also affect you psychologically.

Preschool children with atopic eczema are more likely to have behavioural problems than children who do not have the condition. They are also more likely to be more dependant on their parents compared with children who do not have the condition.

Bullying
School children may experience teasing or bullying if they have atopic eczema. Any kind of bullying can be very traumatic and difficult for a child to deal with. You may find that your child becomes quiet and withdrawn. Make sure you explain the situation to your child's teacher and encourage your child to tell you about how they are feeling.

Sleep disturbance
Research has suggested that approximately 60% of children with atopic eczema have sleep-related problems. During a flare of atopic eczema, it is thought that (on average) five nights sleep are affected.

A lack of sleep may affect your child's mood and behaviour. It may also make it more difficult for them to concentrate at school, which may lead to them falling behind with their work. Again, it is important to let your child's teacher know about their condition, so that they can take factors such as this into consideration.

During an eczema flare, your child may also need to take time away from school. This again may affect their ability to keep up with their studies.

Self-confidence
Atopic eczema can affect the self-confidence of both adults and children. Children may find it particularly difficult to deal with their condition, which may result in them having a poor self-image.

If your child is severely lacking in confidence, it may affect their ability to develop their social skills. Support and encouragement will help boost your child's self-confidence, and give them a more positive attitude with regard to their appearance.

Speak to your GP if you are concerned that your child's eczema is severely affecting their confidence.

NICE guidelines

Atopic eczema: treatment guidelines

It's important to know which sources you can rely on for more information on atopic eczema.

The National Institute for Health and Clinical Excellence (NICE) has produced healthcare guidelines on the treatment of atopic eczema.

This guidance outlines NICE’s main recommendations on how often topical steroids should be applied for this condition, and on treatment with tacrolimus and pimecrolimus (non-steroid creams and ointments).

Expert view

Family doctor Dawn Harper on the questions to ask

We asked Dr Dawn Harper what she would want to know if she was diagnosed with eczema.

What can I use to stop my skin drying out?
Soap will make your eczema worse. Use an emollient, which softens the skin, instead. A soap substitute such as aqueous cream won’t lather but it will work just as well as soap and keeps the skin well moisturised.

Can I still use deodorants and perfumes?
Use alcohol-free roll-on deodorants rather than aerosols and avoid perfumed products that may dry the skin. Wherever possible opt for ‘fragrance free’ products. Perfume can irritate the skin of eczema sufferers.

Is it safe to use a steroid cream?
If you use steroid creams as prescribed by your doctor, they can help reduce inflammation. Some people are scared of using steroid creams because of fears about side effects, but as long as they are used sparingly and are not too strong, they are perfectly safe.

As a rough guide, a blob the size of your fingernail should cover an area twice the size of the palm of your hand. If you do need to use a strong steroid cream, make sure you switch to a weaker strength cream after a few days.

How does the weather affect my condition?
Heat causes your skin to sweat, irritating your eczema and making it worse, and cold air dries it out. Avoiding extremes of temperature will help you to keep your eczema under control.

Do I need to cut certain types of food out of my diet?
Keep a food diary. Diet is often blamed for eczema, but this is the case in only around one in 10 people. A balanced diet is important for everyone, so only exclude foods that clearly aggravate the eczema and do so under advice from a dietitian.

What do I do if my eczema gets worse?
Consult your GP early if you notice a flare-up. Over time, you will recognise the symptoms and your GP may be happy for you to keep a steroid cream at home to treat flare-ups. However, until you are confident, it's best to check with your doctor and you should always seek medical advice if your self-help measures aren’t working.

Real stories

Daniella and Ruby's story

'I hope she'll grow out of the eczema'

Ruby was diagnosed with eczema at six weeks old. Her mum, Daniella, explains how they’ve learned to cope with Ruby’s condition

“At only 10 days old, Ruby developed a rash all over her, a bit like teenage spots with white pimples.

"Doctors thought it was her sebaceous glands not working properly and said it would go away. It did. However, as there's a history of eczema in my husband’s family and mine, and it's a hereditary condition, I always thought she would develop it.

"Doctors tell me not to use any of the commonly marketed baby products, perfumed products or soap. Now, her treatment involves two baths daily, using oil. Before the bath I also cover her body in aqueous cream. I wash her body with a flannel rather than a sponge because flannels can be washed daily.

"She doesn’t sleep with many cuddly toys in her cot as they can carry dust, and I don’t let her near animals as they can irritate and aggravate her skin.

"Some foods have had an effect on her skin too, so I have to make sure she doesn’t eat them and other people don’t give them to her. I also have to be careful with sun lotions and not to let her go in the sun too often.

"At its worst, the eczema on her right arm became infected and her skin went yellow and filled with pus. We quickly took her to the GP and she was put on antibiotics. I spoke to the nurses at the hospital, who suggested trying a wet wrapping with some support, which is like a sports bandage, but I decided to cover the arm in moisturiser with a dry bandage over the top to try to stop her scratching in the night.

"You can’t really stop a baby from scratching. You can distract them where possible and keep them occupied, keep their nails short by trimming them morning and night, and as a last resort I keep Ruby in long sleeves and cover her arms in a wet wrap.

"Once I was driving home in the evening after Ruby’s normal bath time and she was tired and irritable. I noticed in my rear mirror that she was scratching and scratching, and her arm was bleeding. I was stuck in traffic and still far from home, so the best I could do was to sing songs to try to distract her. That was the hardest incident.

"I hope she will grow out of the eczema. I grew out of it and so did other members of my family. However, some of the people on my husband’s side of the family still have it in their old age."

John's story

'A lot of things work for a while, then lose their effectiveness'

Battling against eczema since he was a baby, 30-year-old John Fuller has tried just about every treatment option available

John Fuller’s eczema began when he was a baby. “It was always there as far back as I can remember,” he says. “My skin would turn red raw and I would scratch and scratch. We tried everything from creams to salt baths. I have a very strong memory of sitting for ages in a salt bath because our GP suggested it! Luckily, though, I wasn’t bullied for having eczema like many children seem to be.”

When John was 11, the family went to Barbados for a holiday. While they were there, they discovered the aloe vera plant.

“Someone suggested it might help my eczema and we were ready to try anything. Aloe vera is everywhere now, but back then nobody had heard of it. So when we got back, we started growing it in our back garden. I’d have to rub the plant juice all over me! Amazingly, the eczema cleared up for the next nine years.”

John hoped he’d grown out of the condition. Unfortunately, his eczema came back when he was just finishing university. “The redness and the itching began again,” he says. “Soon it was all over my arms and legs, and it’s been there ever since.”

John says he’s tried ‘every treatment going’, including steroid pills and creams, and cyclosporin, a strong drug used mainly to stop transplant patients rejecting their new organs. It works by damping down the immune system.

“That was effective for a couple of years but it can damage your internal organs, so you can’t stay on a high dose for too long,” he explains. “I had to have regular blood tests to make sure everything was working properly, and eventually had to go on such a low dose it wasn’t worth it.

“I’ve been in hospital three times. In hospital you get the same treatment that you do at home, but it’s more intensive and it’s also cleaner.”

He also experimented with complementary therapies. “I went to a Chinese herbalist, who gave me some disgusting tasting tea to drink every night,” he says. “For a while, it seemed to work. Then the eczema came back. I found a lot of things work for a while but then lose their effectiveness.”

John tries his best to live a normal life, but says it’s not easy. “When the itching is really bad, it’s very hard to concentrate at work,” he says. “Sometimes I have to take time off. Employers don’t like that, and it has an impact on everyone I work with. Sometimes sleeping is just impossible and that affects my daily life as well. I love playing cricket but direct sunlight turns me bright red. I look like a tomato.”

John is resigned to living with his condition, but he still has hope. “Nobody knows why I have eczema and as yet there’s no cure, but you never know. One day I could wake up and the eczema could just be gone. Until then, I just have to make do with the treatment we have.”

Useful links

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External links


This article was originally published by NHS Choices

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