Atopic eczema

Overview

Atopic eczema is a skin condition whose main sign is itchy, dry skin. The National Eczema Society says it affects 1 in 5 children and 1 in 10 adults in the UK. It usually begins in early childhood. Symptoms often come and go in flare-ups, and the NHS says there is currently no cure, although symptoms tend to get better as people get older.

Symptoms

What a clinician may find

• The skin can be itchy, dry, cracked, crusty, scaly or thickened, and may blister or bleed.
• Inflamed skin can look red on white skin, and darker brown, purple or grey on brown or black skin, where it can be harder to see.
• Scratching can make the skin bleed and open the way to infection.

Complications

• Scratching can disrupt sleep.
• Cracked skin can become infected with bacteria, most often Staphylococcus aureus.
• Eczema can become infected with the herpes simplex virus, which can progress to a serious condition called eczema herpeticum.
• People with eczema are more likely to develop hay fever, asthma and food allergy.
• The NHS also lists bullying or teasing in schoolchildren and lower self-confidence among the possible effects.

Diagnosis

Atopic eczema is diagnosed mainly from the skin and the history, so the diagnosis is primarily clinical. For children, NICE advises taking a history of the time of onset, pattern, severity, response to treatment, impact on the family, and personal and family history of atopic conditions. NICE says mild eczema does not usually need allergy tests.

Treatment

There is currently no cure, but treatments can help manage the condition and improve symptoms. Emollients (moisturisers) are the first-line treatment during both flares and remissions, and the NHS names steroid creams or ointments for flare-ups as the other main treatment. A GP may refer the person to a dermatologist if the diagnosis is uncertain, the eczema is not controlled with current treatment or the risk of complications is high. Specialist options for moderate to severe disease include phototherapy, immune-suppressing medicines and injectable biologic medicines such as dupilumab.

Prevention

Flares are managed by continuing moisturiser even when the skin improves and by identifying and avoiding triggers.

Key facts

What does atopic eczema look and feel like?

Itchy, dry skin is the main sign of atopic eczema. The skin can also crack, become crusty, scale, thicken, blister or bleed. Inflamed skin can look red on white skin, and darker brown, purple or grey on brown or black skin, and this can be harder to see on brown and black skin.

Symptoms often come and go in flare-ups. Severity varies widely, from small patches of dry skin to widespread inflammation with constant itching. Scratching can disrupt sleep, make the skin bleed and open the way to infection, and a cycle of itching and regular scratching may develop. The National Eczema Society says that in children the itch can be intense enough to interfere with sleep, especially at night. NICE notes that sleep disturbance is common, especially during flare-ups, and can lead to irritability and poor concentration. In babies and toddlers the eczema often shows on the face, while in older children and adults it tends to appear on the elbows, knees and hands.

What causes it, and what sets off flares?

The exact cause is not fully known. Genetic and environmental factors, a weakened skin barrier and problems with the immune system are thought to contribute. Risk is higher if a parent has the condition, and changes in the filaggrin gene, which supports the skin barrier, are linked to it. The NHS says atopic eczema is not contagious.

The NHS lists common triggers as soaps, washing detergents, some fabrics, pets, pollen, house-dust mites, heat, stress and skin infections. The British Association of Dermatologists also names dry skin, teething in babies, food allergens and airborne allergens such as pet dander, pollen, grass and house dust mites, along with stress. NICE says the role of factors such as stress, humidity and temperature extremes in causing flares is unclear, so sources do not fully agree on every trigger.

How is atopic eczema diagnosed?

Doctors mainly diagnose atopic eczema from the skin and the history, so the diagnosis is primarily clinical. For children, NICE advises taking a history of the time of onset, pattern, severity, response to treatment, impact on the family, and personal and family history of atopic conditions. Mild eczema does not usually need allergy tests, and NICE says there is no evidence that high-street allergy testing is helpful. Food allergy should be considered in children who have reacted to a food with immediate symptoms, or in infants with moderate or severe eczema that does not respond to optimum management.

NICE CKS says referral to a dermatologist should be considered if the diagnosis is uncertain, the eczema is not controlled with current treatment, or there is a high risk of complications. Children with moderate or severe eczema and suspected food allergy should be referred for specialist investigation. Psychological referral is advised when the eczema is controlled but quality of life has not improved.

How is it treated?

There is currently no cure, but treatments can help manage atopic eczema and improve symptoms. NICE CKS says management aims to relieve symptoms and prevent complications such as infection, and rests on skin care, anti-inflammatory treatment, and identifying and avoiding triggers. Emollients, which are moisturisers, are the first-line treatment during both flares and remissions. The NHS advises continuing moisturiser even when the skin improves, and describes emollients as products applied to the skin and also used for washing.

The NHS names steroid creams or ointments as the other main treatment, used for flare-ups. The British Association of Dermatologists says short-term use can help reduce itch during flare-ups, and that steroids and other creams are not recommended as a long-term treatment. For moderate to severe eczema, the National Eczema Society describes phototherapy as treatment with ultraviolet light, given in a hospital dermatology department once topical treatments have not controlled the eczema. Other specialist options include immune-suppressing medicines and injectable biologic medicines such as dupilumab.

Living with atopic eczema and the outlook

The National Eczema Society describes atopic eczema as a common, long-term condition that often runs in families. It usually starts in childhood and can improve as a child gets older, but it can also return at any time. The NHS says symptoms tend to get better as people get older, and that there is currently no cure.

NICE says most people with atopic eczema, more than 80%, have mild disease, and only around 2% to 4% of people with eczema have a severe form. Severity is linked to sleep, with moderate disease described as frequently disturbed sleep and severe disease as nightly loss of sleep. The NHS lists sleep problems, bullying or teasing in schoolchildren, and lower self-confidence among the possible effects, and says people with eczema are more likely to develop hay fever, asthma and food allergy. NICE CKS says that providing appropriate information is essential for managing flares and maintaining control of the condition.

When should someone get medical help?

A GP appointment is the route when symptoms appear or treatments are not helping. The NHS advises an urgent GP appointment or a call to NHS 111 if the eczema is blistered, crusty, leaking fluid or has pus-filled spots, is painful, swollen or warm, suddenly worsens or spreads, or if there is a high temperature or the person feels generally unwell.

Eczema herpeticum is a serious infection in which the cold sore virus spreads through eczema skin. NICE CKS describes rapidly worsening, painful eczema with clustered blisters and punched-out erosions. NHS Scotland guidance describes groups of little blisters that quickly break down into shallow ulcers and spread rapidly, and treats this as an emergency. The National Eczema Society advises seeing a doctor immediately if it is suspected, with NHS 111 or A&E if a GP appointment is not possible. NICE CKS says immediate hospital admission should be arranged if it is suspected.

Frequently asked questions