Atopic dermatitis, commonly called “eczema”, is a very common skin problem which affects 10-20% of the pediatric population and 1-3% of adults worldwide. It typically begins in childhood as a very itchy sensation that leads to scratching, redness, breaks in the skin, & sometimes thickening of the skin. Atopic dermatitis varies widely in severity, may persist into adulthood, and waxes and wanes rather unpredictably.
Atopic dermatitis often starts in infancy as a red, dry, scaly rash on the scalp and face. Sometimes this rash can bubble up and ooze clear liquid which crusts. Atopic dermatitis is itchy. Infants will try to rub against something or try to scratch affected areas. Itch may interfere with sleep.
When atopic dermatitis begins in childhood, it usually appears between the ages of 2 years to puberty. It tends to occur on the inside crease of the elbow, behind the knees and neck. However, any body location may be involved. With long term scratching, the red scaly or crusted skin can get thicker and turn dark in color or appear almost leathery. Due to the compromised skin barrier, bacterial skin infections may occur and appear as honey-colored crusted areas, or patches of skin that are tender, red and hot.
Most people (90%) develop atopic dermatitis in childhood, and half of affected people will clear by adulthood. It tends to become more mild as the person ages. In some adults, however, eczema persists and requires prolonged management.
The cause of atopic dermatitis is thought to be complex and is likely a combination of genetics, environment and the way our immune system functions. Atopic dermatitis is not contagious. It is thought to be an immunologically mediated reaction to environmental allergens such as dust mites, pollens, grass, animal dander, trees, but can also be an allergic reaction to something eaten, such as eggs, peanuts, milk, wheat, fish and soy.
For unknown reasons eczema is more common now than it was decades ago. If someone in your family has had eczema, nasal allergies (hay fever), or asthma, then you have a risk factor for developing eczema. Living in cities and cold climates appears to be a risk factor. It is more common in females, in higher social classes, and older age of mother at the time of birth. Eczema is probably an inherited condition.
There are many over the counter options for treatment of mild atopic dermatitis. Most of these are moisturizing creams, some of which contain a lipid called ceramide that helps seal dry cracked skin. Mild topical corticosteroids such as hydrocortisone can be helpful for treating flares of itchy skin.
If use of over the counter topical products prove ineffective, your dermatologist can prescribe stronger topical corticosteroids than hydrocortisone, nonsteroidal topicals that are anti-inflammatory (tacrolimus, pimecrolimus, crisaborole) and suppress the skin’s immunologic reaction, or in more extensive cases, oral or injectable medications that decrease systemic inflammation or work to suppress the body’s immune reponse (prednisone, methotrexate, cyclosporine, mycofenolate mophetil, dupilumab) .
OTC Treatment Options
Cetaphil Gentle Skin Cleanser
CeraVe Moisturizing Cream
Wash with cleanser. (This step can be eliminated if desired.) After bathing, pat the skin partially dry. Next, apply medicated creams to active areas of rash. Then apply moisturizer on top of medicated cream & to rest of skin. This regimen may be done twice daily.
Use cleansers only as needed. Avoid hot showers or baths & limit bathing time to 5-10 minutes.
Moisturizing more frequently can be helpful, especially when eczema is severe. The best emollients for eczema are cream based, contain ceramides, and are unscented such as CeraVe Moisturizing Cream. When eczema is not as severe, discontinue the hydrocortisone but be sure to continue using ceramide moisturizers to help prevent recurrence of eczema. It is important to keep your skin as moisturized as possible.
Remember that you can cause skin thinning with chronic use of topical hydrocortisone. Hydrocortisone should not be used around the eyes. Hydrocortisone cream is for use in adults and children over the age of 2 and should only be applied for up to 2 weeks. Use as directed only without physician supervision.
If you do not see improvement with these simple measures, see a dermatologist.
Avoid fragrance and scented products.
Use laundry detergent that is labeled “free and clear.” These detergents do not contain the usual ingredients that are the most common allergens for people with sensitive skin. It is better to use a liquid detergent, not powder, and for people with documented sensitivity to detergent a second rinse spin is helpful. Do not to use dryer sheets. To decrease static cling in the dryer, dryer balls may be used instead of dryer sheets. Most major brands of detergents manufacture free and clear versions. All and Kirkland Signature carry types of free and clear detergents.
Keep fingernails short and smooth. This decreases the likelihood that scratching will puncture the skin. Putting cotton gloves on hands at night may help prevent scratching during sleep, particularly in children.
Keep temperature and humidity levels comfortable. Avoid situations in which the air is extremely dry, or where you may sweat and overheat. This is the most common trigger of the itch/scratch cycle.
If your eczema is frequently infected, twice-weekly bleach baths may be beneficial. You should discuss this option with your dermatologist.
Discuss diet with your pediatrician. Atopics are at increased risk for food allergies compared to unaffected individuals. A minority of atopics will flare with certain foods. However, as per the American Academy of Dermatology, “Before you stop feeding your child any foods, talk about this with your child’s dermatologist. Children need certain foods to grow and develop normally”.
Alternative & Complementary Treatments
Coconut oil has been shown to improve skin barrier and act as an antibacterial in atopic dermatitis. Apply the coconut oil twice per day on damp skin. Use “virgin” coconut oil (VCO) since VCO has not undergone chemical refining.
Sunflower oil has been shown to improve the skin barrier and decrease inflammation. Apply the sunflower oil twice per day to damp skin.
Probiotics have recently become a popular complementary treatment for atopic dermatitis. However, to date there is minimal evidence that probiotics improve atopic dermatitis.