Atopic Dermatitis (Eczema)

Overview

Atopic dermatitis, which is commonly known as eczema, is a chronic disease that causes skin inflammation, redness, and irritation. It is the most common chronic inflammatory disease in both children and adults.

Atopic dermatitis is not contagious. The disease usually begins in childhood, but anyone can develop it at any age. For many children, atopic dermatitis goes away before the teenage years. However, some children continue to have symptoms as teens and adults, and for some people, the disease first appears during adulthood.

In most cases, the disease follows a pattern of flares — periods when symptoms worsen — followed by remissions, when the skin improves or clears up entirely.

Researchers do not yet know what causes atopic dermatitis, but studies suggest that genes, the microbiome, the immune system, and the environment all may play a role.

Signs and Symptoms

The most common symptom of atopic dermatitis is itching, which can be severe. Other common symptoms include:

• Red, dry patches of skin
• Rashes that may ooze, weep clear fluid, or bleed when scratched
• Thickening and hardening of the skin

Symptoms can flare in multiple areas of the body at the same time and can appear in the same locations or in new locations. People with darker skin tones often experience darkening or lightening of the skin in areas of inflammation.

Infants (up to Age 2)

During infancy, a red rash that may ooze when scratched. It often appears on the:

• Face
• Scalp
• Area of skin around the bend of joints

The condition rarely appears in the diaper area.

Children (Ages 2 to Puberty)

During childhood, a red, thickened rash that may ooze or bleed when scratched. It most commonly appears on the:

• Elbows and knees, usually in the bend
• Neck
• Ankles

Teens and Adults

During the teenage and adult years, a red to dark brown scaly rash that may bleed and crust when scratched often appears on the:

• Hands
• Neck
• Elbows and knees, usually in the bend
• Skin around the eyes
• Ankles and feet

Other common skin features of atopic dermatitis that may occur at any age include:

• An extra fold of skin under the eye, known as a Dennie-Morgan fold
• Darkening of the skin beneath the eyes
• Extra skin creases on the palms of the hands and soles of the feet

Severe forms of eczema can significantly affect health and quality of life. One common problem is the inability to sleep through the night because of extreme itching, which has harmful effects on both people with eczema and their caregivers.

Related Health Effects

People with atopic dermatitis often develop other conditions. These include:

• Asthma and allergies, including food allergies
• Other skin diseases, such as ichthyosis, which causes dry, thickened skin
• Depression or anxiety
• Sleep loss, which can also lead to behavior issues in children
• Bacterial and fungal skin infections that can worsen from scratching, which are common and may make the disease harder to control
• Viral skin infections like warts or cold sores
• Hand eczema (hand dermatitis)
• Eye problems, including conjunctivitis (pink eye), which causes swelling and redness in the inside of the eyelid and the white part of the eye, and blepharitis, which causes general inflammation and redness of the eyelid

Bacterial Infections

A major health risk associated with atopic dermatitis is skin colonization or infection by bacteria such as Staphylococcus aureus. Sixty to 90 percent of people with atopic dermatitis are likely to have Staph on their skin, and many eventually develop infection, which worsens the atopic dermatitis.

Viral Infections

People with atopic dermatitis are highly vulnerable to certain viral infections of the skin. For example, if infected with herpes simplex virus, they can develop a severe skin condition called atopic dermatitis with eczema herpeticum.

Smallpox Vaccine Risk

Smallpox vaccine is not administered to general public anymore. People with atopic dermatitis should avoid the ACAM2000 smallpox vaccine, which contains a live, replicating vaccinia virus and can cause a serious complication known as eczema vaccinatum in individuals with current or past eczema or in their close household contacts. In contrast, the JYNNEOS vaccine, used for smallpox and mpox prevention, is a non‑replicating vaccine and is safe for people with eczema, including those with a history of the condition. Current CDC guidance emphasizes that ACAM2000 should only be used in emergency situations and is contraindicated for individuals with eczema or other exfoliative skin conditions, while JYNNEOS is the recommended option for those who require orthopoxvirus vaccination.

Allergy Testing Considerations

People with eczema are often diagnosed with allergies they may not actually have, because allergy blood tests measure immunoglobulin E (IgE) levels, and people with eczema tend to have high total IgE levels in general. False-positive allergy tests can lead to an unnecessarily restrictive food-elimination diet with unwanted outcomes such as malnutrition, weight loss, or low weight gain.

Causes and Risk Factors

No one knows what causes atopic dermatitis. Researchers know that changes in the protective layer of the skin can cause it to lose moisture, leading to dryness, damage, and inflammation. New research suggests that inflammation directly triggers sensations of itch, which in turn cause scratching — leading to further skin damage and increased risk for infection.

Researchers know that the following may contribute to changes in the skin barrier:

• Changes (mutations) in genes
• Problems with the immune system
• Exposure to certain things in the environment

Genetics

The chance of developing atopic dermatitis is higher if there is a family history of the disease, hay fever, or asthma. Children of parents who have allergic diseases are more likely to develop eczema than children of parents who do not.

Researchers have found changes to genes that control a specific protein that helps the body maintain a healthy skin layer. Without normal levels of this protein, the skin barrier changes, allowing moisture to escape and exposing the skin immune system to the environment. Recent research has also identified mutated forms of specific genes that may contribute to atopic dermatitis.

Research shows that atopic dermatitis is more common in non-Hispanic Black children, and that women and girls tend to develop the disease slightly more often than men and boys do.

Immune System

The immune system normally helps fight illness, bacteria, and viruses. Sometimes, the immune system becomes overactive, creating inflammation in the skin and leading to atopic dermatitis.

Environment

Environmental factors may trigger the immune system to change the protective barrier of the skin, allowing more moisture to escape. These factors may include:

• Exposure to tobacco smoke
• Certain types of air pollutants
• Fragrances and other compounds found in skin products and soaps
• Excessively dry skin
• Wildfire smoke exposure, a growing trigger in recent years

Skin Microbiome

The bacteria, fungi, viruses, and other microorganisms that live on the skin, collectively called the skin microbiome, may also play a role in eczema development. Researchers have found that the composition of the skin microbiome is very different in people with eczema compared to healthy people, with smaller proportions of microbes that promote healthy skin. It remains unclear whether changes to the skin microbiome are a cause or an effect of the abnormal skin immune function and defective skin barrier found in people with eczema.

Triggers

Many environmental substances and characteristics can cause eczema to worsen. Triggers vary from person to person and may include:

• Pollen
• Mold
• Dust mites
• Animals
• Cold, dry air
• Respiratory viruses, including influenza
• Fumes from wildfires, automobiles, and certain factories
• Certain chemicals such as fragrances and dyes
• Rough fabric such as wool

Emotional factors such as stress can also trigger eczema flares, as can certain foods among people with food allergies.

The latest research has linked sleep impairment to disease severity. Sleep disturbance can lead to emotional, behavioral, and learning problems in children.

Prevention Guidance

Currently, there is no clearly effective way to prevent eczema.

Of the many experimental interventions tested in pregnant and breastfeeding women and in infants to prevent eczema, only a few have led to a small or modest reduction in the risk for childhood eczema:

• Emollients formulated to improve the skin barrier, applied starting in the first few days of life
• Probiotics for pregnant women and infants
• Vitamin D supplementation during pregnancy
• Avoiding unnecessary antibiotic exposure during pregnancy and delivery
• BCG vaccination
• Prevention: Topical probiotics aimed at restoring healthy skin microbial balance

Diagnosis

Diagnosing atopic dermatitis may include the following steps:

• Giving the doctor your or your child’s medical history, including:
  • Family history of allergies
  • Whether you also have diseases such as hay fever, asthma, or food allergies
  • Sleep problems
  • Foods that seem to trigger hives
  • Previous treatments for skin-related symptoms
  • Use of steroids or other medicines
  • Exposure to irritants such as soaps and detergents, perfumes and cosmetics, and cigarette smoke
• Examining your skin and the rash
• Ordering laboratory tests, such as blood tests to check for other causes of the rash, or a skin biopsy of the rash or lesion
• There are commonly used eczema severity scores such EASI (Eczema Area Severity Index) for diagnosis

A doctor may need to see you or your child several times to make an accurate diagnosis and to determine whether symptoms are from atopic dermatitis or from other diseases and conditions.

Treatment and Management

The goals for treating atopic dermatitis include:

• Managing and controlling dry skin
• Reducing skin inflammation
• Controlling itching
• Promoting healing
• Preventing infections
• Preventing flares

A doctor will work with you to develop a treatment plan based on the location and type of rash, the severity of itching, triggers unique to you or your child, and how the skin responds to specific treatments. Treatments usually include a combination of therapies.

The two largest American professional associations of allergists and immunologists jointly recommend several types of products for the treatment of eczema, including topical and systemic medicine. For a summary of the 2024 guidelines, visit the Updated Guidelines for Atopic Dermatitis — AAAAI/ACAAI Joint Task Force. Treatments include the following.

Medicines

A doctor may prescribe one or more of the following medicines, depending on the severity of the disease and the patient’s age:

• Moisturizing creams can help restore the skin barrier.
• Corticosteroid creams and ointments help decrease inflammation. Doctors do not usually prescribe oral corticosteroids to treat atopic dermatitis because stopping the normal dose can cause the condition to flare or rebound more severely than before.
• Topical calcineurin inhibitors decrease inflammation and help prevent flares.
• Phosphodiesterase-4 inhibitors, a topical cream, can help with inflammation when symptoms do not respond to other treatments.
• Pills that reduce the abnormal immune response — including janus kinase (JAK) inhibitors — can be used for more severe disease but require close monitoring.
• Biologic medicine, given by injection just under the skin, blocks specific functions of the immune system to help control and manage atopic dermatitis.

Many people with severe eczema take multiple medicines, which may include corticosteroids, immunosuppressants, antihistamines, and biologics. Immunosuppressants are very strong and can have serious side effects.

Skin Care

Keeping the skin hydrated by applying moisturizers immediately after bathing is important when treating atopic dermatitis. In some cases, doctors may recommend:

• A diluted bleach bath twice a week to help treat atopic dermatitis
• Wet wrap therapy to help increase moisture in the skin when the condition is persistent
• Using mild cleansers that maintain the skin’s healthy protective barrier

Wet Wrap Therapy

Wet wrap therapy is a very effective approach to treating severe eczema that NIAID researchers studied during a clinical trial at the NIH Clinical Center from 2012 to 2017. Researchers found that this form of treatment reduced symptoms quickly and durably, decreasing the need for medicine and improving sleep.

One key to wet wrap therapy is soaking in a lukewarm bath for approximately 15 minutes three times a day. NIAID researchers determined that long soaks are vital to allowing topical medicines — applied after each bath — to penetrate the outer layer of the skin. In severe cases, bleach may be added to the water to combat skin infections.

A five-day treatment regimen with wet wrap therapy can greatly reduce eczema symptoms for several weeks to months. However, the therapy is not a cure — in most cases, people will experience periodic flare-ups that need to be treated.

Phototherapy

If atopic dermatitis is severe, widespread, and has not responded to cream and ointment treatments, a doctor may recommend the use of ultraviolet A or B light waves to treat symptoms.

Living With Atopic Dermatitis

Depending on the location and severity of atopic dermatitis, living with the condition can be hard. The following tips can help control atopic dermatitis:

• Taking lukewarm baths to cleanse and moisturize the skin without drying it excessively — limit baths to once a day
• Using mild, unscented bar soap or a non-soap cleanser
• Patting the skin dry after bathing and moisturizing before the skin gets too dry — avoid rubbing or brisk drying
• Using a moisturizer to seal in water absorbed during bathing — use creams and ointments, and avoid lotions with high water or alcohol content, which can cause burning
• Protecting the skin from irritants and rough clothing, such as wool
• Avoid scratching or rubbing your skin, which increases inflammation and can increase itchiness. Keep your child’s fingernails short to help reduce scratching
• Try keeping the inside of your home at a cool, stable temperature and consistent humidity levels. Avoid situations where overheating may occur, as this may help prevent flares
• Talk to your doctor to check if food allergies could cause flares

Managing Stress

Using stress management and relaxation techniques can help lower stress and decrease the likelihood of flares. Developing a network of support that includes family, friends, health professionals, and support groups can be beneficial. If you feel overwhelmed, embarrassed, or anxious about the condition, seek counseling with a mental health professional.

Getting Restful Sleep

If you or your child cannot get restful sleep at night because of itching and scratching, talk to your doctor about options to better control atopic dermatitis.

Smallpox Vaccine

Anyone with atopic dermatitis should not receive a smallpox vaccine. If you have atopic dermatitis and receive the smallpox vaccine, you are more likely to develop a serious complication, even if your condition is mild or not active at the time of the shot. You should also avoid being around others who have recently received the vaccine.

Caregiver Support

NIH researchers who studied wet wrap therapy focused not only on bringing study participants’ symptoms under control, but also on training caregivers to continue treatment at home. An eczema management plan can help caregivers identify the severity of eczema flare-ups and begin the proper treatment.

Find Clinical Trials

Clinical trials uncover better ways to prevent, diagnose, treat, and understand diseases and conditions. To ensure results apply to everyone, volunteers of all ages, sexes, and backgrounds, including both healthy individuals and those with specific medical conditions, are needed. Find clinical trials on atopic dermatitis.

Find Treatment 

The following healthcare providers may diagnose and treat eczema:

• Dermatologists specialize in conditions of the skin, hair, and nails. You may want to find a dermatologist who specializes in treating eczema.
• Allergists specialize in treating allergies.
• Primary healthcare providers, including family doctors, internists, or pediatricians can often identify and treat eczema.

NIH supports research to understand what causes atopic dermatitis and how to prevent, diagnose, and treat the condition.

Researchers do not know what causes atopic dermatitis, but they do know that genes, the microbiome, the immune system, and the environment play a role in the disease. Some researchers are studying how genetic, environmental, and biological factors combine to cause eczema and related allergic diseases in children. Other researchers are examining genes to better understand how different mutations cause atopic dermatitis.

The NIH-supported Atopic Dermatitis Research Network aims to understand the biological factors behind atopic dermatitis, including the genetic and molecular causes of skin barrier problems, the role of the skin microbiome in immunity, and how the skin and gut interact to drive inflammation. Researchers are also comparing immune responses to viral and bacterial skin infections in people with atopic dermatitis to those with other chronic skin conditions.

To clarify what triggers atopic dermatitis to develop or worsen, some studies are looking at how exposure to certain chemicals and pollutants in the environment affects the skin and how the skin's chemistry differs between people with and without eczema. Other researchers are studying whether treating infants' dry skin early in life can help prevent atopic dermatitis from developing or becoming severe.

Researchers are also working to better distinguish atopic dermatitis from related conditions, such as reactions that can occur after stopping topical steroid treatment, so that people receive the right diagnosis and care.

NIH-supported research on therapeutics for atopic dermatitis currently focuses on topical probiotics, which are medicines that use bacteria found on healthy skin to attempt to treat the disease. People with atopic dermatitis experience imbalances in the skin microbiome. Scientists are studying whether probiotics can restore a healthy balance of skin microorganisms and thus alleviate atopic dermatitis symptoms.

Having atopic dermatitis as a child can lead to the development of asthma and hay fever later in life. Some NIH-supported researchers are working to understand why that happens.

Community Support

The following organizations provide information and support for people with atopic dermatitis:

• National Eczema Association
• American Academy of Dermatology
• American Academy of Allergy, Asthma, and Immunology
• Society for Pediatric Dermatology
• U.S. Food and Drug Administration
• Centers for Disease Control and Prevention, National Center for Health Statistics

Note: This resource list is for informational purposes only. It is not comprehensive, and an organization’s inclusion does not constitute an endorsement by NIH.  

Research Information

The National Institutes of Health (NIH) is the largest public funder of biomedical research in the world. NIH invests most of its budget in medical research seeking to enhance life and to reduce illness and disability. NIH-funded research has led to breakthroughs and new treatments helping people live longer, healthier lives, and building the research foundation that drives discovery.  

Researchers do not know what causes atopic dermatitis, but they do know that genes, the microbiome, the immune system, and the environment play a role in the disease. Researchers continue to study genes to better understand how different mutations cause atopic dermatitis. Researchers also continue to study why having atopic dermatitis as a child can lead to the development of asthma and hay fever later in life.

The Atopic Dermatitis Research Network aims to understand immune system responses in the skin by comparing responses to viral and bacterial skin infections in healthy individuals with those in people with atopic dermatitis.

NIH-supported research on eczema therapeutics currently focuses on topical probiotics, which are medicines that use bacteria found on healthy skin to attempt to treat the disease. People with eczema experience imbalances in the skin microbiome. Scientists are studying whether probiotics can restore a healthy balance of skin microorganisms and thus alleviate eczema symptoms.

Find NIH-funded research projects using NIH RePORTER, a searchable database of current and past research projects supported by NIH and other federal agencies.