Eczema: definition, how to recognise it and which treatment to favour

By Cristiano Antonino On Apr 14, 2023

Atopic eczema (atopic dermatitis) is the most common form of eczema, a condition that causes itching, dryness and cracking of the skin

Atopic eczema is most common in children, often developing before their first birthday

But it can also develop for the first time in adults.

It is usually a long-term (chronic) condition, although it can improve significantly, or even disappear completely, in some children as they grow older.

Symptoms of atopic eczema

Atopic eczema causes the skin to become itchy, dry, cracked and painful.

Some people only have small patches of dry skin, but others may experience inflamed skin spread all over the body.

Inflamed skin may turn red on lighter skin and dark brown, purple or grey on darker skin.

This may also be more difficult to see on darker skin.

Although atopic eczema can affect any part of the body, it most often affects the hands, the inside of the elbows, the back of the knees and the face and scalp in children.

People with atopic eczema usually have periods when symptoms are less noticeable, as well as periods when symptoms become more severe (flare-ups).

See a doctor if you have symptoms of atopic eczema

They will usually be able to diagnose atopic eczema by observing the skin and asking questions such as:

whether the rash is itchy and where it appears
when the symptoms started
whether it comes and goes over time
whether there is a history of atopic eczema in your family
whether you suffer from other conditions, such as allergies or asthma
whether anything in your diet or lifestyle may be contributing to your symptoms

Generally, to be diagnosed with atopic eczema you should have had an itchy skin condition in the last 12 months and 3 or more of the following

visibly irritated red skin in skin folds – such as on the inside of the elbows or behind the knees (or on the cheeks, the outside of the elbows or the front of the knees in children aged 18 months or less) at the time of testing by a health professional
a history of skin irritation occurring in the same areas mentioned above
generally dry skin in the last 12 months
a history of asthma or hay fever – children under 4 years of age must have a close relative, such as a parent, brother or sister, who has 1 of these conditions
the condition started before the age of 2 years (this does not apply to children under 4 years)

Causes of atopic eczema

The exact cause of atopic eczema is unknown, but it is clear that it does not depend on just one thing.

Atopic eczema often occurs in people who suffer from allergies.

“Atopic’ means sensitivity to allergens.

It can run in families and often develops together with other conditions, such as asthma and hay fever.

Symptoms of atopic eczema often have certain triggers, such as soaps, detergents, stress and weather conditions.

Sometimes food allergies can play a role, especially in young children with severe eczema.

You may be asked to keep a food diary to try to determine whether a specific food worsens your symptoms.

Allergy tests are not usually necessary, although they are sometimes helpful in identifying whether a food allergy may be triggering your symptoms.

Treatment of atopic eczema

Treatment for atopic eczema can help relieve symptoms and many cases improve over time.

But there is currently no cure and severe eczema often has a significant impact on daily life, which can be difficult to cope with physically and mentally.

There is also an increased risk of skin infections.

Many different treatments can be used to control symptoms and manage eczema, including

self-care techniques, such as reducing scratching and avoiding triggers
emollients (moisturising treatments) – used daily for dry skin
topical corticosteroids – used to reduce swelling, redness and itching during flare-ups

Other types of eczema

discoid eczema – a type of eczema that occurs in circular or oval patches on the skin
contact dermatitis – a type of eczema that occurs when the body comes into contact with a particular substance
varicose eczema – a type of eczema that most often affects the lower legs and is caused by problems with blood flow through the veins in the legs
seborrhoeic eczema – a type of eczema in which red, scaly patches develop on the sides of the nose, eyebrows, ears and scalp
dyshidrotic eczema (pompholyx) – a type of eczema in which tiny blisters erupt on the palms of the hands

Atopic eczema causes areas of the skin to become itchy, dry, cracked and painful.

There are usually periods when symptoms improve, followed by periods when they worsen (flare-ups).

Relapses may occur as often as 2 or 3 times a month.

Atopic eczema can occur all over the body, but is most common on the hands (especially the fingers), the inside of the elbows or the back of the knees, and the face and scalp in children.

The severity of atopic eczema can vary greatly from person to person. People with mild eczema may only have small areas of dry skin that are occasionally itchy. In more severe cases, atopic eczema can cause widespread inflamed skin all over the body and constant itching.

Inflamed skin may turn red on lighter skin and dark brown, purple or grey on darker skin. This may also be more difficult to see on darker skin.

Scratching can disturb sleep, make the skin bleed and cause secondary infections. Itching can also worsen and a cycle of regular itching and scratching can develop. This can lead to sleepless nights and difficulty concentrating at school or work.

Areas of the skin affected by eczema may also become temporarily darker or lighter after the condition has improved.

This is more noticeable in people with darker skin.

It is not the result of scarring or a side effect of steroid creams, but more of an ‘imprint’ of old inflammation and eventually the skin tone returns to its normal colour.

Signs of an infection

Occasionally, areas of the skin affected by atopic eczema may become infected.

Signs of an infection may include:

your eczema is getting much worse
fluid oozing from the skin
a yellow crust on the surface of the skin or small yellowish-white spots appearing in the eczema
the skin becomes swollen and painful
feeling hot and shivering and general malaise

Consult a doctor as soon as possible if you think your skin or your child’s skin may be infected.

Atopic eczema is likely to be caused by a combination of factors.

People with atopic eczema often have very dry skin because their skin is unable to retain much moisture.

This dryness can increase the likelihood that the skin will react to certain triggers, causing itching and pain.

You may be born with a higher probability of developing atopic eczema because of the genes you inherit from your parents.

Research has shown that children who have 1 or both parents with atopic eczema, or who have other siblings with eczema, are more likely to develop it themselves.

Atopic eczema is not contagious, so it cannot be transmitted through close contact.

There are a number of things that can trigger eczema symptoms.

These can vary from person to person.

Common triggers include:

irritants – such as soaps and detergents, including shampoo, dishwashing liquid and shower gel
environmental factors or allergens – such as cold and dry weather, humidity and more specific things like house dust mites, pet dander, pollen and moulds
food allergies – such as allergies to cow’s milk, eggs, peanuts, soya or wheat
certain materials worn in contact with the skin, such as wool and synthetic fabrics
hormonal changes: women may experience a worsening of symptoms in the days before their period or during pregnancy
skin infections

Some people also report that their symptoms worsen when the air is dry or dusty, or when they are stressed, sweaty, too hot or too cold.

If you are diagnosed with atopic eczema, a doctor will work with you to try to identify possible triggers for your symptoms.

Treatments for atopic eczema can help relieve your symptoms.

There is no cure, but many children find that their symptoms improve naturally as they get older.

The main treatments for atopic eczema are

emollients (moisturisers) – used daily to prevent the skin from drying out
topical corticosteroids – creams and ointments used to reduce swelling and redness during flare-ups

Other treatments include:

topical pimecrolimus or tacrolimus for eczema in sensitive sites that do not respond to the simplest treatment
antihistamines for severe itching
bandages or special suits to allow the body to heal under
more powerful treatments offered by a dermatologist (skin specialist)

Topical corticosteroids

If the skin is painful and inflamed, a general practitioner can prescribe a topical corticosteroid (applied directly to the skin), which can reduce inflammation in a few days.

Topical corticosteroids can be prescribed in different dosages, depending on the severity of the atopic eczema and the affected areas of the skin.

They can be

very mild (such as hydrocortisone)
moderate (such as betamethasone valerate and clobetasone butyrate)
strong (such as a higher dose of betamethasone valerate and betamethasone dipropionate)
very strong (such as clobetasol proprionate and diflucortolone valterate)

If you need to use corticosteroids frequently, consult a family doctor regularly so that he or she can check that the treatment is working effectively and that you are using the right amount.

How to use topical corticosteroids

Don’t be afraid to apply treatment to the affected areas to control eczema.

Unless otherwise directed by a doctor, follow the directions on the patient information leaflet supplied with the medicine.

This will provide details on how much to apply.

Most people only need to apply it once a day as there is no evidence that there is any benefit in applying it more often.

When using a topical corticosteroid

apply your emollient first and ideally wait about 30 minutes until the emollient has absorbed into the skin, or apply the corticosteroid at a different time of day (e.g. at night)
apply the recommended amount of topical corticosteroid to the affected area
continue to use it for up to 48 hours after the flare-up has resolved in order to treat the inflammation below the surface of the skin

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Occasionally, the doctor may suggest using a topical corticosteroid less frequently, but for a longer period of time.

This is designed to help prevent flare-ups.

This is sometimes called weekend treatment, in which a person who has already gained control of their eczema uses the topical corticosteroid every weekend on problematic sites to prevent them from becoming active again.

Side effects

Topical corticosteroids can cause a mild burning sensation for less than a minute while applying them.

In rare cases, they can also cause

thinning of the skin, especially if strong steroids are used in the wrong places, such as the face, for too long (e.g. several weeks)
changes in skin colour – usually, lightening of the skin after many months of using very strong steroids, but most lightening after eczema is an ‘imprint’ of old inflammation and has nothing to do with the treatments
acne (spots) – especially when used on the face in teenagers
increased hair growth

Most of these side effects will improve once treatment is stopped.

The risk of side effects may be increased if a strong topical corticosteroid is used:

for many months
in sensitive areas such as the face, armpits or groin
in large quantities

You should be prescribed the weakest effective treatment to control your symptoms.

Antihistamines

Antihistamines are a type of medicine that blocks the effects of a substance in the blood called histamine.

They can help relieve the itching associated with atopic eczema.

They can be sedatives, which cause drowsiness, or non-sedatives.

If you have severe itching, a doctor may suggest that you try a non-sedating antihistamine.

If itching during a flare-up affects sleep, a doctor may suggest taking a sedative antihistamine.

Sedative antihistamines may cause drowsiness until the next day, so it may be helpful to inform your child’s school that he/she may not be as alert as usual.

Bandages and wet packs

In some cases, a general practitioner may prescribe medicated bandages, clothing or wet packs to be worn on the areas of skin affected by eczema.

These can be used over emollients or with topical corticosteroids to prevent scratching, allow the underlying skin to heal and prevent the skin from drying out.

Corticosteroid tablets

Corticosteroid tablets are rarely used to treat atopic eczema nowadays, but occasionally they may be prescribed for short periods of 5 to 7 days to help control particularly severe flare-ups.

Longer treatment cycles are generally avoided because of the risk of potentially serious side effects.

If a general practitioner thinks your condition may be severe enough to benefit from repeated or prolonged treatment with corticosteroid tablets, he or she will probably refer you to a specialist.

Complementary therapies

Some people may find complementary therapies such as herbal remedies helpful in treating their eczema, but there is little evidence to show that these remedies are effective.

If you are considering using a complementary therapy, talk to a family doctor first to make sure the therapy is safe for you.

Make sure you continue to use other treatments prescribed by a family doctor.

People with atopic eczema can sometimes develop additional physical and psychological problems.

Bacterial skin infections facilitated by eczema

Since atopic eczema can cause cracking and breaking of the skin, there is a risk of the skin becoming infected with bacteria.

The risk is greater if you scratch your eczema or do not use your treatments correctly.

Signs of a bacterial infection may include:

fluid oozing from the skin
a yellow crust on the surface of the skin
small yellowish-white spots appearing in the eczema
the skin becomes swollen and painful
feeling hot and shivering and general malaise

Your normal symptoms may also worsen rapidly and your eczema may not respond to your regular treatments.

You should consult a doctor as soon as possible if you think your skin or your child’s skin may be infected.

They will usually prescribe antibiotics to treat the infection, as well as make sure that the skin inflammation that led to the infection is well controlled.

Talk to a doctor if these do not help or your symptoms worsen.

Once the infection has been cleared, a GP will prescribe new supplies of any creams and ointments you are using to avoid contamination.

Old treatments should be disposed of.

Viral skin infections

It is also possible for eczema to be infected by the herpes simplex virus, which normally causes cold sores.

This can develop into a serious condition called herpetic eczema.

Symptoms of herpetic eczema include:

areas of painful eczema that worsen rapidly
clusters of fluid-filled blisters that open and leave small, shallow sores open on the skin
sensation of heat and chills and general malaise in some cases

If you are diagnosed with herpetic eczema, you will be given an antiviral medicine called acyclovir.

Psychological effects

Besides affecting you physically, atopic eczema can also affect you psychologically.

Preschool children with atopic eczema may be more likely to have behavioural problems such as hyperactivity than children who do not have the condition.

They are also more likely to be more dependent on their parents.

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