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Atopic dermatitis (AD) is the most common type of eczema, affecting more than 9.6 million children and about 16.5 million of adults in the United States. It’s a chronic condition that can come and go for years or throughout life.
In people with AD, for complex reasons science hasn’t fully sorted out, the immune system becomes disordered and overactive. This triggers inflammation that damages the skin barrier, leaving it dry and prone to rashes, itching, redness in lighter skin tones or a purple, brown or grayish hue in darker skin tones.
“This often leads to a vicious cycle of itching, scratching and more itching that further inflames the immune system and further damages the skin barrier,” said Dr. Peter Lio, clinical assistant professor of dermatology and pediatrics at Northwestern University’s Feinberg School of Medicine.
Lio stressed that AD isn’t contagious and is never the fault of the patient—or their parents. “There is so much guilt around this condition and many people, especially parents of children with atopic dermatitis, feel responsible for it,” he said. “This can cause more stress, which can make AD worse and harder to cope with.”
When dermatologists and patients work together, they can often bring AD under control.
“While there is no cure — yet — and AD can be difficult to treat, our understanding of it continues to improve and there is great hope and some amazing new treatments and approaches,” Lio said.
Itching is the hallmark of AD, with some data showing that more than 85% of people with the condition experience this distressing symptom every day. Sore or painful skin and poor sleep caused by itching are also common.
People with AD can get rashes anywhere on the body that can ooze, weep fluid and bleed when scratched. Skin can become dry and discolored with red, brown or lightened patches. Repeated scratching can cause thickening and hardening, and damage makes skin vulnerable to infection.
Often, people with AD also have asthma and food and other allergies. Depression and anxiety can also go along with the condition. It can also overlap with other forms of eczema.
“AD is not just a ‘skin rash,’” Lio said. “It can have a huge impact on quality of life — not just that of the patient, but on family and friends too. The itch can make it difficult to concentrate, poor sleep can make people feel like zombies during the day, and treatments and precautions can take a toll on time, energy and money.”
In most people, AD first appears in infancy or early childhood. In some children, symptoms taper off as they grow. Others have flares throughout life.
Experts believe that genetics, immune system changes and contact with irritants in the environment all play a role in starting the cycle of inflammation and damage that causes AD symptoms.
Researchers, for example, have identified a protein called filaggrin that holds in water and helps keep the skin’s outmost layer intact. Some people with AD have a gene mutation that means they make less of this protein. Low levels leave skin dry and prone to damage and sensitization.
Atopic dermatitis runs in families and having relatives with asthma or hay fever also increases risk. Many things can trigger a flare, including:
When AD is mild, dermatologists may begin treatment by asking patients to avoid known triggers and to moisturize regularly to protect and strengthen the skin barrier.
“If these methods are not enough, or if eczema is more severe, we often add topical corticosteroids, which have rapid, reliable anti-inflammatory and anti-itch effects. This allows us to calm the flare and help break the itch-scratch cycle,” Lio said.
There are also non-steroidal topicals, including tacrolimus, pimecrolimus and crisaborole. “These can play a role if topical steroids aren’t appropriate,” says Lio. “The tradeoff is that, generally, they’re weaker, less reliable and can cause burning or stinging.”
Biologic therapy is the most recent option for adults and teens with moderate to severe AD who don’t improve enough with topical steroids or who shouldn’t use them. Biologics are targeted, genetically engineered yteatments made from living tissue or cells.
Dupixent (dupilumab), given by injection, is the first biologic approved for AD. The U.S. Food and Drug Administration is currently fast-tracking review of the drug for use in children with severe AD who are age 6 and older.
Good self-care also helps keep symptoms in check. This includes:
“I also find that meditation or even hypnosis can be helpful when stress is a big component of AD,” Lio said. “If we can get the skin clear and keep it there, there is a much higher chance of longer periods without flares when treatments may not even be necessary.”