Eczema

What eczema is

In eczema, the skin barrier does not hold moisture well, letting water out and irritants and microbes in. The immune system in the skin overreacts, causing inflammation and itching. Scratching damages the barrier further, creating an itch-scratch cycle.

In atopic dermatitis, many people have changes in the filaggrin gene, which helps build the skin barrier, along with an immune system tilted toward allergic (type 2) inflammation.

Symptoms

• intense itching, often worse at night
• dry, rough or scaly skin
• red patches on lighter skin; dark brown, purple or gray patches on darker skin, which can be harder to see
• small bumps that may ooze and crust when flaring
• thickened, leathery skin (lichenification) from long-term scratching
• cracks and fissures, especially on hands and feet
• lighter or darker patches after a flare settles

Where eczema appears by age

Types of eczema

Causes and risk factors

• Genetics: a family history of eczema, asthma or hay fever.
• Skin barrier defects such as filaggrin mutations.
• Immune system overactivity toward type 2 inflammation.
• Environment: dry climates, cold winters, hard water and urban living are linked to higher rates.

Eczema is part of the "atopic march": many children with eczema later develop food allergy, asthma or hay fever.

Common triggers

• soaps, bubble baths, detergents and fragrances
• wool and synthetic fabrics
• hot water, sweating and overheating
• cold, dry air and central heating
• stress
• skin infections, especially Staphylococcus aureus
• dust mites, pet dander and pollen
• in some young children with severe eczema, certain foods (only confirmed allergies should be avoided)
• hormonal changes, such as before periods or in pregnancy

Diagnosis

Eczema is diagnosed from the appearance of the rash, its location and history. Tests may include:

• patch testing if contact allergy is suspected
• skin swabs if infection is suspected
• allergy testing in selected children with severe eczema and suspected food allergy
• skin biopsy occasionally, to rule out other conditions such as psoriasis or skin lymphoma

Treatment

Daily skin care (the foundation)

• Moisturize at least twice daily with a thick, fragrance-free cream or ointment, and after every bath or hand wash. Use generous amounts.
• Bathe in lukewarm water for 5 to 10 minutes, use a soap-free cleanser, and pat dry.
• "Soak and seal": apply moisturizer within 3 minutes of bathing.
• Wear soft cotton clothing and keep nails short.

Treating flares

• Topical corticosteroids: the main treatment for flares. Strength is matched to the area and severity: mild for the face and skin folds, stronger for thick patches on the body. Used correctly, short courses are safe.
• Topical calcineurin inhibitors (tacrolimus, pimecrolimus): steroid-free, useful for the face and eyelids.
• Crisaborole (a PDE4 inhibitor) and topical JAK inhibitors such as ruxolitinib cream.
• Proactive therapy: using an anti-inflammatory cream twice a week on usual flare sites to prevent relapses.
• Wet wraps: damp bandages over moisturizer and medicated creams for severe flares, under medical guidance.
• Antibiotics or antivirals if infection develops.

Moderate to severe eczema

• Phototherapy (narrowband UVB).
• Biologic injections: dupilumab, tralokinumab, lebrikizumab and others, which target type 2 inflammation.
• Oral JAK inhibitors: such as upadacitinib and abrocitinib.
• Traditional immunosuppressants: methotrexate, cyclosporine.

Oral antihistamines do not treat eczema itself, but a sedating one may help sleep during flares.

Bleach baths

Dilute bleach baths, made according to a dermatologist's instructions, can reduce bacteria and flares in some people with frequent infections.

Eczema in babies

Infant eczema often starts on the cheeks between 2 and 6 months. Gentle skin care and frequent moisturizing are key. Babies with severe early eczema have a higher risk of peanut and egg allergy; current guidance supports introducing peanut and egg early (around 4 to 6 months) after discussing with a pediatrician, rather than delaying them. Many children improve as they grow.

Complications

• skin infections: bacterial (staph), viral (eczema herpeticum, molluscum) and fungal
• sleep loss, affecting mood, school and work
• anxiety and depression
• skin color changes and thickening
• eye problems with eczema around the eyes

Outlook

Eczema often improves during childhood, and many children have far fewer symptoms by adolescence, though dry, sensitive skin may persist and eczema can return in adulthood. With modern treatments, even severe eczema can usually be controlled well.

Frequently asked questions

What causes eczema?

Eczema results from a combination of a weak skin barrier, an overactive skin immune response and genetics, often with a family history of allergies. Triggers such as soaps, fragrances, dry air, sweat, stress and infections cause flares.

What are the main types of eczema?

The main types are atopic dermatitis, contact dermatitis, dyshidrotic eczema, nummular eczema, seborrheic dermatitis and stasis dermatitis. Atopic dermatitis is the most common and usually begins in childhood.

Is eczema contagious?

No. You cannot catch eczema from someone else. However, eczema skin can become infected with bacteria or viruses, and those infections can be contagious.

What is the best treatment for eczema?

Daily moisturizing is the foundation. Topical corticosteroids or non-steroid creams treat flares. For moderate to severe eczema, phototherapy, biologic injections such as dupilumab, or oral JAK inhibitors are highly effective. The best plan depends on severity and age.

Can eczema go away permanently?

Eczema often improves with age, especially in children, and some people have long periods without symptoms. However, the tendency toward dry, sensitive skin usually remains, and flares can return. Ongoing skin care helps keep it under control.

Does diet affect eczema?

In most people, food does not cause eczema. Some young children with severe eczema have food allergies that can worsen it, but foods should only be removed after proper allergy testing and medical advice, to avoid nutritional problems.