Atopic Dermatitis (Eczema): Symptoms, Causes & Treatment

Atopic dermatitis (eczema) is a chronic, non-contagious skin inflammation characterized by intense itching, redness, and severe dryness. Patients experience cycles of symptom flare-ups and periods of remission. The disease results from a defective skin barrier and an overreactive immune response to specific triggers. Although it typically begins in childhood, it can persist into or begin in adulthood.

Atopic dermatitis is prevalent worldwide, affecting 1-3% of adults and 10-20% of children. In the Middle East and Jordan, cases are increasing, especially in urban areas and dry climates. The condition significantly impacts quality of life due to bothersome itching and psychological effects, but is manageable with proper treatment and care.

Understanding the disease and its causes is essential for patients and families. Genetic, environmental, and psychological factors play important roles in disease development, necessitating a comprehensive approach including continuous moisturization, trigger avoidance, and prescribed medications.

Atopic dermatitis symptoms range from mild to severe and vary between individuals. Symptoms can start at any age but are most common in children under 5. In children, symptoms typically appear on the face, hands, and feet, while in adults they can occur anywhere. Itching often worsens at night and increases during stress and cold, dry weather.

• Intense itching: The primary symptom, often painful, worse at night, and affecting sleep.
• Red and inflamed skin: Obvious redness in affected areas with slight swelling.
• Severe skin dryness: Very dry and sensitive skin with possible fine cracks.
• Small red rash: Tiny red bumps, especially on face, neck, and hands.
• Skin scaling: Surface peeling and white scales.
• Cracked skin and bleeding: In severe cases, scratching may cause bleeding.
• Thickened and discolored skin: Repeated scratching causes skin thickening and discoloration.
• Swelling and puffiness: Especially around eyes and lips in severe cases.
• Fluid-filled blisters: In some cases, small blisters leak clear fluid.
• Discomfort and pain: Beyond itching, burning and pain may occur.
• Recurring flares: Symptoms cycle through active periods and remission.
• Increased sensitivity: Skin becomes more reactive to various substances and triggers.

• Defective skin barrier proteins: Mutations in the filaggrin gene weaken the skin barrier, allowing water loss and bacterial invasion.
• Genetic inheritance: The disease runs in families; if a parent has it, the child's risk is approximately 50%.
• Immune system overactivity: The immune system overreacts to harmless environmental triggers, causing inflammation.
• Environmental factors: Cold, dry weather, low humidity, and pollutants exacerbate symptoms.
• Irritating substances: Harsh soaps, fragrances, dyes, and chemicals cause direct skin irritation.
• Psychological stress: Emotional stress and anxiety worsen symptoms and increase flare frequency.
• Bacterial infections: Particularly Staphylococcus aureus, which exploits compromised skin.
• Food and respiratory allergies: Certain foods and seasonal allergies may increase skin inflammation.

• Family history: Having family members with eczema, asthma, or hay fever significantly increases risk.
• Age: Children under 5 are more susceptible, but it can occur at any age.
• Gender: Women are slightly more affected than men, especially in adults.
• Cold and dry climate: Dry climates like Jordan and Arab countries worsen symptoms.
• Occupations requiring frequent washing: Healthcare workers, chefs, and cleaners face higher risk.
• Chronic psychological stress: Ongoing emotional stress increases flare intensity.
• Early infection exposure: Lack of infection exposure in childhood may increase allergy risk.
• Vitamin D deficiency: Studies link low vitamin D to severe eczema.
• Obesity: Overweight individuals have higher susceptibility.
• Anxiety and depression: Accompanying mental health conditions worsen skin condition.

Diagnosis of atopic dermatitis relies primarily on clinical examination by a dermatologist and evaluation of medical history and symptoms. There are no specific blood tests or laboratory markers for diagnosis, though tests may be ordered to exclude other conditions or assess allergies. Diagnostic criteria are based on persistent itching, medical history, and clinical skin appearance.

• Clinical examination: Assessment of affected skin appearance, rash nature, inflammation, dryness, and distribution.
• Medical and family history: Detailed questioning about symptom onset, triggering factors, and family history of allergies.
• Hanifin and Rajka criteria: Standard diagnostic criteria including 15 parameters; at least 3 must be present for diagnosis.
• Patch testing: May be performed to exclude contact dermatitis from specific substances.
• Blood tests (IgE levels): Physician may order immunoglobulin E testing to assess associated allergies.
• Allergen testing: In some cases to identify specific triggers like food allergies.
• Wood's Lamp examination: Used to exclude fungal or viral infections.
• Skin biopsy: Rarely needed but may be requested in unclear or suspicious cases.

Medications

• Moisturizers and emollients: Applied multiple times daily, especially immediately after bathing. Include petrolatum, body oils, and thick creams. Foundation of treatment for all cases.
• Topical corticosteroids: Creams and ointments applied to affected areas to reduce inflammation and itching. Used in graded strengths based on severity.
• Calcineurin inhibitors (Tacrolimus and Pimecrolimus): Non-steroid topical treatments effective for face and neck when steroids are unsuitable.
• Antihistamines: Medications like cetirizine and fexofenadine reduce itching and allergic reactions, available as syrups or tablets.
• Biologic medications: Dupilumab is a subcutaneous injection given every two weeks or monthly, highly effective for severe resistant cases.
• PDE4 inhibitors: Such as crisaborole, modern topical creams effective especially on the face.
• Antibiotics: Prescribed when bacterial infection is suspected (e.g., Staphylococcus aureus).
• Anti-itch medications: Such as tramadol or antidepressants in very severe cases.

Procedures

• Phototherapy: Regular exposure to ultraviolet light (UVA or UVB) under medical supervision, effective for severe widespread cases.
• Water therapy and warm baths: Bathing in warm (not hot) water for 5-10 minutes followed by immediate moisturizer application.
• Psychological therapy and counseling: In cases where stress and anxiety affect symptoms.

Lifestyle Changes

• Avoid known triggers: Identify and avoid substances and factors that worsen symptoms (harsh soaps, fragrances, rough fabrics).
• Keep skin moisturized: Use moisturizers frequently, especially in dry and cold climates like Jordan.
• Wear soft cotton clothing: Avoid synthetic fibers and wool that irritate skin.
• Avoid hot water bathing: Hot water strips natural skin oils; use lukewarm or warm water.
• Use gentle cleansers: Choose fragrance-free, mild soaps.
• Manage stress: Practice relaxation, yoga, and stress-reduction techniques.
• Avoid pollutants and smoke: Stay away from cigarette smoke and environmental pollution.
• Eat a balanced diet: In some cases, certain foods like spicy food and caffeine may worsen symptoms.
• Get adequate sleep: Good sleep strengthens immunity and reduces symptoms.
• Use home humidifiers: Especially in dry climates.

• Secondary bacterial infection: Repeated scratching creates wounds susceptible to bacterial infection, especially Staphylococcus aureus, potentially leading to boils and abscesses.
• Scars and permanent discoloration: Excessive scratching and infection may cause permanent scarring and pigmentation changes.
• Viral infections: Immunocompromised skin may develop herpes simplex due to weakened local immune response.
• Contact dermatitis from medications: Some topical treatments may cause additional irritation or allergic reactions.
• Sleep deprivation and psychological effects: Severe itching affects sleep quality, causing fatigue, anxiety, and depression.
• Impact on child development: Severe cases may affect academic concentration and psychological and social development in children.
• Hypersensitivity and medication side effects: Sensitive skin may react negatively to various topical medications.
• Development of other allergic diseases: Eczema patients are at higher risk for asthma, hay fever, and food allergies.

• Maintain continuous skin hydration: Use moisturizers and oils daily, especially in dry and cold climates like Jordan's winters.
• Avoid irritating substances: Choose fragrance-free soaps, soft cotton clothing, and avoid harsh cleaners and chemical fragrances.
• Bathe correctly: Use lukewarm or warm water for short periods (5-10 minutes) then apply moisturizers immediately to wet skin.
• Manage stress and tension: Practice relaxation techniques such as yoga, meditation, and regular exercise.
• Identify and avoid personal triggers: Keep a log of foods and substances that worsen your symptoms and avoid them.
• Get adequate sleep: Regular adequate sleep (7-9 hours) boosts immunity.
• Improve home air quality: Use humidifiers in dry climates and avoid pollutants and smoke.
• Maintain healthy nutrition: Eat foods rich in vitamins, healthy fats, and fiber.
• Avoid tight and rough clothing: Wear loose, soft clothing, especially while sleeping.
• Regular checkups: With a family history of eczema, schedule periodic dermatology visits for screening and prevention.