Welcome to our deep guide on the topic of eczema. If you would like a shorter introduction into this topic, please check out our concise guide to eczema.
What Is Eczema and Why Do You Get It?
Eczema is a skin condition that can make you feel itchy and cause dry, scaly, reddened patches of skin that can ooze, crust, crack, bleed and stick around for a while. It's often called the "itch that rashes" because scratching can make it worse, creating a cycle that's tough to break.
Eczema can really impact your life, especially if it affects your sleep. Sometimes, eczema gets better and sometimes it gets worse. When it gets worse, it's called a flare-up (Harvard Health, Nutten 2015).
There are a few different types of eczema, with atopic eczema also known as atopic dermatitis (AD) being the most common (National Eczema Association). When people talk about eczema, they are generally referring to AD.
There's also contact dermatitis, which happens when you come into contact with something that causes an allergic reaction, like poison ivy or poison oak. This type of eczema generally goes away when you find out what caused the allergy and remove it (AAD).
Eczema is often associated with babies and childhood as it is very common in these populations in whom the skin barrier and immune system are still developing. Most children outgrow eczema by the time they reach adolescence as the skin barrier and immune system mature (AAD). One estimate points to 70% of children outgrowing it by adolescence (Frazier and Bhardwaj 2020).
Though less common in adults, it is still fairly common in the adult population. Worldwide prevalence of atopic dermatitis by the International Study of Asthma and Allergies in Childhood is estimated to be 15–20% in children and 1–3% in adults (Odhiambo et al. 2009, Nutten 2015).
Factors such as race and geographic location affect these population statistics and can lead to variance of estimates across studies. Further, for reasons unknown, it's becoming more prevalent worldwide particularly in children (Lee et al. 2016).
Adult eczema can also often look different from eczema in babies and children. Babies tend to get it on their face, scalp, trunk, and limbs, while older kids might get it in the creases of their skin like in the elbow crease. Adults might have dry patches on their hands or just one area of their body. Adults with eczema are also susceptible to contact irritation — for example, in the lip region with saliva contact (Harvard Health, Frazier and Bhardwaj 2020, Paller et al. 2023).
Unfortunately, having eczema can also increase your chances of developing other allergies, like food allergies or asthma and hay fever. Called the atopic march, about 50% of those with atopic dermatitis develop other allergies in their first year of life. This may be in part due to the fact that those with eczema may be more genetically prone to developing allergies and in part due to the fact that chronically inflamed skin leads to sensitization to allergens.
The Role of Genetics
Some people who get eczema have a family history of having an exaggerated immune response (Frazier and Bhardwaj 2020).
Others with eczema carry a gene for a skin barrier defect. About 50% of those with eczema have a mutation in a gene that codes for a protein called filaggrin, which is integral for developing and maintaining a healthy skin barrier (Nutten 2015).
You may get eczema if you have a genetic tendency toward allergies or a skin barrier defect that allows allergens to penetrate. The state of chronic skin inflammation further weakens the barrier, contributing to a cycle of continued inflammation (Frazier and Bhardwaj 2020).
The good news is that there are ways to manage eczema, even if there's no cure. If you have eczema, you can work with your doctor to find ways to prevent flare-ups and treat them when they happen (AAD).
How Do You Manage Eczema?
If you're dealing with eczema, you may have heard that cutting back on washing and bathing can reduce flare-ups. This is a myth! In fact, you should do the exact opposite and bathe more (AAD). The problem isn't cleansing — it's using the wrong cleanser.
Soaps and harsh detergents like sulfates can further disrupt your skin barrier. You want to use a cleanser that is soap-free, sulfate-free, dye-free, fragrance-free, and has an acidic pH (AAD, Nutten 2015, Paller et al. 2023). And it's crucial to always moisturize after cleansing to keep skin hydrated.
Bathing Guidelines
Washing with a cleanser is crucial: 90% of people with eczema have skin colonized with greater levels of harmful bacteria such as S. aureus. This is in part because those with eczema have an elevated skin pH that benefits the growth of S. aureus. Since those with eczema have a disrupted skin barrier, the skin is also more susceptible to infection.
In some cases, your doctor may even recommend twice-weekly bathing with dilute bleach (½ cup of 6% bleach in 40 gallons of water) (Ring et al. 2012, Frazier and Bhardwaj 2020). When diluted, bleach forms hypochlorous acid which can effectively kill microbes such as S. aureus on the skin. While generally regarded as safe, it is important to properly dilute the bleach, limit the number of bleach baths, and discontinue if skin irritation or allergic reaction occurs.
Bath additives such as oils or colloidal oatmeal are widely used but there is no high-quality evidence that they provide benefit. In fact, one study showed no benefit and found they can also increase the risk of slipping in the bath — and hence, are not recommended by the AAD and most doctors (AAD, Paller et al. 2023).
Choosing a Moisturizer
For moisturizers, there are over-the-counter options and prescription options. Studies show that both are equally effective, so it's really up to you (Frazier and Bhardwaj 2020). In general, thicker balms, ointments, and creams are preferable to thinner lotions. Many find balms and ointments heavy, greasy, and unpleasant — in which case a rich cream is a good alternative.
Avoid moisturizers that contain potential allergens like peanuts, oats, and fragrances — they can cause skin sensitization and allergic reactions (Ring et al. 2012, Paller et al. 2023).
How Do You Treat Eczema Flare-Ups?
If you're struggling with eczema flare-ups, your doctor may recommend using topical corticosteroids as the first line of treatment. Corticosteroids help decrease the inflammation and itching. They are typically used for two weeks or less because of concerns about side effects such as skin thinning.
There are seven different corticosteroid classes with varying levels of potency, and your doctor will choose the one best suited for your particular case (Frazier and Bhardwaj 2020):
At the very lowest level is hydrocortisone cream, which can commonly be found over the counter at concentrations up to 1%. Stronger corticosteroids are prescription only.
Second-Line Treatments
If corticosteroid treatment doesn't work, your doctor may move on to second-line treatments:
Your doctor will work with you to find the best treatment plan for your particular situation.
Other Considerations
People with eczema have more sensitive skin than others. There are a number of lifestyle and environmental factors worth addressing alongside your cleansing and moisturization routine.
- American Academy of Dermatology Association Site. Eczema Types: Atopic Dermatitis Overview. https://www.aad.org/public/diseases/eczema/types/atopic-dermatitis. Accessed April 2023.
- Frazier W, Bhardwaj N (2020). "Atopic Dermatitis: Diagnosis and Treatment." American Family Physician 101(10): 590–598.
- Lee JH, Son SW, Cho SH (2016). "A Comprehensive Review of the Treatment of Atopic Eczema." AAIR 8(3): 181–190.
- Nutten S (2015). "Atopic Dermatitis: Global Epidemiology and Risk Factors." Ann Nutr Metab 66 (suppl 1): 8–16.
- Harvard Health Publishing Site (2015). "Atopic dermatitis and eczema." https://www.health.harvard.edu/skin-and-hair/atopic-dermatitis-and-eczema-overview. Accessed April 2023.
- Odhiambo JA, Williams HC, Clayton TO, Robertson CF, Asher MI, ISAAC Phase Three Study Group (2009). "Global variations in prevalence of eczema symptoms in children from ISAAC Phase Three." J Allergy Clin Immunol 124: 1251–1258.
- National Eczema Association Site. Atopic dermatitis — https://nationaleczema.org/eczema/types-of-eczema/atopic-dermatitis/ (Accessed January 2024).
- Paller AD, Butala S, Howe W (2023). Treatment of Atopic Dermatitis (Eczema). In: UpToDate, Corona R (Ed), UpToDate, Waltham, MA (Accessed January 15, 2024).
- Ring J, Alomar A, Bieber T, Deleuran M, et al. (2012). "Guidelines for treatment of atopic eczema (atopic dermatitis) Part 1." JEADV 26: 1045–1060.
- Schmitt J, Schakel K, Schmitt N, Meurer M (2007). "Systemic Treatment of Severe Atopic Eczema: A Systematic Review." Acta Derm Venereol. 87: 100–111.
