Atopic dermatitis

Last updated: March 22, 2022

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Atopic dermatitis (AD) is an inflammatory skin disease that typically manifests for the first time in early childhood. Although it often improves during adolescence, it may also become a chronic condition that extends into adulthood. Atopic dermatitis is often associated with other atopic diseases, such as asthma or allergic rhinitis. Although the underlying etiology is not completely understood, genetic components, as well as exogenous and endogenous triggers, are believed to play a role. The main symptoms of atopic dermatitis are severe pruritus and dry skin. Initial management of atopic dermatitis involves avoiding flare triggers and moisturizing the skin. Topical steroids and calcineurin inhibitors may be added if symptoms persist. In refractory and severe cases, phototherapy or systemic therapy with immunomodulating medications may be used. The most common complication of atopic dermatitis is the development of secondary infections; psychosocial complications may also arise.

  • Prevalence: Approx. 8–12% of children and 6–9% of adults are affected. [1][2][3]
  • Age [2][3]
    • Onset of symptoms usually occurs at 3–6 months of age.
    • Disease often improves with age.

Epidemiological data refers to the US, unless otherwise specified.

The etiology of atopic dermatitis is not completely understood. However, genetic factors (polygenic inheritance), as well as exogenous and endogenous triggers, may play a role.

  • Main symptoms: : intense pruritus and dry skin
  • Infantile AD (age < 2 years) [6][7]
    • Eczema involving the face, head, and extensor surfaces of the extremities; that usually spares the diaper area
    • May present initially with features similar to seborrheic dermatitis, e.g., cradle cap [8][9][10]
    • Dennie-Morgan fold: increased folds below the eye
    • Occasionally, lesions appear on the trunk.
  • Childhood AD (age 2–12 years) [7]
  • Adult/adolescent AD (age > 12 years) [6]
  • Associated skin findings in AD [7][11][12]
    • Atopic triad: a triad of asthma, allergic rhinitis, and atopic dermatitis that is linked to allergen-triggered IgE-mast cell activation
    • Food allergies
    • Xerosis
    • White dermographism: transient blanching of skin after skin stroking
      • Caused by cutaneous vasoconstriction
      • Normal variant, but more common in patients with atopic dermatitis
    • Dermatographism: formation of urticaria after minor pressure is applied to the skin, likely mediated by local histamine release
    • Hertoghe sign: thinning or loss of the outer third of the eyebrows
    • Keratosis pilaris: keratinized hair follicles (rough bumps) typically distributed over extensor arms and thighs

The symptoms of atopic dermatitis are variable and often change in the course of a lifetime. Pruritus and dry skin are usually the main symptoms.

Diagnostic criteria [5]

Atopic dermatitis is a clinical diagnosis. Other conditions with a similar appearance should be excluded, e.g., seborrheic dermatitis, psoriasis, other eczematous diseases, or skin infections.

Severity assessment [5][13][14]

  • AD is often stratified by severity for practical purposes (e.g., “mild”, “moderate”, “severe”).
  • There is no accepted gold standard classification system for clinical practice.
  • A multifactorial assessment for individual patients is recommended, including the following:
    • Estimated body surface area involved
    • Clinical features of lesions: e.g., crusting, oozing, redness, swelling
    • Located of lesions in areas of greater sensitivity, visibility, or functional importance: e.g., palms, soles, face, neck, genitals, joints
    • Functional and psychosocial impact of symptoms: e.g., degree of pruritus, sleep disturbance
  • Consider supplementing this assessment with the focused use of scoring systems. [13]

Other investigations [2]

The differential diagnoses listed here are not exhaustive.


Management approach for atopic dermatitis [15][17][18][19]
Therapeutic goal Intervention
Primary prevention [20]

Maintenance therapy and secondary prevention

(flare reduction)

Very mild AD
  • Nonpharmacological therapy, e.g., emollients, can be administered as monotherapy.
Mild-to-moderate AD

Moderate-to-severe AD

(with significant functional impairment)

Treatment of acute flare
Adjunctive care

Nonpharmacological therapy [15][17][18]

  • Avoid triggers of flares
    • Patient-specific allergens and sensitivities (e.g., certain foods, animals, dust mites, excessive heat)
    • Mechanical and chemical irritants (e.g., wool clothing, solvents)
  • Maintain skin hydration
    • Emollients
    • Regular bathing is recommended. [18]
      • Consider bathing up to once daily for short periods of time (e.g., 5–10 minutes).
      • Hypoallergenic cleansers can be used, but with limited frequency.
      • Apply emollients shortly after bathing.
    • For severe or refractory cases: consider wet wrap therapy
      • A moistened bandage is applied with emollients or topical corticosteroids to the affected area.
      • A dry outer bandage is applied around the inner moist bandage.
  • Stress management: to help cope with the impact of AD on daily life (e.g., supportive psychotherapy) [17]

Topical pharmacotherapy [15][18]

Topical antihistamines are not recommended for the treatment of AD due to a lack of benefit and potential for local side effects. [18]

The potency of the topical corticosteroid used should be guided by patient factors (e.g., affected areas of the body, age) and disease severity.

Systemic therapy [15][19]

These advanced therapies should be administered in consultation with a specialist.

The optimal dosing, duration, and monitoring of systemic immunomodulatory therapy are unclear. Treatment should be tailored to the patient and made in consultation with a specialist. [19]Systemic steroids should only be used sparingly in AD due to side effects of corticosteroid therapy and the risk of rebound flares after discontinuation. [19]

We list the most important complications. The selection is not exhaustive.

The symptoms of atopic dermatitis usually improve with age and often resolve completely after puberty. [2]

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  2. Eichenfield LF, Tom WL, Berger TG, et al. Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014; 71 (1): p.116-132. doi: 10.1016/j.jaad.2014.03.023 . | Open in Read by QxMD
  3. Sidbury R, Davis DM, Cohen DE, et al. Guidelines of care for the management of atopic dermatitis: section 3. Management and treatment with phototherapy and systemic agents. J Am Acad Dermatol. 2014; 71 (2): p.327-349. doi: 10.1016/j.jaad.2014.03.030 . | Open in Read by QxMD
  4. Sidbury R, Tom WL, Bergman JN, et al. Guidelines of care for the management of atopic dermatitis: Section 4. Prevention of disease flares and use of adjunctive therapies and approaches. J Am Acad Dermatol. 2014; 71 (6): p.1218-1233. doi: 10.1016/j.jaad.2014.08.038 . | Open in Read by QxMD
  5. Bawany F, Beck LA, Järvinen KM. Halting the March: Primary Prevention of Atopic Dermatitis and Food Allergies. The Journal of Allergy and Clinical Immunology: In Practice. 2020; 8 (3): p.860-875. doi: 10.1016/j.jaip.2019.12.005 . | Open in Read by QxMD
  6. Greer FR, Sicherer SH, Burks AW. The Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Hydrolyzed Formulas, and Timing of Introduction of Allergenic Complementary Foods. Pediatrics. 2019; 143 (4): p.e20190281. doi: 10.1542/peds.2019-0281 . | Open in Read by QxMD
  7. Beck LA, Thaçi D, Hamilton JD, et al. Dupilumab Treatment in Adults with Moderate-to-Severe Atopic Dermatitis. N Engl J Med. 2014; 371 (2): p.130-139. doi: 10.1056/nejmoa1314768 . | Open in Read by QxMD
  8. Chiesa Fuxench ZC, Block JK, Boguniewicz M, et al. Atopic Dermatitis in America Study: A Cross-Sectional Study Examining the Prevalence and Disease Burden of Atopic Dermatitis in the US Adult Population. J Invest Dermatol. 2019; 139 (3): p.583-590. doi: 10.1016/j.jid.2018.08.028 . | Open in Read by QxMD
  9. Bieber T. Atopic Dermatitis. N Engl J Med. 2008; 358 (14): p.1483-1494. doi: 10.1056/nejmra074081 . | Open in Read by QxMD
  10. Eczema Stats. . Accessed: October 25, 2020.
  11. Osawa R, Akiyama M, Shimizu H. Filaggrin Gene Defects and the Risk of Developing Allergic Disorders. Allergology International. 2011; 60 (1): p.1-9. doi: 10.2332/allergolint.10-rai-0270 . | Open in Read by QxMD
  12. Eichenfield LF, Tom WL, Chamlin SL, et al. Guidelines of care for the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol. 2014; 70 (2): p.338-351. doi: 10.1016/j.jaad.2013.10.010 . | Open in Read by QxMD
  13. Eczema Types: Atopic Dermatitis Symptoms. . Accessed: October 25, 2020.
  14. Siegfried E, Hebert A. Diagnosis of Atopic Dermatitis: Mimics, Overlaps, and Complications. J Clin Med. 2015; 4 (5): p.884-917. doi: 10.3390/jcm4050884 . | Open in Read by QxMD
  15. Cradle Cap. Updated: January 1, 2002. Accessed: May 15, 2017.
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  17. Moises-Alfaro CB, Caceres-Rios HW, Rueda M, Velazquez-Acosta A, Ruiz-Maldonado R. Are infantile seborrheic and atopic dermatitis clinical variants of the same disease?. Int J Dermatol. 2002; 41 (6): p.349-351. doi: 10.1046/j.1365-4362.2002.01497.x . | Open in Read by QxMD
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  19. Marks JG Jr, Miller JJ . Lookingbill and Marks' Principles of Dermatology. Saunders Elsevier ; 2013
  20. Boguniewicz M, Alexis AF, Beck LA, et al. Expert Perspectives on Management of Moderate-to-Severe Atopic Dermatitis: A Multidisciplinary Consensus Addressing Current and Emerging Therapies. J Allergy Clin Immunol Pract. 2017; 5 (6): p.1519-1531. doi: 10.1016/j.jaip.2017.08.005 . | Open in Read by QxMD
  21. Boguniewicz M, Fonacier L, Guttman-Yassky E, Ong PY, Silverberg J, Farrar JR. Atopic dermatitis yardstick: Practical recommendations for an evolving therapeutic landscape. Ann Allergy Asthma Immunol. 2018; 120 (1): p.10-22.e2. doi: 10.1016/j.anai.2017.10.039 . | Open in Read by QxMD
  22. Wedi B, Kapp A. Differential Diagnosis of Atopic Eczema. Springer-Verlag ; 2020 : p. 100-107
  23. Abeck D, Mempel M. Staphylococcus aureus colonization in atopic dermatitis and its therapeutic implications. Br J Dermatol. 1998; 139 : p.13-16.
  24. Liaw FY, Huang CF, Hsueh JT, Chiang CP. Eczema herpeticum: a medical emergency.. Can Fam Physician. 2012; 58 (12): p.1358-61.
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  26. Complications of Atopic Dermatitis. Updated: February 1, 2004. Accessed: May 15, 2017.
  27. Causes of Atopic Dermatitis. Updated: February 1, 2004. Accessed: September 3, 2017.

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