Atopic dermatitis

Last updated: November 20, 2023

Summarytoggle arrow icon

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.

Epidemiologytoggle arrow icon

  • 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.

Etiologytoggle arrow icon

Although the etiology of AD is not completely understood, genetic factors have been shown to play a role in its development. Certain social and environmental risk factors are believed to be associated with AD, but the evidence is inconclusive. Exogenous and endogenous triggers can induce flares of AD. [2][4][5]

The most important risk factors in the development of atopic dermatitis are a family history of atopy and mutations in the FLG gene.

Pathophysiologytoggle arrow icon

Multiple complex mechanisms are involved in the manifestation of AD, but the pathophysiology is not fully understood. [4][5]

  • Epidermal barrier dysfunction (due to filaggrin deficiency and decreased ceramide levels) → loss of moisture → dry skin
    • Increased water loss
    • Microbiome imbalance
    • Increased risk of secondary infections
    • Triggering of inflammatory processes
    • Increased skin pH
    • Immune cell infiltration
  • Inflammation of the skin → severe pruritus
    • Promotion of IgE-mediated hypersensitivity
    • Triggering of epidermal barrier dysfunction
    • Increased T-cell infiltration
    • Imbalance of Th2 to Th1 cytokines
    • Increased Th2-cell-mediated response
    • Increased antigen presentation
    • Imbalance in genetic expression of regulatory and inflammatory protein

Clinical featurestoggle arrow icon

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.

Diagnosticstoggle arrow icon

Diagnostic criteria [6]

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 [6][14][15]

  • 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.
  • An individual multifactorial assessment is recommended and includes the following:
    • Estimated body surface area involved
    • Clinical features of lesions (e.g., crusting, oozing, redness, swelling)
    • Identification 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. [14]

Other investigations [2]

Differential diagnosestoggle arrow icon

The differential diagnoses listed here are not exhaustive.

Managementtoggle arrow icon


Management approach for atopic dermatitis [16][18][19][20]
Therapeutic goal Intervention
Primary prevention [21][22]
  • Breastfeeding is recommended during infancy.
  • Introduction of allergenic foods should not be delayed.

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 [16][18][19]

  • Avoid triggers of flares: See “Triggers” in “Etiology” section above.
  • Maintain skin hydration
    • Emollients
    • Regular bathing is recommended. [19]
      • 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) [18]

Topical pharmacotherapy [16][19]

Topical antihistamines are not recommended for the treatment of AD due to a lack of benefit and potential for local side effects. [19]

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 [16][20]

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. [20]Systemic steroids should only be used sparingly in AD due to side effects of corticosteroid therapy and the risk of rebound flares after discontinuation. [20]

Complicationstoggle arrow icon

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

Prognosistoggle arrow icon

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

Referencestoggle arrow icon

  1. Williams HC. Atopic Dermatitis. N Engl J Med. 2005; 352 (22): p.2314-2324.doi: 10.1056/nejmcp042803 . | Open in Read by QxMD
  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. Weidinger S, Beck LA, Bieber T, Kabashima K, Irvine AD. Atopic dermatitis. Nat Rev Dis Primers. 2018; 4 (1).doi: 10.1038/s41572-018-0001-z . | Open in Read by QxMD
  9. 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
  10. Bieber T. Atopic Dermatitis. N Engl J Med. 2008; 358 (14): p.1483-1494.doi: 10.1056/nejmra074081 . | Open in Read by QxMD
  11. Avena-Woods C. Overview of Atopic Dermatitis. Am J Manag Care. 2017; 23 (8).
  12. Boothe WD et al.. Management of Atopic Dermatitis. Springer International Publishing ; 2017
  13. 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
  14. Eczema Types: Atopic Dermatitis Symptoms. . Accessed: October 25, 2020.
  15. 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
  16. Cradle Cap. Updated: January 1, 2002. Accessed: May 15, 2017.
  17. Yates VM, Kerr REI, MacKie RM. Early diagnosis of infantile seborrhoeic dermatitis and atopic dermatitis—clinical features. Br J Dermatol. 1983; 108 (6): p.633-638.doi: 10.1111/j.1365-2133.1983.tb01074.x . | Open in Read by QxMD
  18. 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
  19. Bolognia J, Jorizzo J, Schaffer J. Dermatology: 2-Volume Set. Elsevier ; 2012
  20. Marks JG Jr, Miller JJ . Lookingbill and Marks' Principles of Dermatology. Saunders Elsevier ; 2013
  21. 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
  22. 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
  23. Wedi B, Kapp A. Differential Diagnosis of Atopic Eczema. Springer-Verlag ; 2020: p. 100-107
  24. Abeck D, Mempel M. Staphylococcus aureus colonization in atopic dermatitis and its therapeutic implications. Br J Dermatol. 1998; 139: p.13-16.
  25. Liaw FY, Huang CF, Hsueh JT, Chiang CP. Eczema herpeticum: a medical emergency.. Can Fam Physician. 2012; 58 (12): p.1358-61.
  26. Weston WL Howe W. Atopic Dermatitis (Eczema): Pathogenesis, Clinical Manifestations, and Diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. Last updated: March 20, 2017. Accessed: May 15, 2017.
  27. Complications of Atopic Dermatitis. Updated: February 1, 2004. Accessed: May 15, 2017.
  28. Causes of Atopic Dermatitis. Updated: February 1, 2004. Accessed: September 3, 2017.

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