Atopic Dermatitis (Eczema)

What It Is

• Atopic dermatitis is a chronic, relapsing skin disease characterised by itch, dry skin, and eczematous patches that may worsen in episodes.
• It is not contagious, but it can run in families and commonly occurs in people with an “atopic” tendency, such as asthma or allergic rhinitis.
• The disease can look different at different ages, so the location and shape of the rash may vary in infants, children, teens, and adults.

Epidemiology

• Global research estimates the prevalence of atopic dermatitis at about 6%, affecting around 204 million people worldwide.
• The burden is substantial in both adults and children, with paediatric prevalence generally higher than adult prevalence in global estimates.
• The disease varies by geography, age, and sex, and large gaps in epidemiological data still exist in many countries.
• In children, recent global analysis showed 4 million cases in 2021, with major regional variation in prevalence.

Causes and Triggers

• Atopic dermatitis develops from a mix of intrinsic and extrinsic factors rather than a single cause.
• A weakened skin barrier allows moisture loss and makes the skin more vulnerable to irritants, allergens, and microbes.
• Immune dysregulation, especially a type 2 inflammatory pattern, drives redness, itching, and chronic inflammation.
• Environmental triggers may include harsh soaps, detergents, fragrances, preservatives, pollution, sweat, climate changes, and frequent washing.

Intrinsic Factors

• Genetic predisposition, including filaggrin-related barrier defects, can increase transepidermal water loss and dry skin.
• Family history of eczema, asthma, or allergic rhinitis raises the likelihood of disease.
• Immune tendency toward type 2 inflammation contributes to chronic itch and flares.

Extrinsic Factors

• Irritating skin care products, alkaline detergents, chemicals, fragrance, and preservatives can aggravate eczema.
• Environmental pollution and airborne irritants can worsen inflammation and itch.
• Sweating, overheating, emotional stress, and seasonal dryness are common real-world flare triggers seen in clinic practice.

• Pathophysiology
• The core of atopic dermatitis is a vicious cycle of barrier dysfunction, inflammation, and itch.
• When the skin barrier is impaired, the skin loses water, becomes dry, and allows easier entry of irritants and allergens.
• Filaggrin and other barrier abnormalities are associated with increased transepidermal water loss and disrupted skin protection.
• Immune signaling is dominated by type 2 cytokines such as IL-4 and IL-13, with additional contributions from other inflammatory pathways.
• Itch is not just a symptom; it also drives scratching, which further damages the skin and fuels the flare cycle.

Common Symptoms

• Persistent itching, often worse at night.
• Dry, rough, sensitive skin.
• Red or dark inflamed patches, depending on skin tone.
• Cracking, scaling, oozing, or crusting during flares.
• Thickened skin from repeated scratching in chronic disease.
• Sleep disturbance, irritability, and reduced concentration due to itch.

Treatment Options

• Treatment is usually individualised based on age, severity, body area involved, and response to therapy.
• The goals are to reduce itch, calm inflammation, repair the barrier, prevent infection, and reduce future flares.
• A practical plan often includes regular moisturization, trigger avoidance, topical anti-inflammatory therapy, and escalation to systemic treatment when needed.

Topical Treatment

• Moisturizers/emollients are the foundation of treatment because they restore barrier function and reduce dryness and itch; this remains standard of care across guidelines.
• Topical corticosteroids are effective for active flares and remain a mainstay of treatment.
• Tacrolimus and pimecrolimus are highly useful steroid-sparing options, especially for sensitive areas such as the face, eyelids, neck, and folds.
• Newer non-steroidal topical options such as crisabarole.
• Topical Jak inhibitors among the effective newer topical options in evidence reviews.

Oral and Systemic Treatment

• For moderate-to-severe or refractory disease, systemic therapy may be needed.
• Oral cyclosporine remains an established option for selected patients needing faster control.
• Biologic therapies such as dupilumab, are helping many patients with difficult disease.
• Oral JAK inhibitors such as tofacitinib, baricitinib, upadacitinib, and abrocitinib are now important options for moderate-to-severe atopic dermatitis.

Role of JAK Inhibitors

• JAK inhibitors target intracellular inflammatory signaling and can reduce both inflammation and itch quickly.
• They are especially valuable in moderate-to-severe disease when topical treatment alone is not enough.
• They are promising effective alternatives, emphasis on careful patient selection and safety monitoring.
• Oral JAK inhibitors are positioned alongside biologics, phototherapy, and cyclosporine for refractory disease.
• In practice, they may be particularly helpful for patients whose biggest complaint is rapid, severe itch and widespread eczema.

Role of Diet

• Diet is often overestimated as a cause of eczema, and routine elimination diets are not recommended for every patient.
• Unnecessary food restriction can lead to nutritional problems, especially in children, and may distract from proven eczema care.
• Diet changes should be individualized and based on documented food allergy, clear symptom correlation, or specialist advice.
• Some patients may benefit from carefully selected supplementation or gut-health-focused dietary approaches, but the evidence remains mixed and not universal.
• For most patients, the priority should remain skin-barrier care, anti-inflammatory treatment, and trigger control rather than broad food avoidance.

Prognosis

• The overall prognosis is generally favourable, especially when treatment is started early and maintained consistently.
• Some patients improve with age, while others experience a relapsing course that needs long-term control strategies.
• Severe, widespread disease and associated allergic conditions such as asthma or allergic rhinitis are linked with poorer outcomes.
• Good prognosis depends on regular moisturiser use, early flare treatment, and a treatment plan tailored to the patient’s disease pattern.

Latest Advances

• Recent progress in atopic dermatitis treatment has focused on better control of inflammation with targeted therapies.
• Key newer options include dupilumab, tofacitinib, upadacitinib, abrocitinib.
• Evidence reviews show strong performance for tacrolimus, pimecrolimus, and moderate-potency topical corticosteroids, while topical JAK-related therapies are expanding the armamentarium.
• The field is moving toward personalized care based on severity, itch burden, age, comorbidities, and treatment goals.

When To See A Dermatologist

• See a dermatologist if itching is persistent, sleep is disturbed, flares keep returning, or over-the-counter creams are not helping.
• Medical review is also important if there are signs of infection, widespread eczema, facial involvement, or impact on daily life.
• Children with suspected food allergy, poor growth, or severe eczema should be assessed carefully before any dietary restriction is started.
• A dermatologist can create a safe, stepwise plan that is realistic for both the patient and family.