What is Moderate to Severe Eczema?

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Skin is the largest organ of the human body. A healthy skin barrier protects us from germs. It helps us regulate our body temperature. And it helps us feel things like hot or cold. But for those living with eczema, their skin may feel like an enemy.

Eczema is a chronic condition that affects approximately 32 million Americans. Nearly 10.2% of adults have eczema and 10.7% of children have eczema. And of those, nearly 40% of adults have moderate to severe eczema and 33% of children have moderate to severe eczema.

Baby with severe eczema on its face

Eczema is actually a collection of seven different skin disorders,  The most common is called atopic dermatitis (sometimes called atopic eczema). It is a skin condition characterized by skin inflammation. This inflammation leads to itchy patches of skin with flaking, cracking, swelling, oozing, crusting, dryness, pain and sensitivity. Symptoms can come and go. They can occur in different stages in some patients.

While mild eczema is usually treated with moisturizers, moderate and severe eczema are typically treated with medications. That’s why you often see moderate and severe eczema grouped together. People with moderate to severe eczema report more widespread symptoms that may affect their ability to do daily tasks. These symptoms can significantly impact quality of life.

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One hand putting cream on the other hand with severe eczema

What are the symptoms of severe eczema?

Common eczema symptoms include:

  • itchy skin
  • redness on light skin; purple, brown or ashen gray in people of color
  • flaking skin
  • scaly skin
  • cracking skin
  • swelling skin
  • open oozing skin
  • crusting on skin
  • dry skin
  • sensitive skin

And those with severe eczema may experience any or all of these symptoms most days of the week.

People with full-body eczema have these symptoms all over their body. In addition to full body eczema, people also get severe eczema on:

  • face

  • eyelids and around the eyes

  • lips

  • ears

  • neck

  • scalp

  • hands

  • arms and elbows

  • feet

  • legs and behind the knees

  • ankles

What does severe eczema feel like?

People with severe eczema (or severe atopic dermatitis) may experience periods of intense skin itching or burning sensation. They may even feel like they are being poked with needles. Those with the most severe forms may experience these symptoms daily.

How painful is severe eczema?

Not everyone with severe eczema experiences pain. Approximately 40-60% of people with eczema say they experience pain. For those who do experience pain, it can be quite severe. It can be as high as 7 on a 0-10 scale.

What does severe eczema look like?

Severe eczema looks different on different people. The skin may look red and inflamed, or purple, brown or ashen gray. Some people may have patches of lighter skin (called hypopigmentation) or darker skin (called hyperpigmentation).

It may appear rough and scaly. You may see oozing and scabbing. While the skin may make a person look ill, it is important to remember that eczema is not contagious.

Does severe eczema in Black skin or Brown skin look different?

For people with darker pigmentation to their skin, such as those with Black or Brown skin, eczema may not look as obvious. It may be harder to see the rough, scaly patches of skin. You may not notice any redness. You may see darker brown or even purplish or gray-appearing skin. The website EczemaInSkinofColor.org is a great resource to see pictures of severe eczema in a person of color.

What is considered severe eczema?

There is no specific type of blood work or testing that measures the severity of someone’s eczema. So, determining if someone has severe eczema largely involves:

  • identifying and reporting symptoms, including the extent of the area affected (percent of the body surface);
  • the severity of those symptoms (thickening of the skin, oozing, crusting, infection);
  • areas affected (face, hands, feet, etc.);
  • how frequently patients experience symptoms;
  • patients’ ability to live (including sleep) and the degree of itching.

People with severe eczema may experience multiple symptoms daily that significantly impacts their quality of life.If you feel like you are seeing signs of worsening eczema, discuss your concerns with your healthcare provider. Tools are available to better understand and assess the severity of your eczema.

Man putting cream on his moderate eczema on the inside of his elbow

What causes severe eczema?

Severe eczema is an inflammatory skin condition that is caused by an overactive immune system. It can be worsened by environmental triggers, including:

  • Allergens (pets, food, environmental, chemicals etc.)

  • Bacterial, viral or fungal infections

  • Skin irritants and allergens

  • Dry skin

  • Dust Mites

  • Hormones

  • Extreme temperatures (both hot and cold) and humidity

  • Stress

  • Tobacco smoke

You also may be more likely to develop eczema based upon your genetics. Often people with eczema have other family members who also have it. And certain genes have been identified as predisposing people to developing eczema. People with other atopic conditions such as allergies or asthma are also more at risk for developing eczema.

Is severe eczema dangerous?

Severe eczema in and of itself is not dangerous. But the side effects can be. Eczema is known for the “itch scratch cycle”. Itching causes scratching which causes inflammation which causes more itching. And the more you itch, the more your skin gets irritated and may crack and bleed and ooze. And now you have a compromised skin barrier where germs can get in and lead to a skin infection. If an infection spreads, it can be very dangerous, especially if you have a compromised immune system.

The other danger from eczema is its effect on a person’s mental health. The constant itching and even pain can affect sleep, ability to perform tasks, and a person’s appearance. One survey found that more than 30% of people with eczema have been diagnosed with anxiety and/or depression.

Can stress cause severe eczema?

Stress is a common trigger for eczema flare-ups. Consider that stress causes your body to produce more cortisol. An increase in cortisol can cause inflammation throughout the body. And this inflammation causes an eczema flare-up. The problem is the flare-up can lead to even more stress. So, learning to manage stress is an important part of managing eczema.

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How is moderate to severe eczema diagnosed?

There are no specific tests to diagnose eczema. Your healthcare provider will evaluate your skin and review your symptoms, health history and family history. They may perform skin prick or patch testing to look for specific allergies that could be triggering symptoms.

Similarly, there is no specific way to determine the severity of someone’s eczema. Rather, they rely on tools to help determine the severity of symptoms. These tools include:

  • Eczema Area and Severity Index (eEASI)
  • SCOring Atopic Dermatitis (SCORAD)
  • Investigator Global Assessment (IGA)
  • Patient-Oriented Eczema Measure (POEM)
  • Atopic Dermatitis Severity Index (ADSI)
  • Body Surface Area (BSA)
  • Six Area, Six Sign Atopic Dermatitis (SASSAD)

None of these tools is perfect, but they do help your healthcare provider understand your disease better and determine its severity.

Woman scratching her neck because of moderate eczema

What is the treatment for severe eczema?

While you may feel your symptoms are out of control, there is help for severe eczema in adults, teenagers and now in children 6 months of age and older. Here are four keys to eczema treatment National Eczema Association (NEA):

According to the National Eczema Association, there are four keys to eczema treatment: :

1. Know your triggers

Understand what triggers symptoms or makes your eczema worse. Avoid triggers when possible.

2. Develop a bathing and moisturizing routine

Bathe in lukewarm (not hot) water. Use gentle cleansers and avoid harsh soaps. Don’t allow your skin to fully dry before applying moisturizers and topical medications (if prescribed).

  • You may also want to consider wet wrap therapy. This involves placing moisturizer on the affected skin after the bath and then wrapping your skin in a warm, damp cloth or gauze. You can put light cotton clothing on over the wraps. And you can leave this on from two hours to overnight. This relieves inflammation and reduces itching. It helps reduce the need for medication, protects the skin and promotes healing. Wet wrap therapy can provide a lasting benefit.

3. Use over-the-counter (OTC) and prescription medications as directed

Your healthcare provider may advise you use both OTC and prescription medications to help control your symptoms. This may include pain medicine, topical ointments, creams or lotions, pills to reduce inflammation, or biologic medications. It is important to work with your healthcare provider to develop a personalized treatment plan to help manage symptoms.

4. Monitor your skin for signs and symptoms of infection

Skin infections are a serious risk associated with eczema. Part of treatment is monitoring your skin for signs of an infection. These signs may include:

  • increased redness or purplish skin
  • warm or hot skin
  • swelling
  • pain
  • discharge
  • fever.

For any signs of infection, contact your healthcare provider right away to determine the correct treatment.

How is severe eczema treated in babies and toddlers?

For severe eczema in babies and toddlers, treatment is similar – identifying triggers, bathing and moisturizing. OTC and prescription treatments are more limited in young children and infants.

A biologic medication called dupilumab was recently approved for children ages 6 months and older with moderate to severe eczema.

What biologics are available for severe eczema?

Biologic medications are now used in the treatment of moderate to severe atopic dermatitis.

Biologics are medications made from living organisms such as humans, animals, plants, fungi, or microbes. They work by targeting specific immune cells that cause inflammation.

They help stop symptoms before they can start, leading to disease suppression or remission. Dupilumab is the first biologic approved for treating eczema. Tralokinumab is another biologic approved for eczema.

Learn more about biologics at BiologicMeds.org.

What are JAK inhibitors for severe eczema?

Janus kinase (JAK) inhibitor medications are designed to block an overactive pathway of enzymes. They limit the production of immune messengers called cytokines that cause eczema symptoms. This reduces inflammation, skin thickness and scaling, relieves itching and promotes clear skin.

Three JAK inhibitors are available: abrocitinib (Cibinqo®), ruxolitinib (Opzelura™) and upadactinib (Rinvoq®). Baricitinib is another JAK inhibitor awaiting FDA review.

  • JAK inhibitors are approved for adults and children ages 12 and older with moderate to severe atopic dermatitis.
  • Medication side effects may include mild nausea, nasal swelling, cough, headaches and high blood pressure.
  • JAK inhibitors alter the immune system’s ability to react to germs, which can put patients at risk for bacterial, fungal and viral infections and/or certain cancers.
  • FDA requires product warnings on JAK inhibitors about increased risk of serious heart-related events and blood clots.
  • JAK inhibitors are expensive, but they are usually covered by insurance.

What is phototherapy (light therapy) for severe eczema?

Phototherapy, also called light therapy, is an in-office medical procedure conducted by either an allergist or dermatologist. It involves exposing the skin affected by eczema to ultraviolet (UV) light. A special light machine is used to deliver targeted bands of UV light. The amount of light exposure is timed and increased as treatment progresses.

Phototherapy can help reduce inflammation, relieve itching and boost the body’s ability to fight bacteria. It can be used in specific areas that aren’t responding to other treatments, or over the entire body if needed.

Side effects include sunburn, skin that appears to age rapidly, hyperpigmentation (darkening of the skin) in people of color, and possibly skin cancer.

Nearly 70 percent of patients who are treated with phototherapy have positive results, but it is important to note that this treatment is not for everybody. Phototherapy is considered a second-line treatment for severe eczema and is used only for patients who have not had success with other measures.

How does moderate to severe eczema impact mental health?

People often underestimate how much eczema can impact a person’s mental health and affect quality of life. Eczema is more than just a physical symptom. Many people with eczema suffer from anxiety and depression. They tend to avoid social interaction, isolate themselves, and avoid taking part in activities because of their skin appearance. Constant itchiness, oozing rashes and blisters can affect a person’s mood, spirit and resilience.

If you or a loved one is struggling with mental health due to eczema, seek help from a mental health professional. Talk with your doctor and ask for a referral if needed. You can learn strategies to help you cope with eczema and lead a full and active life.

Some people may experience suicidal thoughts due to eczema. If you or someone you know struggles with thoughts of suicide, please get help right away. Talk to a mental health specialist or call the National Suicide Prevention Lifeline at 800-273-8255.

Can I use prednisone for severe eczema?

Prednisone is an oral corticosteroid and it is not typically prescribed for eczema. In rare cases, it may be prescribed to treat severe eczema flare-ups. This is normally done for a short period of time. Long-term use of prednisone poses health risks including glaucoma or cataracts, elevated blood sugars, thin bones, increased risk of infection, and skin thinning.

Infographic of 6 common eczema triggers: Dry skin, Food allergies, Contact allergies, Skin irritants, Environmental allergies, Heat

What are the complications of severe eczema?

Eczema in and of itself is not dangerous. But severe eczema can lead to skin infections, which can be very serious if untreated. Topical steroid withdrawal is a potential complication for people using long-term topical steroids. And let’s not forget the implications of severe eczema on a person’s mental health and quality of life.

Can severe eczema cause death?

Eczema cannot cause or lead to death. However, cellulitis, which is a serious skin infection, can cause death if left untreated. An eczema-related infection can spread to the full body, causing sepsis, which can be fatal. That is why a key component of eczema treatment is monitoring for infection.

Topical steroid withdrawal (TSW)

Topical steroid withdrawal (TSW) is a condition just now starting to be understood. It is a side effect that occurs in people when they stop using topical corticosteroids. TSW is more common in women who use topical steroids on their face or genitals.

According to the National Eczema Association, symptoms may include:

  • burning
  • weeping
  • flaking
  • shedding
  • peeling
  • spreading
  • swelling
  • redness
  • wrinkling
  • thin skin
  • pus-filled bumps
  • cracking
  • itching
  • nodules
  • pain
  • insomnia
  • hair loss
  • shivering
  • fatigue
  • depression
  • disability.

More research is needed to understand TSW and how to prevent it and manage symptoms.

Infections due to severe eczema

Any time the skin barrier is compromised, it allows the opportunity for germs to invade. Often times, your body’s immune system may be able to fight these invaders, but sometimes your body may need the help of modern medicine. So, for any signs of an infection, it is important to see your healthcare provider to determine appropriate treatment. This could include topical or oral antibiotics. For severe infections, you may need to be hospitalized for intravenous antibiotics and additional treatment.

Itch scratch cycle chart showing how it goes from itch to scratch to skin damaged to allergens or bacteria entering to inflammation and redness back to itch again.

How does severe eczema impact quality of life?

Compared to the general population, adults and children with eczema have decreased social functioning and poorer mental health. It makes sense because those with moderate to severe eczema have a profoundly low quality of life. Many are in constant pain and suffering from debilitating itch. They are at a significant risk for depression and anxiety. They struggle to sleep due to symptoms. There have been some studies showing that eczema can even lead to suicidal ideation, specifically in teen girls.

People with moderate to severe eczema are at risk for infections. With children, the whole family is affected – if the child is in pain and cannot sleep, the whole family may not sleep and it has a negative impact on everyone’s quality of life.

Young Black woman with a smile, wearing a tank top, isputting eczema cream on her elbow

How to manage severe eczema?

One of the most important ways to manage eczema is to understand your triggers. Do you have food allergies that trigger symptoms? See a board-certified allergist or dermatologist for testing and evaluation.

Do you find your symptoms are worse in certain environments, including home or work? Then explore what in those environments might be triggering symptoms. It could be a chemical or pet dander or lots of dust. Once you understand what is triggering your symptoms, you may be able to reduce flare-ups.

Work with your healthcare team to find the right bathing and moisturizing routine that helps manage symptoms.

While the most effective management may require prescription medication, there is a lot that you can do to help with your symptoms.

How to manage eczema triggers

Managing your eczema triggers may take time. If you know your trigger, great! Try to avoid that trigger. But knowing your trigger may not be so straightforward. It may help to keep a diary of your symptoms. When and where are they worse? What is in that particular environment? What did you eat? Did you use a new cleanser, lotion, or detergent? Does stress seem to be a major trigger?

Work with your healthcare provider to help explore what may be triggering your symptoms. You may want to do allergy testing to rule out potential allergy triggers. Then consider working with a therapist to find ways to reduce and manage your stress, anxiety and depression.

Is there a best hand cream for severe eczema?

There is no “best” hand cream for severe eczema. But avoid hand creams with scents and dyes. Look for ones that are hypoallergenic. An allergist or dermatologist may be able to provide you with a list of hand creams that you can try. The best hand cream is the one that works best for you.

Is there a best ointment for severe eczema?

Just like with hand creams, there is no “best” ointment. Look for an ointment with a high oil content (should be greasy) and without scents or dyes. Your allergist or dermatologist may offer recommendations.

Is there a best over-the-counter medicine for severe eczema?

There are plenty of over-the-counter treatments for severe eczema. They include ointments, creams and lotions, topical hydrocortisone, pain medicine, antihistamines, and even certain shampoos. Talk with your healthcare provider to determine what treatments may work best for your skin.

Remember that treating severe eczema looks different for everyone. So discuss your symptoms with your doctor and develop a personalized treatment plan.

Are there any home remedies for severe eczema?

Some home remedies may help manage severe eczema. Cool compresses on itchy skin can help. Following a bathing and moisturizing routine is essential. Bathing in lukewarm water with colloidal oatmeal may provide relief.

Bleach baths or bathing with apple cider vinegar may help, but discuss those options and the correct way to do that with your healthcare provider.

Find ways to distract yourself or your child from itching. Stay busy so you keep your hands occupied. Keep fingernails cut very short. Put eczema mittens on a baby’s hands; your baby still may try to scratch, but not with fingernails. If you must scratch, try stroking the itchy area using the top side of the hand instead of your fingernails.

Is there a best diet for severe eczema?

There is no specific diet that is best for eczema. Rather, eating a healthy diet with lots of anti-inflammatory foods such as fresh fruits and vegetables, whole grains and lean meats and avoiding processed foods is most helpful to your general well-being.

If you have a diagnosed food allergy, talk with your doctor about avoiding the food that triggers your symptoms. Working with a nutritionist may be helpful. Not everyone with eczema has dietary triggers, but you can’t go wrong by trying to eat healthy.

What foods should I eat or avoid to reduce my risk of eczema?

There are no specific foods to eat or avoid to reduce the risk of eczema. If you find a certain food triggers symptoms, or suspect you have food allergies, consult with your allergist to get evaluated. If you have a known food allergy, avoid that food.

Male doctor in white protective gloves hold magnifying glass. Examines patient which type of eczema she has. There is a doctor's office in the background.

Can severe eczema be prevented?

There is no specific way to prevent severe eczema. Prevention relies heavily on trigger avoidance and keeping the skin well-moisturized and free from infection.

How can I prevent future eczema flares?

Severe eczema flares are normally triggered by something. What is that something? For every person it is different. Identifying your triggers is essential.

Adhering to your treatment plan may also prevent flare-ups. This may include a combination of OTC and prescription treatments.

Can severe eczema be cured?

There is no cure for severe eczema. Some people do seem to outgrow it. Others learn their triggers and are able to manage symptoms by trigger avoidance. But, for other people, dealing with severe eczema is a lifelong challenge that requires long-term care and systemic treatments.

Can eczema lead to other diseases?

Eczema can lead to infections and negatively impact mental health. But there are other conditions that are often found with eczema. These are called comorbidities. Some comorbidities associated with eczema include:

  • allergic rhinitis (hay fever)
  • asthma
  • food allergies
  • alopecia (sudden hair loss)
  • chronic urticaria (hives)
  • osteoporosis
  • substance use disorder
  • ADHD
  • metabolic syndrome.

Are there other conditions that may look like eczema but are not eczema?

There are other conditions that are different than eczema, but the symptoms, diagnosis and treatment vary depending upon the condition. Here are some of them.

Hereditary Angioedema


Chronic Idiopathic Urticaria (CIU)

Cold Urticaria

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Reviewed by:

Luz Fonacier, MD is Professor of Medicine at NYU Long Island School of Medicine and is the Head of Allergy and Training Program Director in Allergy and Immunology at NYU Winthrop Hospital. In 2020-21, she served as President of the American College of Allergy, Asthma & Immunology (ACAAI), becoming the fourth woman and first Asian American to serve in that role.