Eczema
Skin is the largest organ of the human body. A healthy skin barrier protects us from germs and bacteria. It helps us regulate our body temperature. And it helps us feel things like heat and cold.
Some people live with a chronic skin condition called eczema. It is not a single condition, but rather a grouping of several types of skin conditions, not all of which are related to each other.
How common is eczema?
Eczema is a skin condition that affects 31.6 million people in the United States. Atopic dermatitis is the most common type of eczema. Approximately 16.5 million adults and 9.6 million children under the age of 18 have atopic dermatitis. And about 6.6 million people, including 3.2 million children, live with moderate-to-severe symptoms.
Eczema often develops in early childhood. It can appear within the first 6 months of life or within the first 5 years.
What causes eczema?
The exact cause of eczema remains unknown, but experts believe it may involve:
- Genetics. Approximately 70% of people with eczema report a family history of the condition.
- Immune system sensitivity. An overactive immune response to allergens and irritants.
- Defective skin barrier. A weakened barrier that allows moisture to escape while letting allergens and bacteria in.
When people with eczema are exposed to allergens or irritants, their immune system releases chemicals like histamines and cytokines (proteins) to fight them off. This triggers skin inflammation, leading to eczema symptoms including an itchy rash.
Too much scratching of the itchy rash can cause thickened skin. If the skin becomes broken, there is an increased risk of infection. Signs of infection include yellow crusting (often on top of the eczema), swollen bumps or blisters, and pus-filled blisters.
Some people with eczema may lack a specific type of protein, called filaggrin, in their skin. This protein serves as a protective barrier from allergens, irritants and infections. When there is not enough filaggrin, it weakens the skin barrier.
Some people with eczema also have high blood levels of Immunoglobulin E (IgE), which are antibodies produced by the immune system. High levels of IgE can set off allergy symptoms and cause an eczema flare.
What are the different types of eczema?
There are seven different types of eczema. Each type has its own unique triggers and causes. Treatment options may vary depending on the type of eczema a person has. Let’s look at the different types of eczema.
1. Atopic dermatitis
Atopic dermatitis is a chronic inflammatory skin condition. It is the most common type of eczema. You may often see atopic dermatitis used interchangeably with eczema, even though it is only one type. Atopic dermatitis has a genetic component as it tends to run in families.
With atopic dermatitis, the immune system is easily triggered and sensitive to allergens and irritants. Many people with atopic dermatitis also have a mutation to the filaggrin gene, causing them to have a compromised skin barrier. This, along with inflammation that can damage the skin, allows for moisture to escape and allergens and bacteria to invade.
Symptoms may come and go. They include:
- Red, itchy patches of skin on light skin; dark brown, purple or ashen gray on dark skin
- Dry and scaly skin
- Small bumps
- Swelling of the skin (inflammation)
- Areas of thickened skin
- Open, oozing, and crusty sores.
People with atopic dermatitis often also have other allergic conditions such as asthma or allergic rhinitis.
2. Dyshidrotic eczema
Dyshidrotic eczema is another common form of eczema. It causes small, itchy, fluid-filled blisters to form on the hands and feet as the result of an allergic response. It tends to run in families. Dyshidrotic eczema is seen in people with other types of eczema and it is more common in women than men. It rarely appears in children under 10.
3. Contact dermatitis
Unlike many other types of eczema, contact dermatitis doesn’t run in families. With contact dermatitis, the skin becomes irritated when it encounters an allergen or irritant.
There are two subtypes of contact dermatitis: allergic or irritant.
- Irritant contact dermatitis – this is the most common type of contact dermatitis. The skin becomes damaged due to contact with an irritant such as a cleaning product (detergent, soap), makeup or certain metals. It can also occur from the skin rubbing against scratchy clothing.
- Allergic contact dermatitis – the skin becomes damaged due to skin contact with something you are allergic to. This could be something like nickel (found in some jewelry), topical antibiotics, some makeup, or fragrances.
4. Neurodermatitis
Neurodermatitis affects approximately 12% of the U.S. population. Whereas atopic dermatitis tends to be widespread across the body, neurodermatitis is normally confined to one or two patches of skin. The most common areas affected are arms, shoulders, elbows, legs, ankles, wrists, hands, back of the neck or scalp. These patches of skin can be dry, thick, scaly, leathery or different colored. They are very itchy.
Neurodermatitis is more common in women than men. Many people report the itchiness being worse when trying to relax, such as at bedtime, or during periods of high stress.
5. Nummular eczema
People with nummular eczema develop coin-shaped patches of skin that are itchy and may ooze. These areas often develop on arms, legs, hands, or torso. They itch and burn, and fluid may leak out and crust on the skin. The condition is more common in males than females. It can be seen independent from other types of eczema or at the same time.
6. Seborrheic dermatitis
Seborrheic dermatitis is a skin condition most common on the scalp. It also occurs in other areas with lots of oil gland activity. Seborrheic dermatitis is characterized by red, itchy, scaly and greasy patches of skin which produce flaking. It is commonly known as dandruff in adults and teens or cradle cap in infants.
Approximately 11% of the U.S. population has seborrheic dermatitis. It is common in people with certain medical conditions such as adult Hodgkin’s lymphoma, HIV, Down syndrome and Parkinson’s disease.
7. Stasis dermatitis
Stasis dermatitis occurs in people with poor circulation (venous insufficiency) to their lower legs. It is most common in older adults and women. Common risk factors for developing poor circulation include varicose veins, high blood pressure, obesity and heart failure.
People with stasis dermatitis often start with ankle swelling and orange-brown spots. It may also lead to skin color changes, itching, scaliness and dry skin.
So eczema is a versatile disease. Each type has different causes and manifestations. It is important to work with an allergist or dermatologist (skin doctor) for treatment. Depending on your type of eczema, you may need to also work with other specialists to help treat conditions that may be contributing to your eczema.
What are common symptoms of eczema?
Eczema can come and go, but even when skin appears clear, there may be inflammation under the surface of the skin, waiting to flare.
Common signs and symptoms of eczema include:
- itching
- flaking
- cracking
- swelling
- open oozing skin
- crusting
- dry skin
- sensitive skin
Eczema often appears on the following parts of the body:
- face
- neck
- hands
- wrists
- elbows
- knees
- ankles
- feet
What are the different types of skin changes associated with eczema?
If you were to open a dermatology textbook, you would be flooded with terms used to describe skin conditions and their manifestations. While people with eczema may not need to know all the different terms used to describe eczema, it may be helpful to understand some of the more common ones. These describe the abnormalities, or skin lesions, associated with eczema.
- atrophy – a thinning of the upper layers of skin (or dermis). The thinning makes the skin more fragile and prone to tearing. Atrophy is more common as people age, but it also can be caused by use of topical steroid medications.
- erythema – traditionally described as reddening of the skin. However, in people with darker skin pigmentation, symptoms may be less obvious. There may be areas of darker, ashen gray, or purple skin.
- follicular accentuation – inflammation of the hair follicles. This may present as a rash that looks like goosebumps.
- hyperpigmentation – patches of skin that are darker in color than the surrounding skin.
- hypopigmentation – patches of skin that are lighter in color than the surrounding skin.
- lichenification – thickening of skin patches caused by chronic scratching. Lichenified skin may appear red or darker than surrounding skin.
- striae – commonly referred to as “stretch marks.” These may present as indented streaks or streaks of darker or different colored skin. Striae can also result from the use of topical steroid medications.
- telangiectasia – dilated or broken blood vessels on the surface of the skin.
- xerosis – excessively dry skin. This may cause itching, skin flaking, or cracking.
What triggers eczema?
An important part of an eczema care plan is avoiding allergens and irritants that set off symptoms.
Triggers are different for everyone. What can make identifying them so challenging is sometimes a flare-up can occur hours after the initial exposure. Some people may experience symptoms in certain areas of the body or only at certain times of the year.
Trigger avoidance is essential in managing eczema, but it’s important to remember that, since eczema is a systemic condition, it is not a cure.
Work together with your doctor or healthcare provider to identify what is triggering your eczema. It may be helpful to keep notes on what you were exposed to when symptoms first emerged.
Following are common eczema triggers:
Contact allergies
Eczema is sometimes set off by something a person is in contact with on a regular basis. It could be a piece of jewelry that contains nickel, rubber or chemicals used in cosmetics, disinfectants and skin products.
An allergist can do a patch test to identify the specific allergens causing the problem.
Other potential skin irritants include:
- Antibacterial ointments such as neomycin and bacitracin
- Formaldehyde, which is found in some household cleaning products.
Dry skin
When your skin is dried out, it can trigger eczema symptoms. A lack of the protein filaggrin can cause your skin to lose moisture. This allows allergens, irritants and germs to enter the skin more easily, leading to symptoms.
The best way to prevent an eczema flare is to keep your skin well moisturized. Recent research suggests that moisturizing a baby’s skin from birth may help prevent eczema from developing.
Dust mites
These tiny insects live in mattresses, pillows, upholstered furniture – anywhere they can find moisture along with their favorite food, tiny bits of shed human skin.
Eczema patients may be allergic to dust mites. Allergens from their droppings and dead bodies collect in bedding, furnishings and house dust, then irritate skin, airways and eyes on contact.
When eczema is already flaring, dust mite allergens can worsen the problem. Encase your bed’s pillows and mattress with allergen-proof covers to put a barrier between you and the dust mites. Wash linens weekly in hot water and vacuum carpets, floors and furnishings with a HEPA vacuum.
Environmental Allergies
People with eczema may experience symptoms after exposure to certain grass, tree or ragweed pollen and/or indoor or outdoor mold.
It’s best to treat symptoms that arise from environmental allergens with aggressive moisturizing, along with antihistamines and topical corticosteroids if necessary.
Skin prick or blood testing for environmental allergies will help identify specific allergens to avoid.
Some people with eczema may do well with allergen immunotherapy (allergy shots or tablets). This is when a patient is given a gradually increasing amount of an allergen to build tolerance and reduce the risk of symptoms.
Food Allergies
Food allergies can play a role in the onset of eczema symptoms, particularly for infants and young children. Between 35 and 60 percent of young children with moderate-to-severe eczema also have food allergies.
It’s believed the breakdown of the skin barrier contributes to an allergic response when a food allergen is consumed.
Among children under the age of 2, eczema is most often related to milk or egg allergy, but it can occur with any food. Other common food allergens include peanut, tree nuts, fish, shellfish, soy, wheat and sesame.
Doctors recommend introducing foods like peanut and egg to babies starting at 4-6 months of age. This can help lower the risk of developing food allergies. Babies who are showing eczema symptoms at 4-6 months of age should be introduced to these foods under the supervision of a doctor.
Consult with a board-certified allergist or dermatologist for a diagnosis and then develop a plan to avoid the food allergen. (People with food allergies are also at risk for anaphylaxis, a severe allergic reaction. Epinephrine is the first-line treatment for anaphylaxis if you have a severe food allergy.)
Pet Allergies
Pet dander (dead skin cells), saliva or urine are normally harmless proteins for most people. For people with eczema, they can trigger skin symptoms. Research has found that exposure to pet dander in early childhood may lead to the development of eczema in children who are prone to the condition.
It may be best to find a new home for your furry pet – this can reduce the levels of pet allergens in the home. But if that’s not a consideration for your family, bathe your pet at least once a week and set up no-pet zones, especially the bedroom. Consider using a high-efficiency particulate air (HEPA) filter in your home to help remove pet dander from indoor air.
Hormones
Hormone fluctuations may trigger or make eczema worse for women. Hormone changes occur just before and during menstruation, during pregnancy, after pregnancy, or when transitioning to menopause.
Outdoor Temperatures
Heat can dry out the skin or cause sweating. Sweat, in particular, can collect in your armpits or inner part of your elbow, leading to skin irritation.
Meanwhile, in winter months, humidity that provides moisture in the air decreases, also resulting in dry skin. A sudden rise or drop in temperature can trigger an eczema flare.
Strategies to keep comfortable in hot and cold weather include:
Hot Weather
- Wear appropriate clothing: light, breathable clothes in the summer.
- Avoid going outside during peak heat times during the day, usually between 10 a.m. and 3 p.m. If you do go outside, keep a small towel with you to wipe away excess sweat.
- Stay hydrated to moisturize from the inside out.
Cold Weather
- Wear gloves in the winter (since hands are particularly sensitive and often exposed to cold).
- Consider a humidifier to moisturize the indoor air.
Skin Irritants (Soaps, Clothing)
Some soaps, shampoos, detergents, and wool or synthetic clothing can significantly irritate sensitive skin.
When bathing or putting dirty clothes in the washing machine, it’s best to use gentle, fragrance-free, non-irritating products. When you find a product that works for your skin, stick with it!
Heavy or tight clothing that rubs against the skin can also cause symptoms. Natural fiber clothing such as cotton or silk is usually most comfortable. Look for clothes with soft or small seams that won’t rub against the skin. Once an area gets irritated, it can take a long time for it to calm down.
Stress
An increase in stress may either cause eczema flare-ups or make eczema worse. Some patients may scratch more often when they’re feeling pressure. Managing stress effectively can reduce flares.
Coping strategies such as meditation or yoga, regular exercise, and getting enough sleep are great ways to take your mind off your worries.
Tobacco Smoke
Cigarette smoke, including secondhand smoke, can irritate skin (in addition to the lungs). Set a no-smoking policy both inside and outside your home. Smoking is a major health issue for everyone.
Viral and Bacterial Infections
The common cold and the flu can cause an eczema flare. In addition, the herpes virus, which can cause cold sores in and around the mouth, can cause eczema flare-ups.
Exposure to bacteria can cause harmful toxins to secrete into the skin, prompting an immune reaction and causing skin inflammation. One of the more common bacteria is Staphylococcus aureus, which can not only worsen eczema but also slow skin healing.
Eczema occurs in all races and ethnicities, but it has a unique appearance in people of color. See our partner website for more information ⤑
Eczema occurs in all races and ethnicities, but it has a unique appearance in people of color. See our partner website for more information ⤑
How is eczema diagnosed?
First, your doctor will examine your skin for symptoms of eczema. Then the doctor will take your medical history, focusing on…
- Personal and family history of eczema, allergies, or asthma symptoms
- Lifestyle factors such as the environment you live or work in, your stress levels, etc.
- What triggers your eczema or makes it worse — are you using products that cause inflamed, itchy skin, for example.
As part of the diagnosis, you may be asked to undergo testing to find out what allergens and irritants are triggering symptoms. When you know how your eczema occurs, you are one step closer to reducing symptoms, whether it’s through avoidance, medication or other treatments.
Skin Prick Tests
Droplets of suspected allergens are placed on or just under the skin surface. Raised bumps (about the size of a mosquito bite) strongly indicate an allergy to the substance. Skin prick testing is commonly used by allergists because of its accuracy, ease of use and immediate results. Results are typically known within 20 minutes.
Blood Test
When a blood sample is drawn, it is analyzed to detect IgE antibodies directed at specific allergens. Tests may measure specific or overall levels of IgE. Some may also break down common allergens and measure IgE to specific components. Lab results may take several days. Consult with your doctor to ensure that the blood test is interpreted correctly. Eczema typically results in very high IgE levels and may falsely elevate results.
Patch Test
Chambers containing chemicals of potential triggers on adhesive strips are placed on the patient’s back. After 2-3 days, the patches are removed by the doctor and the skin is evaluated for reactions. If symptoms appear, then it’s confirmation of an allergy. Patch testing is commonly used for contact allergies to fragrances, detergents, metal and other chemical substances.
Oral Food Challenge
If it’s believed that a food is causing eczema symptoms, your doctor may want to perform an oral food challenge. In this test, the patient eats a tiny amount of a suspected allergen, and then gradually larger amounts, to determine if or when an allergic reaction occurs. An oral food challenge should only be done by a doctor and at a medical facility that has access to epinephrine and other emergency treatments.
Other tests helpful in diagnosing eczema
- Buccal swabs, or cheek swabs, are used to detect mutations in the filaggrin gene, the protein that helps protect the body from allergens and bacteria. A lack of filaggrin weakens the skin barrier, reducing the amount of moisture in the skin and leading to eczema.
- A skin biopsy can also be used to measure filaggrin levels, but it is mostly used to rule out other skin diseases, such as psoriasis or cancer. In a biopsy, a tiny piece of skin is removed and then analyzed under a microscope.
After testing is complete, your doctor will compile all of the evidence together to reach a diagnosis. Your physical exam, test results, personal and family health history, home and work environments, and any activities that might expose you to allergens will all be taken into account as part of the diagnosis.
What is the difference between mild, moderate and severe eczema?
Mild eczema involves small patches of dry, itchy and slightly inflamed skin. It causes minimal or no disruption with activities or sleep. It is usually manageable with moisturizers or over-the-counter treatments.
Moderate eczema involves larger areas of inflamed and itchy skin, often with scaling, thickening, or cracking. It can disrupt sleep or daily tasks and requires prescription topical treatments.
Severe eczema is widespread inflammation and intense itching, often leading to bleeding or secondary infections. It can significantly affect quality of life, making it difficult to sleep or concentrate. Severe eczema requires intensive therapies such as biologics, immunosuppressants, or phototherapy.
What other conditions look similar to eczema?
Another challenge of diagnosing eczema is that there are other skin conditions that may appear to be eczema or may appear to be eczema or have similar symptoms to eczema. As a result, people can experience symptoms and not get the right treatment due to misdiagnosis or delayed diagnosis.
These skin conditions may include:
- psoriasis
- scabies
- allergies
- hives
- ringworm
- acne
- cutaneous t-cell lymphoma
- Netherton disease
- hereditary angioedema
- chronic urticaria
Many of these conditions may have a similar appearance to eczema or even overlap with eczema.
That’s why it is very important to work with an allergist or dermatologist for diagnosis and treatment.
Caring for your skin and eczema medications are essential to avoiding skin complications and improving quality of life.
Medications and treatments may include:
- moisturizers
- topical medications
- advanced medications for moderate to severe eczema, such as JAK inhibitors (topical and oral) or biologics (injections)
- wet wrap therapy
- phototherapy
How does pregnancy affect eczema?
Eczema can occur for the first time during pregnancy. If you have a history of eczema prior to pregnancy, your symptoms may worsen during pregnancy. However, about 1 in 4 women with a history of eczema say their symptoms actually improve during pregnancy.
How do I cope with the challenges of eczema?
Coping with eczema is a challenge for many people, including caregivers. If you live with eczema, you know that it can greatly affect your quality of life and well-being. The itching, scratching, loss of sleep, and anxiety about physical appearance can greatly impact day-to-day living. It can take an emotional toll on both patients and families.
Although there’s no cure for eczema, there are now more advanced treatments available that can help manage severe eczema. In addition to treatments, controlling the itch-scratch cycle can help you cope with eczema and keep symptoms from getting worse.
Be sure to practice good self-care and seek out the support you need and deserve.
Are there other conditions that may look like eczema but are not eczema?
Several skin conditions can mimic eczema, but they differ in symptoms, diagnosis, and treatment. Here are a few examples:
Reviewed by:
Weily Soong, MD, is a board-certified allergist and immunologist and Chief Medical Officer with Allervie Health (previously Alabama Allergy & Asthma Center). Dr. Soong also serves as Medical Director of the Clinical Research Association of Alabama.
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.
