Eczema (Atopic Dermatitis)

Who's At Risk?

Infants are more likely to have eczema if they have other allergies, such as to foods or milk, as well as seasonal allergies, or if they have other family members who were affected by eczema as an infant. Infants who have asthma are also more likely to have eczema.

Signs & Symptoms

The first location affected by eczema in an infant is usually the cheeks. The scalp, elbows and knees, and skin of other parts of the body may be affected as well. Eczema skin lesions frequently come and go within days to weeks. It is normal for new areas of eczema to appear in various places on the body as others resolve.

Thickened, scaly papules (small, raised bumps) and plaques (areas of raised skin that are larger than a thumbnail and feel rough and flaky) are seen in these areas. The condition may be:

• Localized – A few scattered areas of involvement that are easily treated with self-care measures. Eczema of the hands and/or feet is a common example of localized disease.
• Moderate – More extensive involvement that is more difficult to control with self-care measures and may require topical or other prescription therapy.
• Severe – Widespread involvement that is too difficult to treat with topical prescription therapy and frequently requires the use of more aggressive prescription treatments to keep the skin clear.

In lighter skin colors, affected areas may appear pink or red; however, in darker skin colors, the redness may be subtle or may even appear more purplish or darker brown.

Areas of eczema that become infected with a bacteria, virus, or fungus (known as a superimposed infection) can develop thick yellow-to-orange crusts, blisters, or open skin sores. Secondary skin infections are common in individuals with eczema.

Self-Care Guidelines

Maintaining healthy, moisturized skin is very important for those with eczema.

• Moisturizing daily skin-care routines with fragrance-free moisturizers are essential.
• Avoid bathing your baby in long, hot baths. Hot water can dry out the skin, resulting in eczema worsening.
• Hypoallergenic moisturizing soaps, such as unscented Dove, Vanicream bar soap, and Nature by Canus, are recommended.
• Thick moisturizing creams or ointments such as petroleum jelly, Aquaphor ointment, CeraVe healing ointment, CeraVe moisturizing cream, Cetaphil cream, Eucerin cream, and Aveeno cream should be applied to damp skin at least once daily, often after showers or baths.
• Treat red, itchy areas with over-the-counter hydrocortisone cream or ointment 0.5%-1% (eg, Cortaid, Cortisone-10) twice daily. To avoid thinning of the skin, do not use steroid creams for longer than 3 weeks continuously without a 1-week break in between.
• Attempt to minimize exposure to heat, low humidity, detergents / soaps, abrasive clothing, chemicals, smoke, environmental allergens (eg, trees and grasses), and stress.
• Fragrance-free household products and laundry detergent may also be beneficial.
• Keep the home from getting too dry by using a humidifier, especially in the bedroom.

Treatments

Topical or oral (systemic) medications can include:

• Topical steroid creams or ointments to treat active areas of limited (localized) eczema. Low-strength steroids may be used on the face and genitals, and medium-to-high-strength steroids may be used on the body (trunk) and arms or legs (extremities). Care should be taken when using topical steroids in skin folds for more than 3 weeks continuously because of the risk of thinning (or atrophy) of the skin.
• Crisaborole (Eucrisa) ointment for children 3 months and older may be prescribed in place of topical steroids and is safe on sensitive areas of the body.
• Oral antihistamines may be prescribed to decrease itching or help with associated hay fever.
• Light therapy (or phototherapy) 3-5 times weekly may be recommended for treatment of widespread or resistant eczema.
• Newer injectable medications known as biologics, such as dupilumab (Dupixent) in children 6 months and older, are the most promising treatments for moderate-to-severe eczema as they are highly effective treatments with very few side effects.
• In individuals who have multiple areas of broken skin or a history of bacterial skin infections, diluted bleach baths several times per week may be recommended.
• If an infection is suspected, topical / oral antibiotics, antifungal, or antiviral medications may be prescribed to treat the secondary infection.

Visit Urgency

See your baby’s medical professional for evaluation if you notice no improvement with self-care measures or the eczema gets worse. Also seek medical care if you see areas of pus, large numbers of yellow crusty areas, or blisters as these may be signs of a secondary skin infection.

Not all red, scaly rashes on the body are eczema. Many other medical conditions can mimic eczema, such as psoriasis, fungal or other infections, medication reactions, allergic or irritant skin reactions, food allergies or nutritional deficiencies, and other autoimmune conditions. Your medical provider can help you determine the cause of your rash if it is unclear.

Trusted Links

• Eczema
• Clinical Information and Differential Diagnosis of Dermatitis, Atopic (Eczema)
• Living Your Best Life With Atopic Dermatitis: A Patient and Caregiver Education and Resource Center

References

Bolognia J, Schaffer JV, Cerroni L. Dermatology. 4^th ed. Philadelphia, PA: Elsevier; 2018.

James WD, Elston D, Treat JR, Rosenbach MA. Andrew’s Diseases of the Skin. 13^th ed. Philadelphia, PA: Elsevier; 2019.

Kang S, Amagai M, Bruckner AL, et al. Fitzpatrick’s Dermatology. 9^th ed. New York, NY: McGraw-Hill Education; 2019.

Paller A, Mancini A. Paller and Mancini: Hurwitz Clinical Pediatric Dermatology. 6^th ed. St. Louis, MO: Elsevier; 2022.