If you've lived with atopic dermatitis (AD) for a while, you've seen how the dryness, scaling, and unrelenting itch takes over your life. But do you know what goes on under the surface to irritate your skin so much?
Understanding how problems with your skin's barrier cause AD symptoms, and which treatments relieve those symptoms, will make you a more active part of your care team. Then you can work with your dermatologist and allergist to discover your triggers and find treatments to strengthen your skin's barrier and relieve that annoying itch.
How AD Affects Skin
Doctors don't fully understand what causes AD. They think problems with the skin barrier and immune system may be to blame.
The epidermis is your outer layer of skin. It acts like a fortress to keep out germs, irritating chemicals, and allergens like pollen and pet dander. Your epidermis also holds in water to keep your skin hydrated.
The top layer of the epidermis is made up of proteins like filaggrin and keratin, plus fats. Proteins and fats stick together like bricks and mortar to form a tight seal.
When you have AD, a problem with your immune system makes it release too many inflammatory chemicals called cytokines. These chemicals reduce the amount of protein and fats in the outer layer of skin. They create openings that allow germs and allergens to slip through your skin's leaky barrier.
Your immune system responds to these foreign substances by releasing even more cytokines, which causes more inflammation. Without treatment, the cycle of skin damage and inflammation goes on and on.
What Does AD Look and Feel Like?
Itching is one of the main symptoms of AD, and it can be intense. You'll also see a scaly rash. Though the rash can appear anywhere on your body, you're most likely to find it on your elbows, the backs of your knees, and your hands.
An eczema rash looks:
- Red, white, grey, or purple, depending on your skin tone
- Dry and cracked
- Scaly
- Crusted
- Oozing
- Thick
- Bumpy
What Happens If You Don't Treat AD?
Without treatment, itching and other symptoms won't get better. If the itch is intense, you might scratch your skin so much that it breaks open and bleeds. Then germs can get inside and cause an infection.
Signs of an infection include:
- Pain
- Redness
- Swelling
- Pus
Other possible complications of untreated AD are:
- Scars
- Thick, leathery patches of skin called lichen simplex chronicus
- Patches of lighter or darker skin
- Trouble sleeping because of the itching
- Depression and anxiety from the constant itch and sleep problems
How to Treat AD
The goal in treating AD is to reduce inflammation in your skin, relieve itching, prevent flares, and help your skin heal. To do all those things may require a combination of moisturizers, topical medicines, oral and injected medicines, and lifestyle changes.
Which of these treatments your doctor recommends depends on the severity of your AD and how much of your skin the rash covers.
Moisturizers
The faulty skin barrier lets water leak out, which dries out skin. Moisturizers keep your skin hydrated and soft. They also help with itching, redness, and cracks.
The best moisturizers for AD are emollients containing ingredients like glycol and glyceryl stearate, or products with petroleum jelly and mineral oil. Choose moisturizers that are fragrance free and dye free. Apply them every day after you get out of the bath or shower, and pat your skin dry.
Moisturizers may be enough to treat mild AD. For more severe symptoms, use a moisturizer with the medicines and phototherapy your doctor prescribed.
Wet wraps
After coating your skin with a topical medicine or moisturizer, wrap it in bandages or gauze to seal it in. The wet wrap helps the medicine absorb into your skin and prevents you from scratching. You can wear a wet wrap for a few hours at a time or a full day.
Topical medicines
If moisturizers don't relieve your symptoms enough, your doctor might recommend a topical medicine that works directly on eczema rashes.
Corticosteroids. Steroid cream acts on immune cells in your skin to reduce inflammation and itch. Using these medicines for a short period of time is fine, but long-term use isn't recommended because the medicine could thin your skin and cause other side effects.
Calcineurin inhibitors. Tacrolimus ointment (Protopic) and pimecrolimus cream (Elidel) block cytokines to reduce inflammation in your skin.
Crisabarole ointment (Eucrisa). This newer treatment for mild-to-moderate atopic dermatitis reduces skin inflammation and relieves itching.
Roflumilast cream (Zoryve). It relieves itching and other AD symptoms.
Tapinarof cream (Vtama). This once-a-day topical product relieves itching and may clear the skin.
Phototherapy
Also known as light therapy, phototherapy might be an option if you tried topical therapies but they didn't clear your skin enough. This treatment exposes your skin to the sun or ultraviolet A (UVA) or UVB light. You get this treatment at a dermatologist's office, phototherapy center, or hospital two to three times a week for a few months. Sometimes doctors prescribe phototherapy with medicines.
Side effects of this treatment include skin damage, changes in skin color, and an increased risk for skin cancer.
Medicines to control inflammation
For more severe eczema, your doctor can prescribe a medicine that reduces inflammation all over your body. You take these medicines by mouth or get them as an injection:
- Azathioprine (Azasan, Imuran)
- Corticosteroids
- Cyclosporine (Neoral, Sandimmune)
- Methotrexate (Jylamvo, Trexall)
- Mycophenolate mofetil
- Tacrolimus (Prograf)
Newer AD medicines treat moderate-to-severe AD that hasn't responded to other therapies. Dupilumab (Dupixent) and tralokinumab (Adbry) are biologic drugs. They work on your immune system to reduce inflammation.
Abrocitinib (Cibinqo), ruxolitinib (Opzelura), and upadacitinib (Rinvoq) are Janus kinase (JAK) inhibitors. They block signals in your body that cause inflammation.
Other treatments are for the AD symptoms. Antihistamines relieve itching. Antihistamines control allergies. Antibiotics clear up infections.
Caring for AD Skin
Medicine is just one part of managing AD symptoms. Lifestyle changes are also important. Start by identifying what triggers your flares. Everyone has different triggers, but some common ones are stress, chemicals, high temperatures, and allergens like pollen or pet dander.
Protect your skin by bathing and moisturizing it every day. Start with a lukewarm shower or bath (hot water irritates the skin). When you get out, gently pat your skin almost dry. Then apply an emollient to seal in the moisture.
These are some other things you can do:
- Keep the temperature in your home cool and the humidity set between 30% and 60%.
- Sleep well. If scratching keeps you awake, ask your doctor to recommend treatments that relieve itching.
- Don't scratch or rub your skin
Holistic Treatments for AD
In addition to medical treatments, you might try one of these evidence-based alternative therapies:
- Acupuncture. Stimulating various points around your body with fine needles may relieve stress, which is a common AD trigger.
- Coconut oil. This moisturizer alternative hydrates skin and kills the germs that cause infections.
- Sunflower seed oil. It helps with itchiness and rashes, and it may strengthen your skin's barrier.
- Baking soda. Mix water with baking soda and spread the paste onto your skin to relieve itching.
- Bleach baths. Bathe in a mixture of bleach and water two or three times a week to reduce inflammation and itch.
What Can You Do to Prevent Skin Damage?
AD is an itchy disease. When you itch, you scratch. Scratching inflames and damages your skin even more. Doctors call this the scratch-itch cycle. There are a few things you can do to prevent skin damage:
- Apply a moisturizer every day. Keep the bottle in the fridge. The cold will feel soothing on your skin.
- Trim your nails close and then file them until smooth. If you're still scratching, wear gloves.
- Take an antihistamine.
- Buy clothes made from soft fabrics like cotton. Avoid wool and other itchy fabrics.
- Wear a sunscreen that has at least 8% zinc oxide and an SPF of at least 15 every time you're outside to prevent sunburn.
Show Sources
SOURCES:
Allergy & Asthma Network: "Ask the Allergist: Breaking the Itch-Scratch Cycle."
Allergy and Asthma Proceedings: "Pathophysiology of Atopic Dermatitis: Clinical Implications."
Allergy, Asthma & Immunology Research: "Significance of Skin Barrier Dysfunction in Atopic Dermatitis."
American Academy of Dermatology: "Eczema Treatment: Crisaborole (Eucrisa) Ointment," "Eczema Types: Atopic Dermatitis Diagnosis and Treatment," "JAK Inhibitors: What Your Dermatologist Wants You to Know."
American Academy of Pediatrics: "Alternative Treatments for Atopic Dermatitis."
American Family Physician: "Atopic Dermatitis: Diagnosis and Treatment."
Cleveland Clinic: "Atopic Dermatitis."
DermNet: "Barrier Function in Atopic Dermatitis."
Journal of the American Academy of Dermatology: "Guidelines of Care for the Management of Atopic Dermatitis. Section 2. Management and Treatment of Atopic Dermatitis with Topical Therapies," "Guidelines of Care for the Management of Atopic Dermatitis. Section 3. Management and Treatment with Phototherapy and Systemic Agents."
Mayo Clinic: "20 Lifestyle and Health Hacks for Controlling Eczema," "Atopic Dermatitis (Eczema)."
National Eczema Association: "Atopic Dermatitis," "Bleach Baths for Atopic Dermatitis," "Household Irritants and Eczema," "Top 7 Natural and Alternative Treatments for Eczema."
National Jewish Health: "Eczema: Lifestyle Management."
NHS: "Atopic Eczema."
National Institute of Arthritis and Musculoskeletal and Skin Diseases: "Atopic Dermatitis: Diagnosis, Treatment, and Steps to Take."
UpToDate: "Patient Education: Eczema (Atopic Dermatitis) (Beyond the Basics)."
