What Is Eczema?
Atopic dermatitis (AD), commonly called eczema, is a chronic inflammatory skin condition characterised by dry, intensely itchy skin that flares in patches — most often on the face, neck, inner elbows, and behind the knees. It affects roughly 31 million Americans (10–20% of children, 3% of adults) and is strongly associated with asthma, allergic rhinitis, and food allergies — the "atopic march."
What Causes Eczema?
Eczema is driven by two interacting problems:
- A defective skin barrier — mutations in the FLG gene (encoding filaggrin, a key structural protein) cause excessive water loss and allow allergens and irritants to penetrate the skin
- Immune dysregulation — type 2 inflammation (IL-4, IL-13, IL-31 pathways) drives the itch-scratch cycle and perpetuates inflammation
Genetics play a major role: if one parent has atopy, a child has a 30–50% chance of developing eczema; if both parents are affected, the risk rises to 60–80%.
Common Triggers
- Dry air, especially in winter with indoor heating
- Soaps, detergents, fragrances, and cleaning products
- Sweating and heat
- Wool or synthetic fabrics against the skin
- Stress (triggers neuroinflammatory flares)
- Certain foods (in children: egg, milk, peanut, wheat — rarely the primary cause in adults)
- House dust mites, pet dander, pollen
- Bacterial colonisation with Staphylococcus aureus — found on lesional skin in up to 90% of patients
Treatment: A Step-Up Approach
Baseline Care
Regular moisturisation (emollients applied twice daily) is the foundation of eczema management — it restores the skin barrier, reduces flare frequency, and decreases the need for steroids. Apply within three minutes of bathing to lock in moisture.
Topical Steroids
Topical corticosteroids remain the first-line anti-inflammatory treatment for flares. Low-potency steroids (hydrocortisone 1%) for the face and skin folds; moderate to high potency (betamethasone, mometasone) for the body. Overuse risks skin thinning (atrophy), but appropriately used short courses are safe.
Topical Calcineurin Inhibitors
Tacrolimus (Protopic) and pimecrolimus (Elidel) are non-steroidal alternatives suitable for sensitive areas and long-term use. They work by blocking T-cell activation without causing skin atrophy.
Biologics and Small Molecules
Dupilumab (Dupixent) — a monoclonal antibody blocking IL-4 and IL-13 receptors — has transformed moderate-to-severe eczema treatment. In phase 3 trials, 51% of patients achieved clear or almost clear skin at 16 weeks. JAK inhibitors (upadacitinib, abrocitinib) offer a fast-acting oral alternative for patients who fail biologics.
Living with Eczema
Identifying and avoiding personal triggers, using fragrance-free products, wearing loose cotton clothing, keeping nails short (to reduce damage from scratching), and managing stress all help reduce flare frequency. Eczema is not contagious and often improves with age.