View source for Medicine:Atopic dermatitis

{{Short description|Long-term form of skin inflammation}}
{{Infobox medical condition
| name            = Atopic dermatitis
| synonyms        = Atopic eczema, infantile eczema, prurigo Besnier, allergic eczema, neurodermatitis<ref name=Wil2000/>
| image           = Atopy2010.JPG
| caption         = Atopic dermatitis of the inside crease of the elbow
| field           = Dermatology, [[Biology:Immunology|Clinical Immunology and Allergy]]
| symptoms        = Itchy, red, swollen, cracked skin<ref name=NIH2013/>
| complications   = Skin infections, hay fever, [[Medicine:Asthma|asthma]]<ref name=NIH2013/>
| onset           = Childhood<ref name=NIH2013/><ref name=Toll2014/>
| duration        =
| types           =
| causes          = Unknown<ref name=NIH2013/><ref name=Toll2014/>
| risks           = [[Medicine:Family history|Family history]], living in a city, dry climate<ref name=NIH2013/>
| diagnosis       = Based on symptoms after ruling out other possible causes<ref name=NIH2013/><ref name=Toll2014/>
| differential    = Contact dermatitis, [[Medicine:Psoriasis|psoriasis]], seborrheic dermatitis<ref name=Toll2014/>
| prevention      =
| treatment       = Avoiding things that worsen the condition, daily bathing followed by moisturising cream, [[Biology:Corticosteroid|steroid]] creams for flares<ref name=Toll2014/> [[Engineering:Humidifier|Humidifier]]
| medication      =
| prognosis       =
| frequency       = ~20% at some time<ref name=NIH2013/><ref name=Thom2014/>
| deaths          =
}}

<!-- Definition and symptoms -->
'''Atopic dermatitis''' ('''AD'''), also known as '''atopic eczema''', is a long-term type of inflammation of the skin ([[Medicine:Dermatitis|dermatitis]]).<ref name=NIH2013/> It results in itchy, red, swollen, and cracked skin.<ref name=NIH2013/> Clear fluid may come from the affected areas, which can thicken over time.<ref name=NIH2013>{{cite web|title=Handout on Health: Atopic Dermatitis (A type of eczema)|url=http://www.niams.nih.gov/Health_Info/Atopic_Dermatitis/default.asp|website=National Institute of Arthritis and Musculoskeletal and Skin Diseases|access-date=19 June 2015|date=May 2013|url-status=live|archive-url=https://web.archive.org/web/20150530092344/http://www.niams.nih.gov/Health_Info/Atopic_Dermatitis/default.asp|archive-date=30 May 2015}}</ref> AD may also simply be called eczema, a term that generally refers to a larger group of skin conditions.<ref name="NIH2013" /><ref>{{cite journal | vauthors = Johansson SG, Bieber T, Dahl R, Friedmann PS, Lanier BQ, Lockey RF, Motala C, Ortega Martell JA, Platts-Mills TA, Ring J, Thien F, Van Cauwenberge P, Williams HC | display-authors = 6 | title = Revised nomenclature for allergy for global use: Report of the Nomenclature Review Committee of the World Allergy Organization, October 2003 | journal = The Journal of Allergy and Clinical Immunology | volume = 113 | issue = 5 | pages = 832–836 | date = May 2004 | pmid = 15131563 | doi = 10.1016/j.jaci.2003.12.591 | doi-access = free }}</ref>

Atopic dermatitis affects about 20% of people at some point in their lives.<ref name=NIH2013/><ref name=Thom2014>{{cite journal | vauthors = Thomsen SF | title = Atopic dermatitis: natural history, diagnosis, and treatment | journal = ISRN Allergy | volume = 2014 | pages = 354250 | date = 2014 | pmid = 25006501 | pmc = 4004110 | doi = 10.1155/2014/354250 | doi-access = free }}</ref> It is more common in younger children.<ref name=Toll2014/> Females are slightly more affected than males.<ref>{{cite web |title=Atopic Dermatitis |url=https://www.niams.nih.gov/health-topics/atopic-dermatitis |website=National Institute of Arthritis and Musculoskeletal and Skin Diseases |access-date=29 August 2022 |language=en |date=September 2019}}</ref> Many people outgrow the condition.<ref name=Toll2014/>

While the condition may occur at any age, it typically starts in childhood, with changing severity over the years.<ref name="NIH2013" /><ref name="Toll2014" /> In children under one year of age, the face and limbs and much of the body may be affected.<ref name="Toll2014" /> As children get older, the areas on the insides of the knees and folds of the elbows and around the neck are most commonly affected.<ref name="Toll2014" /> In adults, the hands and feet are commonly affected.<ref name="Toll2014">{{cite journal | vauthors = Tollefson MM, Bruckner AL | title = Atopic dermatitis: skin-directed management | journal = Pediatrics | volume = 134 | issue = 6 | pages = e1735–e1744 | date = December 2014 | pmid = 25422009 | doi = 10.1542/peds.2014-2812 | doi-access = free }}</ref> Scratching the affected areas worsens the eczema and increases the risk of skin infections.<ref name="NIH2013" /> Many people with atopic dermatitis develop hay fever or [[Medicine:Asthma|asthma]].<ref name="NIH2013" />

<!-- Cause and diagnosis -->
The cause is unknown but believed to involve [[Biology:Genetics|genetics]], [[Biology:Immune system|immune system]] dysfunction, environmental exposures, and difficulties with the [[Physics:Semipermeable membrane|permeability]] of the skin.<ref name="NIH2013" /><ref name="Toll2014" /> If one identical twin is affected, the other has an 85% chance of having the condition.<ref>{{cite book| vauthors = Williams H |title=Evidence-Based Dermatology|year=2009|publisher=John Wiley & Sons|isbn=9781444300178|pages=128|url=https://books.google.com/books?id=SbsQij5xkfYC&pg=PA128|url-status=live|archive-url=https://web.archive.org/web/20170908181020/https://books.google.com/books?id=SbsQij5xkfYC&pg=PA128|archive-date=2017-09-08}}</ref> Those who live in cities and dry climates are more commonly affected.<ref name="NIH2013" /> Exposure to certain chemicals or frequent hand washing makes symptoms worse.<ref name="NIH2013" /> While emotional stress may make the symptoms worse, it is not a cause.<ref name="NIH2013" /> The disorder is not [[Philosophy:Contagious disease|contagious]].<ref name="NIH2013" /> A diagnosis is typically based on the signs, symptoms and [[Medicine:Family history|family history]].<ref name="Toll2014" />

<!-- Prevention and treatment -->
Treatment involves avoiding things that make the condition worse, enhancing the skin barrier through skin care and treating the underlying skin inflammation. Moisturising creams are used to make the skin less dry and prevent AD flare-ups. Anti-inflammatory [[Biology:Corticosteroid|corticosteroid]] creams are used to control flares-ups.<ref name="Toll2014" /> Creams based on calcineurin inhibitors (tacrolimus or pimecrolimus) may also be used to control flares if other measures are not effective.<ref name="NIH2013" /><ref name="Carr2013">{{cite journal | vauthors = Carr WW | title = Topical calcineurin inhibitors for atopic dermatitis: review and treatment recommendations | journal = Paediatric Drugs | volume = 15 | issue = 4 | pages = 303–310 | date = August 2013 | pmid = 23549982 | pmc = 3715696 | doi = 10.1007/s40272-013-0013-9 }}</ref> Certain [[Chemistry:Antihistamine|antihistamine]] pills might help with itchiness.<ref name="Toll2014" /> Things that commonly make it worse include [[Biology:House dust mite|house dust mite]], [[Medicine:Psychological stress|stress]] and seasonal factors.<ref>{{cite journal | vauthors = Langan SM, Williams HC | title = What causes worsening of eczema? A systematic review | journal = The British Journal of Dermatology | volume = 155 | issue = 3 | pages = 504–514 | date = September 2006 | pmid = 16911274 | doi = 10.1111/j.1365-2133.2006.07381.x | s2cid = 43247714 }}</ref> Phototherapy may be useful in some people.<ref name="NIH2013" /> Antibiotics (either by mouth or topically) are usually not helpful unless there is secondary bacterial infection or the person is unwell.<ref>{{cite journal | vauthors = Ong PY, Boguniewicz J, Chu DK | title = Skin Antiseptics for Atopic Dermatitis: Dissecting Facts From Fiction | language = English | journal = The Journal of Allergy and Clinical Immunology. In Practice | date = January 2023 | volume = 11 | issue = 5 | pages = 1385–1390 | pmid = 36702247 | doi = 10.1016/j.jaip.2023.01.012 | s2cid = 256222372 }}</ref> Dietary exclusion does not benefit most people and it is only needed if food allergies are suspected.<ref>{{cite journal | vauthors = Oykhman P, Dookie J, Al-Rammahy H, de Benedetto A, Asiniwasis RN, LeBovidge J, Wang J, Ong PY, Lio P, Gutierrez A, Capozza K, Martin SA, Frazier W, Wheeler K, Boguniewicz M, Spergel JM, Greenhawt M, Silverberg JI, Schneider L, Chu DK | display-authors = 6 | title = Dietary Elimination for the Treatment of Atopic Dermatitis: A Systematic Review and Meta-Analysis | language = English | journal = The Journal of Allergy and Clinical Immunology. In Practice | volume = 10 | issue = 10 | pages = 2657–2666.e8 | date = October 2022 | pmid = 35987995 | doi = 10.1016/j.jaip.2022.06.044 | s2cid = 250710625 }}</ref> More severe AD cases may need systemic medicines such as [[Chemistry:Ciclosporin|cyclosporin]], [[Chemistry:Methotrexate|methotrexate]], [[Chemistry:Dupilumab|dupilumab]] or [[Chemistry:Baricitinib|baricitinib]].

Other names of the condition include "infantile eczema", "flexural eczema", "prurigo Besnier", "allergic eczema", and "neurodermatitis".<ref name="Wil2000">{{cite journal | vauthors = Williams HC | title = Epidemiology of atopic dermatitis | journal = Clinical and Experimental Dermatology | volume = 25 | issue = 7 | pages = 522–529 | date = October 2000 | pmid = 11122223 | doi = 10.1046/j.1365-2230.2000.00698.x | url = https://books.google.com/books?id=q8OZ4O_gjQUC&pg=PA10 | url-status = live | publisher = Cambridge University Press | isbn = 9780521570756 | s2cid = 31546363 | archive-url = https://web.archive.org/web/20150619134904/https://books.google.ca/books?id=q8OZ4O_gjQUC&pg=PA10 | archive-date = 2015-06-19 }}</ref>

== Signs and symptoms ==
[[File:Child with Eczema (34034003933).jpg|thumb|Child with atopic dermatitis]]
Symptoms refer to the sensations that people with AD feel, whereas signs refers to a description of the visible changes that result from AD.[[File:Pattern of atopic eczema varies with age.png|thumb|The pattern of atopic eczema varies with age.]]The main symptom of AD is itching which can be intense. Some people experience burning or soreness or pain.<ref name="NIH2013" />

People with AD often have a generally dry skin that can look greyish in people with darker skin tones of colour. Areas of AD are not well defined, and they are typically inflamed (red in a light coloured skin or purple or dark brown in people with dark skin of colour).<ref>{{cite journal | vauthors = Kaufman BP, Guttman-Yassky E, Alexis AF | title = Atopic dermatitis in diverse racial and ethnic groups-Variations in epidemiology, genetics, clinical presentation and treatment | journal = Experimental Dermatology | volume = 27 | issue = 4 | pages = 340–357 | date = April 2018 | pmid = 29457272 | doi = 10.1111/exd.13514 | s2cid = 3379280 | doi-access = free }}</ref> Surface changes include:

* scaling cracking (fissures) 
* swelling ([[Medicine:Edema|oedema]]) 
* scratch marks (excoriation) 
* bumpiness (papulation) 
* oozing of clear fluid
* thickening of the skin (lichenification) where the AD has been present for a long time.<ref name="NIH2013" />

Eczema often starts on the cheeks and outer limbs and body in infants and frequently settles in the folds of the skin such as behind the knees, folds of the elbows, around the neck, wrists and under the buttock folds as the child grows.<ref>{{Cite book |url=https://www.worldcat.org/oclc/605909001 |title=Rook's Textbook of Dermatology |date=2010 |publisher=Wiley-Blackwell | vauthors = Rook A, Burns T |isbn=978-1-4443-1764-0 |edition=8th |location=Chichester, UK |chapter=Atopic dermatitis |oclc=605909001}}</ref> Any part of the body can be affected by AD.<ref>{{cite book | vauthors = Friedmann PS, Holden CA | chapter = Atopic Dermatitis |date= January 2004 | title = Rook's Textbook of Dermatology |pages=755–786 | veditors =  Burns T, Breathnach S, Cox N, Griffiths C |place=Malden, Massachusetts, USA |publisher=Blackwell Publishing, Inc. |language=en |doi=10.1002/9780470750520.ch18 |isbn=978-0-470-75052-0 }}</ref>

AD commonly affects the eyelids, where an extra prominent crease can form under the eyelid due to skin swelling known as [[Medicine:Dennie–Morgan fold|Dennie-Morgan infraorbital folds]].<ref name="The infra-auricular fissure: a beds">{{cite journal | vauthors = Kwatra SG, Tey HL, Ali SM, Dabade T, Chan YH, Yosipovitch G | title = The infra-auricular fissure: a bedside marker of disease severity in patients with atopic dermatitis | journal = Journal of the American Academy of Dermatology | volume = 66 | issue = 6 | pages = 1009–1010 | date = June 2012 | pmid = 22583715 | doi = 10.1016/j.jaad.2011.10.031 }}</ref> Cracks can form under the ears which can be painful (infra-auricular fissure).<ref>{{cite journal | vauthors = Langan SM, Irvine AD, Weidinger S | title = Atopic dermatitis | journal = Lancet | volume = 396 | issue = 10247 | pages = 345–360 | date = August 2020 | pmid = 32738956 | doi = 10.1016/S0140-6736(20)31286-1 | s2cid = 220873055 }}</ref><ref name="The infra-auricular fissure: a beds"/>

The inflammation from AD often leaves "footprints" known as postinflammatory pigmentation that can be lighter than the normal skin or darker. These marks are not scars and eventually go back to normal over a period of months providing the underlying AD is treated effectively.<ref>{{Cite web | vauthors = Lambert A |date=2021-02-09 |title=Skin pigmentation and eczema |url=https://eczema.org/information-and-advice/living-with-eczema/skin-pigmentation/ |access-date=2023-04-06 |website=National Eczema Society |language=en}}</ref>

People with AD often have dry and scaly skin that spans the entire body, except perhaps the diaper area, and intensely itchy red, splotchy, raised [[Medicine:Lesion|lesion]]s to form in the bends of the arms or legs, face, and neck.<ref name="AFP">{{cite journal | vauthors = Berke R, Singh A, Guralnick M | title = Atopic dermatitis: an overview | journal = American Family Physician | volume = 86 | issue = 1 | pages = 35–42 | date = July 2012 | pmid = 22962911 | url = http://www.aafp.org/afp/2012/0701/p35.pdf | url-status = live | archive-url = https://web.archive.org/web/20150906111528/http://www.aafp.org/afp/2012/0701/p35.pdf | archive-date = 2015-09-06 }}</ref><ref name="MSR">{{cite web |date=21 January 2014 |title=Atopic Dermatitis |url=http://emedicine.medscape.com/article/1049085-overview#showall |url-status=live |archive-url=https://web.archive.org/web/20140210011334/http://emedicine.medscape.com/article/1049085-overview#showall |archive-date=10 February 2014 |access-date=3 March 2014 |work=Medscape Reference |publisher=WebMD |vauthors=Kim BS |veditors=Fritsch P, Vinson RP, Perry V, Quirk CM, James WD}}</ref><ref>{{cite book |title=Encyclopedia of molecular mechanisms of diseases |vauthors=Brehler R |publisher=Springer |year=2009 |isbn=978-3-540-67136-7 | veditors = Lang F |location=Berlin |chapter=Atopic Dermatitis}}</ref><ref>{{cite journal | vauthors = Baron SE, Cohen SN, Archer CB | title = Guidance on the diagnosis and clinical management of atopic eczema | journal = Clinical and Experimental Dermatology | volume = 37 | issue = Suppl 1 | pages = 7–12 | date = May 2012 | pmid = 22486763 | doi = 10.1111/j.1365-2230.2012.04336.x | s2cid = 28538214 | doi-access = free }}</ref><ref name="symp13">{{cite journal | vauthors = Schmitt J, Langan S, Deckert S, Svensson A, von Kobyletzki L, Thomas K, Spuls P | title = Assessment of clinical signs of atopic dermatitis: a systematic review and recommendation | journal = The Journal of Allergy and Clinical Immunology | volume = 132 | issue = 6 | pages = 1337–1347 | date = December 2013 | pmid = 24035157 | doi = 10.1016/j.jaci.2013.07.008 | doi-access = free }}</ref>

== Causes ==

The cause of AD is not known, although  some evidence indicates environmental, immunologic, and potential genetic factors.<ref name=GreyMaguiness2016>{{cite journal | vauthors = Grey K, Maguiness S | title = Atopic Dermatitis: Update for Pediatricians | journal = Pediatric Annals | volume = 45 | issue = 8 | pages = e280–e286 | date = August 2016 | pmid = 27517355 | doi = 10.3928/19382359-20160720-05 | type = Review }}</ref>

=== Pollution ===
Since 1970, the rates of atopic dermatitis in the US and UK have increased 3-6 fold.<ref name=":6">{{Cite web |date=2023-01-23 |title=NIAID Researchers Identify Link Between Common Chemicals and Eczema {{!}} NIH: National Institute of Allergy and Infectious Diseases |url=https://www.niaid.nih.gov/news-events/researchers-identify-link-between-common-chemicals-and-eczema |access-date=2023-11-23 |website=www.niaid.nih.gov |language=en}}</ref> Even today, people who migrate from developing nations before the age of 4 years to industrialized nations experience a dramatic rise in the risk of atopic dermatitis and have an additional risk when living in urbanized areas of the industrial nation.<ref name=":7">{{Cite journal |last1=Zeldin |first1=Jordan |last2=Chaudhary |first2=Prem Prashant |last3=Spathies |first3=Jacquelyn |last4=Yadav |first4=Manoj |last5=D'Souza |first5=Brandon N. |last6=Alishahedani |first6=Mohammadali E. |last7=Gough |first7=Portia |last8=Matriz |first8=Jobel |last9=Ghio |first9=Andrew J. |last10=Li |first10=Yue |last11=Sun |first11=Ashleigh A. |last12=Eichenfield |first12=Lawrence F. |last13=Simpson |first13=Eric L. |last14=Myles |first14=Ian A. |date=2023-01-06 |title=Exposure to isocyanates predicts atopic dermatitis prevalence and disrupts therapeutic pathways in commensal bacteria |journal=Science Advances |volume=9 |issue=1 |pages=eade8898 |doi=10.1126/sciadv.ade8898 |issn=2375-2548 |pmc=9821876 |pmid=36608129|bibcode=2023SciA....9E8898Z }}</ref> Recent work has shed light on these and other data strongly suggesting that early life industrial exposures may cause atopic dermatitis.<ref name=":6" /><ref name=":8">{{Cite web |date=2023-03-26 |title=Eczema's cause could be in the air we breathe |url=https://www.nbcnews.com/health/health-news/causes-eczema-air-breathe-new-science-suggests-rcna76427 |access-date=2023-11-23 |website=NBC News |language=en}}</ref> Chemicals such as [[Chemistry:Isocyanate|(di)isocyanates]] and [[Chemistry:Xylene|xylene]] prevent the skin bacteria from producing [[Chemistry:Ceramide|ceramide]]-[[Biology:Sphingolipid|sphingolipid]] family lipids.<ref name=":6" /><ref name=":8" /> Early life deficiency in these lipids predictive which children will go on to develop atopic dermatitis.<ref>{{Cite journal |last1=Chaudhary |first1=Prem Prashant |last2=Myles |first2=Ian A. |last3=Zeldin |first3=Jordan |last4=Dabdoub |first4=Shareef |last5=Deopujari |first5=Varsha |last6=Baveja |first6=Rajiv |last7=Baker |first7=Robin |last8=Bengtson |first8=Sarah |last9=Sutton |first9=Ashleigh |last10=Levy |first10=Shira |last11=Hourigan |first11=Suchitra K. |date=October 2023 |title=Shotgun metagenomic sequencing on skin microbiome indicates dysbiosis exists prior to the onset of atopic dermatitis |journal=Allergy |volume=78 |issue=10 |pages=2724–2731 |doi=10.1111/all.15806 |issn=1398-9995 |pmid=37422700|pmc=10543534 |pmc-embargo-date=October 1, 2024 }}</ref><ref name=":9">{{Cite journal |last1=Berdyshev |first1=Evgeny |last2=Kim |first2=Jihyun |last3=Kim |first3=Byung Eui |last4=Goleva |first4=Elena |last5=Lyubchenko |first5=Taras |last6=Bronova |first6=Irina |last7=Bronoff |first7=Anna Sofia |last8=Xiao |first8=Olivia |last9=Kim |first9=Jiwon |last10=Kim |first10=Sukyung |last11=Kwon |first11=Mijeong |last12=Lee |first12=Sungjoo |last13=Seo |first13=Yu Jeong |last14=Kim |first14=Kyunga |last15=Choi |first15=Suk-Joo |date=May 2023 |title=Stratum corneum lipid and cytokine biomarkers at age 2 months predict the future onset of atopic dermatitis |journal=The Journal of Allergy and Clinical Immunology |volume=151 |issue=5 |pages=1307–1316 |doi=10.1016/j.jaci.2023.02.013 |issn=1097-6825 |pmid=36828081|s2cid=255078763 }}</ref><ref>{{Cite journal |last1=Rinnov |first1=Maria Rasmussen |last2=Halling |first2=Anne-Sofie |last3=Gerner |first3=Trine |last4=Ravn |first4=Nina Haarup |last5=Knudgaard |first5=Mette Hjorslev |last6=Trautner |first6=Simon |last7=Goorden |first7=Susan M. I. |last8=Ghauharali-van der Vlugt |first8=Karen J. M. |last9=Stet |first9=Femke S. |last10=Skov |first10=Lone |last11=Thomsen |first11=Simon Francis |last12=Egeberg |first12=Alexander |last13=Rosted |first13=Aske L. L. |last14=Petersen |first14=Troels |last15=Jakasa |first15=Ivone |date=March 2023 |title=Skin biomarkers predict development of atopic dermatitis in infancy |journal=Allergy |volume=78 |issue=3 |pages=791–802 |doi=10.1111/all.15518 |issn=1398-9995 |pmid=36112082|doi-access=free }}</ref><ref>{{Cite journal |last1=Yamamoto-Hanada |first1=Kiwako |last2=Saito-Abe |first2=Mayako |last3=Shima |first3=Kyoko |last4=Fukagawa |first4=Satoko |last5=Uehara |first5=Yuya |last6=Ueda |first6=Yui |last7=Iwamura |first7=Maeko |last8=Murase |first8=Takatoshi |last9=Kuwano |first9=Tetsuya |last10=Inoue |first10=Takayoshi |last11=Ohya |first11=Yukihiro |date=July 2023 |title=mRNAs in skin surface lipids unveiled atopic dermatitis at 1 month |journal=Journal of the European Academy of Dermatology and Venereology: JEADV |volume=37 |issue=7 |pages=1385–1395 |doi=10.1111/jdv.19017 |issn=1468-3083 |pmid=36897437|doi-access=free }}</ref> These chemicals also directly activate an itch receptor in the skin known as [[Biology:TRPA1|TRPA1]].<ref>{{Cite journal |last1=Yadav |first1=Manoj |last2=Chaudhary |first2=Prem Prashant |last3=D'Souza |first3=Brandon N. |last4=Ratley |first4=Grace |last5=Spathies |first5=Jacquelyn |last6=Ganesan |first6=Sundar |last7=Zeldin |first7=Jordan |last8=Myles |first8=Ian A. |date=2023 |title=Diisocyanates influence models of atopic dermatitis through direct activation of TRPA1 |journal=PLOS ONE |volume=18 |issue=3 |pages=e0282569 |doi=10.1371/journal.pone.0282569 |issn=1932-6203 |pmc=9987805 |pmid=36877675 |bibcode=2023PLoSO..1882569Y |doi-access=free }}</ref> The industrial manufacturing and use of both xylene and diisocyanates greatly increased starting in 1970, which greatly expanded the average exposure to these substances. For example, these chemicals are components of several exposures known to increase the risk of atopic dermatitis or worsen symptoms including: wildfires, automobile exhaust, wallpaper adhesives, paints, non-latex foam furniture, cigarette smoke, and are elements of fabrics like [[Chemistry:Polyester|polyester]], [[Chemistry:Nylon|nylon]], and [[Chemistry:Spandex|spandex]].<ref name=":7" /><ref name=":6" /><ref name=":8" />

===Climate===
Low [[Physics:Humidity|humidity]], and low [[Physics:Temperature|temperature]] increase the prevalence and risk of flares in patients with atopic dermatitis.<ref>{{cite journal |vauthors=Engebretsen KA, Johansen JD, Kezic S, Linneberg A, Thyssen JP |title=The effect of environmental humidity and temperature on skin barrier function and dermatitis |journal=Journal of the European Academy of Dermatology and Venereology |volume=30 |issue=2 |pages=223–249 |date=February 2016 |pmid=26449379 |doi=10.1111/jdv.13301 |s2cid=12378072 |doi-access=free}}</ref>

=== Genetics ===
Many people with AD have a family history or a personal history of atopy. Atopy is a term used to describe individuals who produce substantial amounts of [[Biology:Immunoglobulin E|IgE]]. Such individuals have an increased tendency to develop [[Medicine:Asthma|asthma]], [[Medicine:Allergic rhinitis|hay fever]], [[Medicine:Dermatitis|eczema]], [[Medicine:Hives|urticaria]] and allergic rhinitis.<ref name="AFP" /><ref name="MSR" /> Up to 80% of people with atopic dermatitis have elevated total or allergen-specific IgE levels.<ref name="Stander" />

About 30% of people with atopic dermatitis have mutations in the gene for the production of [[Biology:Filaggrin|filaggrin]] (''FLG''), which increase the risk for early onset of atopic dermatitis and developing asthma.<ref name=ParkPak2016>{{cite journal |vauthors=Park KD, Pak SC, Park KK |title=The Pathogenetic Effect of Natural and Bacterial Toxins on Atopic Dermatitis |journal=Toxins |volume=9 |issue=1 |pages=3 |date=December 2016 |pmid=28025545 |pmc=5299398 |doi=10.3390/toxins9010003 |type=Review |doi-access=free}}</ref><ref>{{cite journal |vauthors=Irvine AD, McLean WH, Leung DY |title=Filaggrin mutations associated with skin and allergic diseases |journal=The New England Journal of Medicine |volume=365 |issue=14 |pages=1315–1327 |date=October 2011 |pmid=21991953 |doi=10.1056/NEJMra1011040 |type=Review}}</ref> However, expression of filaggrin protein or breakdown products offer no predictive utility in atopic dermatitis risk.<ref name=":9" />

=== Hygiene hypothesis ===
According to the [[Unsolved:Hygiene hypothesis|hygiene hypothesis]], early childhood exposure to certain microorganisms (such as [[Biology:Gut flora|gut flora]] and helminth parasites) protects against [[Medicine:Allergy|allergic]] diseases by contributing to the development of the [[Biology:Immune system|immune system]].<ref name="CleaningUpHygieneHypothesis">{{cite journal |vauthors=Scudellari M |title=News Feature: Cleaning up the hygiene hypothesis |journal=Proceedings of the National Academy of Sciences of the United States of America |volume=114 |issue=7 |pages=1433–1436 |date=February 2017 |pmid=28196925 |pmc=5320962 |doi=10.1073/pnas.1700688114 |doi-access=free |bibcode=2017PNAS..114.1433S}}</ref> This exposure is limited in a modern "sanitary" environment, and the incorrectly developed immune system is prone to develop allergies to harmless substances.

Some support exists for this hypothesis with respect to AD.<ref>{{cite journal | vauthors = Bieber T | title = Atopic dermatitis | journal = The New England Journal of Medicine | volume = 358 | issue = 14 | pages = 1483–1494 | date = April 2008 | pmid = 18385500 | doi = 10.1056/NEJMra074081 }}</ref> Those exposed to dogs while growing up have a lower risk of atopic dermatitis.<ref>{{cite journal | vauthors = Pelucchi C, Galeone C, Bach JF, La Vecchia C, Chatenoud L | title = Pet exposure and risk of atopic dermatitis at the pediatric age: a meta-analysis of birth cohort studies | journal = The Journal of Allergy and Clinical Immunology | volume = 132 | issue = 3 | pages = 616–622.e7 | date = September 2013 | pmid = 23711545 | doi = 10.1016/j.jaci.2013.04.009 | hdl-access = free | hdl = 2434/239729 }}</ref> Also, epidemiological studies support a protective role for helminths against AD.<ref name="epid">{{cite journal | vauthors = Flohr C, Mann J | title = New insights into the epidemiology of childhood atopic dermatitis | journal = Allergy | volume = 69 | issue = 1 | pages = 3–16 | date = January 2014 | pmid = 24417229 | doi = 10.1111/all.12270 | s2cid = 32645590 | doi-access = free }}</ref> Likewise, children with poor hygiene are at a lower risk for developing AD, as are children who drink unpasteurized milk.<ref name="epid" />

=== Allergens ===
In a small percentage of cases, atopic dermatitis is caused by sensitization to foods<ref name=diMauroBernardin2016>{{cite journal | vauthors = di Mauro G, Bernardini R, Barberi S, Capuano A, Correra A, De' Angelis GL, Iacono ID, de Martino M, Ghiglioni D, Di Mauro D, Giovannini M, Landi M, Marseglia GL, Martelli A, Miniello VL, Peroni D, Sullo LR, Terracciano L, Vascone C, Verduci E, Verga MC, Chiappini E | display-authors = 6 | title = Prevention of food and airway allergy: consensus of the Italian Society of Preventive and Social Paediatrics, the Italian Society of Paediatric Allergy and Immunology, and Italian Society of Pediatrics | journal = The World Allergy Organization Journal | volume = 9 | pages = 28 | year = 2016 | pmid = 27583103 | pmc = 4989298 | doi = 10.1186/s40413-016-0111-6 | type = Review | doi-access = free }}</ref> such as milk, but there is growing consensus that [[Medicine:Food allergy|food allergy]] most likely arises as a result of skin barrier dysfunction resulting from AD, rather than food allergy causing the skin problems.<ref>{{cite journal | vauthors = Brough HA, Nadeau KC, Sindher SB, Alkotob SS, Chan S, Bahnson HT, Leung DY, Lack G | display-authors = 6 | title = Epicutaneous sensitization in the development of food allergy: What is the evidence and how can this be prevented? | journal = Allergy | volume = 75 | issue = 9 | pages = 2185–2205 | date = September 2020 | pmid = 32249942 | pmc = 7494573 | doi = 10.1111/all.14304 }}</ref> Atopic dermatitis sometimes appears associated with coeliac disease and non-coeliac gluten sensitivity. Because a gluten-free diet (GFD) improves symptoms in these cases, gluten seems to be the cause of AD in these cases.<ref name="FasanoSapone2015">{{cite journal | vauthors = Fasano A, Sapone A, Zevallos V, Schuppan D | title = Nonceliac gluten sensitivity | journal = Gastroenterology | volume = 148 | issue = 6 | pages = 1195–1204 | date = May 2015 | pmid = 25583468 | doi = 10.1053/j.gastro.2014.12.049 | type = Review | doi-access = free | quote = Many patients with celiac disease also have atopic disorders. About 30% of patients' allergies with gastrointestinal (GI) symptoms and mucosal lesions, but negative results from serologic (TG2 antibodies) or genetic tests (DQ2 or DQ8 genotype) for celiac disease, had reduced GI and atopic symptoms when they were placed on GFDs. These findings indicated that their symptoms were related to gluten ingestion. }}</ref><ref name="MansuetoSeidita2014">{{cite journal | vauthors = Mansueto P, Seidita A, D'Alcamo A, Carroccio A | title = Non-celiac gluten sensitivity: literature review | journal = Journal of the American College of Nutrition | volume = 33 | issue = 1 | pages = 39–54 | date = 2014 | pmid = 24533607 | doi = 10.1080/07315724.2014.869996 | hdl-access = free | s2cid = 22521576 | hdl = 10447/90208 | type = Review }}</ref> A diet high in fruits seems to have a protective effect against AD, whereas the opposite seems true for heavily processed foods.<ref name="epid" />

Exposure to [[Biology:Allergen|allergen]]s, either from food or the environment, can exacerbate existing atopic dermatitis.<ref>{{cite journal | vauthors = Williams H, Flohr C | title = How epidemiology has challenged 3 prevailing concepts about atopic dermatitis | journal = The Journal of Allergy and Clinical Immunology | volume = 118 | issue = 1 | pages = 209–213 | date = July 2006 | pmid = 16815157 | doi = 10.1016/j.jaci.2006.04.043 | url = http://eprints.nottingham.ac.uk/861/2/revised_final_rostrum.pdf | access-date = 2019-02-05 | url-status = dead | archive-url = https://web.archive.org/web/20180719092709/http://eprints.nottingham.ac.uk/861/2/revised_final_rostrum.pdf | archive-date = 2018-07-19 }}</ref> Exposure to dust mites, for example, is believed to contribute to the risk of developing AD.<ref>{{cite journal | vauthors = Fuiano N, Incorvaia C | title = Dissecting the causes of atopic dermatitis in children: less foods, more mites | journal = Allergology International | volume = 61 | issue = 2 | pages = 231–243 | date = June 2012 | pmid = 22361514 | doi = 10.2332/allergolint.11-RA-0371 | doi-access = free }}</ref>

===Role of ''Staphylococcus aureus''===
Colonization of the skin by the bacterium ''[[Medicine:Staphylococcus aureus|S. aureus]]'' is extremely prevalent in those with atopic dermatitis.<ref>{{cite journal | vauthors = Goh CL, Wong JS, Giam YC | title = Skin colonization of Staphylococcus aureus in atopic dermatitis patients seen at the National Skin Centre, Singapore | journal = International Journal of Dermatology | volume = 36 | issue = 9 | pages = 653–657 | date = September 1997 | pmid = 9352404 | doi = 10.1046/j.1365-4362.1997.00290.x | s2cid = 3112669 }}</ref> Abnormalities in the skin barrier of persons with AD are exploited by ''S. aureus'' to trigger cytokine expression, thus aggravating the condition.<ref>{{cite journal | vauthors = Nakatsuji T, Chen TH, Two AM, Chun KA, Narala S, Geha RS, Hata TR, Gallo RL | display-authors = 6 | title = Staphylococcus aureus Exploits Epidermal Barrier Defects in Atopic Dermatitis to Trigger Cytokine Expression | journal = The Journal of Investigative Dermatology | volume = 136 | issue = 11 | pages = 2192–2200 | date = November 2016 | pmid = 27381887 | pmc = 5103312 | doi = 10.1016/j.jid.2016.05.127 }}</ref> However, atopic dermatitis is non-communicable and therefore could not be directly caused by a highly [[Medicine:Infection|infectious]] organism. Furthermore, there is insufficient evidence for the effectiveness of anti-staphylococcal treatments for treating ''S. aureus'' in infected or uninfected eczema.<ref name=":4">{{cite journal | vauthors = George SM, Karanovic S, Harrison DA, Rani A, Birnie AJ, Bath-Hextall FJ, Ravenscroft JC, Williams HC | display-authors = 6 | title = Interventions to reduce Staphylococcus aureus in the management of eczema | journal = The Cochrane Database of Systematic Reviews | volume = 2019 | issue = 10 | date = October 2019 | pmid = 31684694 | pmc = 6818407 | doi = 10.1002/14651858.CD003871.pub3 | collaboration = Cochrane Skin Group }}</ref>

=== Hard water ===
The prevalence of atopic dermatitis in children may be linked to the level of [[Chemistry:Calcium carbonate|calcium carbonate]] or "[[Physics:Hard water|hardness]]" of household drinking water.<ref name=Sengupta2013>{{cite journal | vauthors = Sengupta P | title = Potential health impacts of hard water | journal = International Journal of Preventive Medicine | volume = 4 | issue = 8 | pages = 866–875 | date = August 2013 | pmid = 24049611 | pmc = 3775162 | type = Review }}</ref><ref name=":2">{{cite journal | vauthors = Jabbar-Lopez ZK, Ung CY, Alexander H, Gurung N, Chalmers J, Danby S, Cork MJ, Peacock JL, Flohr C | display-authors = 6 | title = The effect of water hardness on atopic eczema, skin barrier function: A systematic review, meta-analysis | journal = Clinical and Experimental Allergy | volume = 51 | issue = 3 | pages = 430–451 | date = March 2021 | pmid = 33259122 | doi = 10.1111/cea.13797 | s2cid = 227245344 }}</ref> Living in areas with hard water may also play a part in the development of AD in early life. However, when AD is already established, using [[Chemistry:Water softening|water softeners]] at home does not reduce the severity of the symptoms.<ref name=":2" />

==Pathophysiology==
Excessive [[Biology:Type 2 inflammation|type 2 inflammation]] underlies the pathophysiology of atopic dermatitis.<ref>{{cite journal | vauthors = Gandhi NA, Bennett BL, Graham NM, Pirozzi G, Stahl N, Yancopoulos GD | title = Targeting key proximal drivers of type 2 inflammation in disease | journal = Nature Reviews. Drug Discovery | volume = 15 | issue = 1 | pages = 35–50 | date = January 2016 | pmid = 26471366 | doi = 10.1038/nrd4624 | s2cid = 2421591 }}</ref><ref>{{cite journal | vauthors = Akdis CA, Arkwright PD, Brüggen MC, Busse W, Gadina M, Guttman-Yassky E, Kabashima K, Mitamura Y, Vian L, Wu J, Palomares O | display-authors = 6 | title = Type 2 immunity in the skin and lungs | journal = Allergy | volume = 75 | issue = 7 | pages = 1582–1605 | date = July 2020 | pmid = 32319104 | doi = 10.1111/all.14318 | doi-access = free }}</ref>

Disruption of the epidermal barrier is thought to play an integral role in the pathogenesis of AD.<ref name="Stander">{{cite journal | vauthors = Ständer S | title = Atopic Dermatitis | journal = The New England Journal of Medicine | volume = 384 | issue = 12 | pages = 1136–1143 | date = March 2021 | pmid = 33761208 | doi = 10.1056/NEJMra2023911 | s2cid = 232355341 }}</ref> Disruptions of the epidermal barrier allows allergens to penetrate the epidermis to deeper layers of the skin. This leads to activation of [[Biology:Dendritic cell|epidermal inflammatory dendritic]] and [[Biology:Innate lymphoid cell|innate lymphoid cell]]s which subsequently attracts [[Biology:T helper cell|Th2 CD4+ helper T cells]] to the skin.<ref name="Stander" /> This dysregulated Th2 inflammatory response is thought to lead to the eczematous lesions.<ref name="Stander" /> The Th2 helper T cells become activated, leading to the release of inflammatory cytokines including [[Biology:Interleukin 4|IL-4]], IL-13 and IL-31 which activate downstream [[Biology:Janus kinase|Janus kinase (Jak)]] pathways. The active Jak pathways lead to inflammation and downstream activation of plasma cells and B lymphocytes which release antigen specific IgE contributing to further inflammation.<ref name="Stander" /> Other CD4+ helper T-cell pathways thought to be involved in atopic dermatitis inflammation include the Th1, [[Biology:T helper 17 cell|Th17]], and Th22 pathways.<ref name="Stander" /> Some specific CD4+ helper T-cell inflammatory pathways are more commonly activated in specific ethnic groups with AD (for example, the Th-2 and Th-17 pathways are commonly activated in Asian people) possibly explaining the differences in phenotypic presentation of atopic dermatitis in specific populations.<ref name="Stander" />

Mutations in the filaggrin gene, ''FLG'', also cause impairment in the skin barrier that contributes to the pathogenesis of AD.<ref name="Stander" /> Filaggrin is produced by epidermal skin cells (keratinocytes) in the [[Biology:Stratum corneum|horny layer]] of the epidermis. Filaggrin stimulates skin cells to release moisturizing factors and lipid matrix material, which cause adhesion of adjacent keratinocytes and contributes to the skin barrier.<ref name="Stander" /> A loss-of-function mutation of filaggrin causes loss of this lipid matrix and external moisturizing factors, subsequently leading to disruption of the skin barrier. The disrupted skin barrier leads to transdermal water loss (leading to the xerosis or dry skin commonly seen in AD) and antigen and allergen penetration of the epidermal layer.<ref name="Stander" /> Filaggrin mutations are also associated with a decrease in natural antimicrobial peptides found on the skin; subsequently leading to disruption of skin flora and bacterial overgrowth (commonly ''[[Medicine:Staphylococcus aureus|Staphylococcus aureus]]'' overgrowth or colonization).<ref name="Stander" />

Atopic dermatitis is also associated with the release of pruritogens (molecules that stimulate pruritus or itching) in the skin.<ref name="Stander" /> Keratinocytes, [[Biology:Mast cell|mast cell]]s, [[Biology:Eosinophil|eosinophil]]s and [[Biology:T cell|T-cells]] release pruritogens in the skin; leading to activation of [[Biology:Group A nerve fiber|Aδ fibers]] and [[Biology:Group C nerve fiber|Group C nerve fiber]]s in the [[Biology:Epidermis|epidermis]] and [[Biology:Dermis|dermis]] contributing to sensations of pruritus and pain.<ref name="Stander" /> The pruritogens include the Th2 cytokines IL-4, IL-13, IL-31, histamine, and various neuropeptides.<ref name="Stander" /> Mechanical stimulation from scratching lesions can also lead to the release of pruritogens contributing to the itch-scratch cycle whereby there is increased pruritus or itch after scratching a lesion.<ref name="Stander" /> Chronic scratching of lesions can cause thickening or lichenification of the skin or prurigo nodularis (generalized nodules that are severely itchy).<ref name="Stander" />

== Diagnosis ==
AD is typically diagnosed clinically, meaning it is based on signs and symptoms alone, without special testing.<ref name="EichenfieldSec1">{{cite journal | vauthors = Eichenfield LF, Tom WL, Chamlin SL, Feldman SR, Hanifin JM, Simpson EL, Berger TG, Bergman JN, Cohen DE, Cooper KD, Cordoro KM, Davis DM, Krol A, Margolis DJ, Paller AS, Schwarzenberger K, Silverman RA, Williams HC, Elmets CA, Block J, Harrod CG, Smith Begolka W, Sidbury R | display-authors = 6 | title = Guidelines of care for the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis | journal = Journal of the American Academy of Dermatology | volume = 70 | issue = 2 | pages = 338–351 | date = February 2014 | pmid = 24290431 | pmc = 4410183 | doi = 10.1016/j.jaad.2013.10.010 }}</ref> Several different criteria developed for research have also been validated to aid in diagnosis.<ref name=":0">{{cite journal | vauthors = Brenninkmeijer EE, Schram ME, Leeflang MM, Bos JD, Spuls PI | title = Diagnostic criteria for atopic dermatitis: a systematic review | journal = The British Journal of Dermatology | volume = 158 | issue = 4 | pages = 754–765 | date = April 2008 | pmid = 18241277 | doi = 10.1111/j.1365-2133.2007.08412.x | s2cid = 453564 | doi-access = free }}</ref> Of these, the UK Diagnostic Criteria, based on the work of Hanifin and Rajka, has been the most widely validated.<ref name=":0" /><ref name=":1">{{cite journal | vauthors = Williams HC, Burney PG, Pembroke AC, Hay RJ | title = The U.K. Working Party's Diagnostic Criteria for Atopic Dermatitis. III. Independent hospital validation | journal = The British Journal of Dermatology | volume = 131 | issue = 3 | pages = 406–416 | date = September 1994 | pmid = 7918017 | doi = 10.1111/j.1365-2133.1994.tb08532.x | s2cid = 37406163 }}</ref>
{| class="wikitable"
|+UK diagnostic criteria<ref name=":1" />
!People must have itchy skin, or evidence of rubbing or scratching, plus three or more of:
|-
|Skin creases are involved - flexural dermatitis of fronts of ankles, antecubital fossae, popliteal fossae, skin around eyes, or neck, (or cheeks for children under 10)
|-
|History of [[Medicine:Asthma|asthma]] or [[Medicine:Allergic rhinitis|allergic rhinitis]] (or family history of these conditions if patient is a child ≤4 years old)
|-
|Symptoms began before age 2 (can only be applied to patients ≥4 years old)
|-
|History of dry skin (within the past year)
|-
|[[Medicine:Dermatitis|Dermatitis]] is visible on flexural surfaces (patients ≥age 4) or on the cheeks, forehead, and extensor surfaces (patients<age 4)
|}
Other diseases that must be excluded before making a diagnosis include contact dermatitis, [[Medicine:Psoriasis|psoriasis]], and seborrheic dermatitis.<ref name="Toll2014" />

== Treatments ==
No cure for AD is known, although treatments may reduce the severity and frequency of flares.<ref name = AFP/> The most commonly used topical treatments for AD are topical corticosteroids (to get control of flare-ups) and moisturisers (emollients) to help keep control.<ref>{{Cite web |title=What are Topical Treatments for Eczema and How Should They Be Used? |url=https://nationaleczema.org/eczema/treatment/topicals/ |access-date=2023-06-22 |website=National Eczema Association |language=en-US}}</ref> Clinical trials often measure the efficacy of treatments with a severity scale such as the SCORAD index or the Eczema Area and Severity Index.<ref name="EichenfieldSec1" /><ref>{{Cite journal |last1=Chopra |first1=Rishi |last2=Silverberg |first2=Jonathan I. |date=2018 |title=Assessing the severity of atopic dermatitis in clinical trials and practice |url=https://www.sciencedirect.com/science/article/pii/S0738081X1830141X |journal=Clinics in Dermatology |series=Atopic Dermatits: Part II |volume=36 |issue=5 |pages=606–615 |doi=10.1016/j.clindermatol.2018.05.012 |pmid=30217273 |s2cid=52277845 |issn=0738-081X}}</ref>

=== Moisturisers ===
Daily basic care is intended to stabilize the barrier function of the skin to mitigate its sensitivity to irritation and penetration of allergens. Affected persons often report that improvement of skin hydration parallels with improvement in AD symptoms. Moisturisers (or emollients) can improve skin comfort and may reduce disease flares.<ref>{{cite journal | vauthors = Ridd MJ, Roberts A, Grindlay D, Williams HC | title = Which emollients are effective and acceptable for eczema in children? | journal = BMJ | volume = 367 | pages = l5882 | date = October 2019 | pmid = 31649114 | doi = 10.1136/bmj.l5882 | hdl = 1983/2c0e2127-710c-46a9-bd5c-89574b11c9ee | s2cid = 204882682 | url = https://research-information.bris.ac.uk/ws/files/219950607/bmj.l5882.full.pdf }}</ref> They can be used as leave-on treatments, bath additives or [[Chemistry:Soap substitute|soap substitute]]s. There are many different products but the majority of leave-on treatments (least to most greasy) are [[Medicine:Lotion|lotion]]s, [[Medicine:Cream (pharmacy)|creams]], [[Physics:Gel|gel]]s or [[Medicine:Topical medication|ointments]]. None of the different types of moisturisers are more effective than the others so people need to choose one or more products that suit them, according to their age, body site effected, climate/season and personal preference.<ref name=":5">{{cite journal |display-authors=6 |vauthors=Ridd MJ, Santer M, MacNeill SJ, Sanderson E, Wells S, Webb D, Banks J, Sutton E, Roberts A, Liddiard L, Wilkins Z, Clayton J, Garfield K, Barrett TJ, Lane JA, Baxter H, Howells L, Taylor J, Hay AD, Williams HC, Thomas KS |date=August 2022 |title=Effectiveness and safety of lotion, cream, gel, and ointment emollients for childhood eczema: a pragmatic, randomised, phase 4, superiority trial |journal=The Lancet. Child & Adolescent Health |volume=6 |issue=8 |pages=522–532 |doi=10.1016/S2352-4642(22)00146-8 |pmid=35617974 |s2cid=249024141|doi-access=free |hdl=1983/e4009d3c-127f-4aa9-bf71-e40401b33eee |hdl-access=free }}</ref> Non-medicated prescription moisturisers may also be no more effective than [[Medicine:Over-the-counter drug|over-the-counter]] moisturisers.<ref name=":10">{{Cite journal |last1=Chu |first1=Derek K. |last2=Chu |first2=Alexandro W. L. |last3=Rayner |first3=Daniel G. |last4=Guyatt |first4=Gordon H. |last5=Yepes-Nuñez |first5=Juan José |title=Topical treatments for atopic dermatitis (eczema): Systematic review and network meta-analysis of randomized trials |url=https://www.jacionline.org/article/S0091-6749(23)01113-2/fulltext |journal=The Journal of Allergy and Clinical Immunology |date=2023 |volume=152 |issue=6 |pages=1493–1519 |doi=10.1016/j.jaci.2023.08.030 |issn=1097-6825 |pmid=37678572|s2cid=261610152 }}</ref>

There is no evidence that the additional use of emollient bath additives is beneficial.<ref>{{cite journal | vauthors = Santer M, Ridd MJ, Francis NA, Stuart B, Rumsby K, Chorozoglou M, Becque T, Roberts A, Liddiard L, Nollett C, Hooper J, Prude M, Wood W, Thomas KS, Thomas-Jones E, Williams HC, Little P | display-authors = 6 | title = Emollient bath additives for the treatment of childhood eczema (BATHE): multicentre pragmatic parallel group randomised controlled trial of clinical and cost effectiveness | journal = BMJ | volume = 361 | pages = k1332 | date = May 2018 | pmid = 29724749 | pmc = 5930266 | doi = 10.1136/bmj.k1332 }}</ref>

===Medication===

==== Topical ====
Corticosteroids applied directly on skin ([[Chemistry:Topical steroid|topical]]) have proven effective in managing atopic dermatitis.<ref name="AFP" /><ref name="MSR" /><ref name=":10" /><ref name=":3">{{cite journal | vauthors = Lax SJ, Harvey J, Axon E, Howells L, Santer M, Ridd MJ, Lawton S, Langan S, Roberts A, Ahmed A, Muller I, Ming LC, Panda S, Chernyshov P, Carter B, Williams HC, Thomas KS, Chalmers JR | display-authors = 6 | title = Strategies for using topical corticosteroids in children and adults with eczema | journal = The Cochrane Database of Systematic Reviews | volume = 2022 | issue = 3 | pages = CD013356 | date = March 2022 | pmid = 35275399 | pmc = 8916090 | doi = 10.1002/14651858.CD013356.pub2 | collaboration = Cochrane Skin Group }}</ref> Newer (second generation) corticosteroids, such as [[Chemistry:Fluticasone propionate|fluticasone propionate]] and [[Biology:Mometasone|mometasone furoate]], are more effective and safer than older ones. Strong and moderate corticosteroids work better than weaker ones. They are also generally safe when used in intermittent bursts to treat AD flare-ups. Applying once daily is as effective as twice or more daily application.<ref name=":10" /><ref name=":3" />

In addition to topical corticosteroids, topical calcineurin inhibitors such as [[Chemistry:Tacrolimus|tacrolimus]] or [[Chemistry:Pimecrolimus|pimecrolimus]] are also recommended as first-line therapies for managing atopic dermatitis.<ref name=":10" /><ref name=":11">{{Cite journal |last1=AAAAI/ACAAI JTF Atopic Dermatitis Guideline Panel |last2=Chu |first2=Derek K. |last3=Schneider |first3=Lynda |last4=Asiniwasis |first4=Rachel Netahe |last5=Boguniewicz |first5=Mark |date= 2023|title=Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine-based recommendations |journal=Annals of Allergy, Asthma & Immunology|pages=S1081–1206(23)01455–2 |doi=10.1016/j.anai.2023.11.009 |issn=1534-4436 |pmid=38108679|doi-access=free }}</ref> Both tacrolimus and pimecrolimus are effective and safe to use in AD.<ref>{{cite journal | vauthors = Cury Martins J, Martins C, Aoki V, Gois AF, Ishii HA, da Silva EM | title = Topical tacrolimus for atopic dermatitis | journal = The Cochrane Database of Systematic Reviews | volume = 2015 | issue = 7 | pages = CD009864 | date = July 2015 | pmid = 26132597 | pmc = 6461158 | doi = 10.1002/14651858.CD009864.pub2 }}</ref><ref>{{cite journal | vauthors = Devasenapathy N, Chu A, Wong M, Srivastava A, Ceccacci R, Lin C, MacDonald M, Wen A, Steen J, Levine M, Pyne L, Schneider L, Chu DK | display-authors = 6 | title = Cancer risk with topical calcineurin inhibitors, pimecrolimus and tacrolimus, for atopic dermatitis: a systematic review and meta-analysis | journal = The Lancet. Child & Adolescent Health | volume = 7 | issue = 1 | pages = 13–25 | date = January 2023 | pmid = 36370744 | doi = 10.1016/S2352-4642(22)00283-8 | s2cid = 253470127 }}</ref> [[Biology:Crisaborole|Crisaborole]], an inhibitor of PDE-4, is also effective and safe as a topical treatment for mild-to-moderate AD.<ref>{{cite journal | vauthors = McDowell L, Olin B | title = Crisaborole: A Novel Nonsteroidal Topical Treatment for Atopic Dermatitis | journal = The Journal of Pharmacy Technology | volume = 35 | issue = 4 | pages = 172–178 | date = August 2019 | pmid = 34861031 | pmc = 6600556 | doi = 10.1177/8755122519844507 }}</ref><ref>{{Cite journal | vauthors = He Y, Liu J, Wang Y, Kuai W, Liu R, Wu J |date=2023-02-06 | veditors = Pimpinelli N |title=Topical Administration of Crisaborole in Mild to Moderate Atopic Dermatitis: A Systematic Review and Meta-Analysis |journal=Dermatologic Therapy |language=en |volume=2023 |pages=1–9 |doi=10.1155/2023/1869934 |issn=1529-8019|doi-access=free }}</ref> [[Chemistry:Ruxolitinib|Ruxolitinib]], a Janus kinase inhibitor, has uncertain efficacy and safety.<ref name=":10" /><ref name=":11" />

==== Systemic ====
Oral medications used for AD include systemic [[Chemistry:Immunosuppressive drug|immunosuppressants]] such as [[Chemistry:Ciclosporin|ciclosporin]], [[Chemistry:Methotrexate|methotrexate]], interferon gamma-1b, mycophenolate mofetil, and [[Chemistry:Azathioprine|azathioprine]].<ref name="AFP" /><ref>{{cite journal | vauthors = Yarbrough KB, Neuhaus KJ, Simpson EL | title = The effects of treatment on itch in atopic dermatitis | journal = Dermatologic Therapy | volume = 26 | issue = 2 | pages = 110–119 | date = March–April 2013 | pmid = 23551368 | pmc = 4524501 | doi = 10.1111/dth.12032 }}</ref> [[Chemistry:Antidepressant|Antidepressant]]s and [[Chemistry:Naltrexone|naltrexone]] may be used to control pruritus (itchiness).<ref>{{cite journal | vauthors = Kim K | title = Neuroimmunological mechanism of pruritus in atopic dermatitis focused on the role of serotonin | journal = Biomolecules & Therapeutics | volume = 20 | issue = 6 | pages = 506–512 | date = November 2012 | pmid = 24009842 | pmc = 3762292 | doi = 10.4062/biomolther.2012.20.6.506 }}</ref> Leukotriene inhibitors such as [[Chemistry:Montelukast|montelukast]] are of unclear benefit as of 2018.<ref>{{cite journal | vauthors = Chin WK, Lee SW | title = A systematic review on the off-label use of montelukast in atopic dermatitis treatment | journal = International Journal of Clinical Pharmacy | volume = 40 | issue = 5 | pages = 963–976 | date = October 2018 | pmid = 29777328 | doi = 10.1007/s11096-018-0655-3 | s2cid = 21753181 }}</ref><ref>{{cite journal | vauthors = Ferguson L, Futamura M, Vakirlis E, Kojima R, Sasaki H, Roberts A, Mori R | title = Leukotriene receptor antagonists for eczema | journal = The Cochrane Database of Systematic Reviews | volume = 2018 | issue = 10 | pages = CD011224 | date = October 2018 | pmid = 30343498 | pmc = 6517006 | doi = 10.1002/14651858.cd011224.pub2 }}</ref>

In 2017, the [[Biology:Monoclonal antibody|monoclonal antibody]](mAb) [[Chemistry:Dupilumab|dupilumab]] under the trade name Dupixent was approved to treat moderate-to-severe eczema.<ref name="FDA-Dupilumab">{{cite web |date=28 March 2017 |title=FDA approves new eczema drug Dupixent |url=https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm549078.htm |url-status=live |archive-url=https://web.archive.org/web/20170328204026/https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm549078.htm |archive-date=28 March 2017 |access-date=29 March 2017 |publisher=US Food & Drug Administration}}</ref>
In 2021, an additional monoclonal antibody, [[Chemistry:Tralokinumab|tralokinumab]], was approved in the EU & UK with the trade name Adtralza then later in the US as Adbry for similarly severe cases.<ref name="Adtralza EPAR">{{cite web |date=20 April 2021 |title=Adtralza EPAR |url=https://www.ema.europa.eu/en/medicines/human/EPAR/adtralza |access-date=9 July 2021 |website=[[Organization:European Medicines Agency|European Medicines Agency]] (EMA)}} Text was copied from this source which is © European Medicines Agency. Reproduction is authorized provided the source is acknowledged.</ref><ref name="FDA-Adbry">{{cite web |date=December 27, 2021 |title=Drug Approval Package: ADBRY |url=https://www.accessdata.fda.gov/drugsatfda_docs/nda/2022/761180Orig1s000TOC.cfm |access-date=March 6, 2022 |publisher=US Food & Drug Administration}}</ref> As of 2023, another monoclonal antibody treatment, [[Chemistry:Lebrikizumab|lebrikizumab]], is awaiting approval in the US and Europe.<ref>{{Cite web |date=2022-10-28 |title=Almirall granted EMA approval for lebrikizumab in atopic dermatitis |url=https://www.pmlive.com/pharma_news/almirall_granted_ema_approval_for_lebrikizumab_in_atopic_dermatitis_1479922 |access-date=2023-03-05 |website=PMLive |language=en}}</ref><ref>{{Cite web |title=Eli Lilly Submits BLA for Lebrikizumab AD Treatment |url=https://www.dermatologytimes.com/view/eli-lilly-submits-bla-for-lebrikizumab-ad-treatment |access-date=2023-03-05 |website=Dermatology Times |date=9 November 2022 |language=en}}</ref> These monoclonal antibodies are highly effective for managing atopic dermatitis, but modestly increase the risk of [[Medicine:Conjunctivitis|conjunctivitis]].<ref name=":11" /><ref name=":12">{{Cite journal |last1=Chu |first1=Alexandro W. L. |last2=Wong |first2=Melanie M. |last3=Rayner |first3=Daniel G. |last4=Guyatt |first4=Gordon H. |last5=Díaz Martinez |first5=Juan Pablo |title=Systemic treatments for atopic dermatitis (eczema): Systematic review and network meta-analysis of randomized trials |journal=The Journal of Allergy and Clinical Immunology |date=2023 |volume=152 |issue=6 |pages=1470–1492 |doi=10.1016/j.jaci.2023.08.029 |issn=1097-6825 |pmid=37678577|doi-access=free }}</ref>

Some JAK inhibitors such as [[Chemistry:Abrocitinib|abrocitinib]], trade name Cibinqo,<ref>{{cite press release |title=U.S. FDA Approves Pfizer's Cibinqo (abrocitinib) for Adults with Moderate-to-Severe Atopic Dermatitis |website=Pfizer Inc. |date=14 January 2022 |url=https://www.pfizer.com/news/press-release/press-release-detail/us-fda-approves-pfizers-cibinqor-abrocitinib-adults |access-date=16 January 2022}}</ref> and [[Chemistry:Upadacitinib|upadacitinib]], trade name Rinvoq,<ref>{{cite press release |url=https://news.abbvie.com/news/press-releases/us-fda-approves-rinvoq-upadacitinib-to-treat-adults-and-children-12-years-and-older-with-refractory-moderate-to-severe-atopic-dermatitis.htm |title=U.S. FDA Approves RINVOQ® (upadacitinib) to Treat Adults and Children 12 Years and Older with Refractory, Moderate to Severe Atopic Dermatitis |website=AbbeVie |access-date=March 6, 2022}}</ref> have been approved in the US for the treatment of moderate-to-severe eczema as of January 2022. These treatments are among the most effective systemic treatments, but have uncertain serious harms.<ref name=":11" /><ref name=":12" />

Allergen immunotherapy may be effective in relieving symptoms of AD but it also comes with an increased risk of [[Medicine:Adverse event|adverse event]]s.<ref>{{cite journal | vauthors = Yepes-Nuñez JJ, Guyatt GH, Gómez-Escobar LG, Pérez-Herrera LC, Chu AW, Ceccaci R, Acosta-Madiedo AS, Wen A, Moreno-López S, MacDonald M, Barrios M, Chu X, Islam N, Gao Y, Wong MM, Couban R, Garcia E, Chapman E, Oykhman P, Chen L, Winders T, Asiniwasis RN, Boguniewicz M, De Benedetto A, Ellison K, Frazier WT, Greenhawt M, Huynh J, Kim E, LeBovidge J, Lind ML, Lio P, Martin SA, O'Brien M, Ong PY, Silverberg JI, Spergel J, Wang J, Wheeler KE, Schneider L, Chu DK | display-authors = 6 | title = Allergen immunotherapy for atopic dermatitis: Systematic review and meta-analysis of benefits and harms | journal = The Journal of Allergy and Clinical Immunology | volume = 151 | issue = 1 | pages = 147–158 | date = January 2023 | pmid = 36191689 | doi = 10.1016/j.jaci.2022.09.020 | s2cid = 252656283 | doi-access = free }}</ref> This treatment consists of a series of injections or drops under the tongue of a solution containing the allergen.<ref name="Tam2016">{{cite journal | vauthors = Tam H, Calderon MA, Manikam L, Nankervis H, García Núñez I, Williams HC, Durham S, Boyle RJ | display-authors = 6 | title = Specific allergen immunotherapy for the treatment of atopic eczema | journal = The Cochrane Database of Systematic Reviews | volume = 2016 | issue = 2 | pages = CD008774 | date = February 2016 | pmid = 26871981 | pmc = 8761476 | doi = 10.1002/14651858.CD008774.pub2 | hdl-access = free | hdl = 10044/1/31818 }}</ref>

Antibiotics, either by mouth or applied topically, are commonly used to target overgrowth of ''S. aureus'' in the skin of people with AD, but there is insufficient evidence for the effectiveness of anti-staphylococcal treatments for treating ''S. aureus'' in infected or uninfected eczema.<ref name=":4" />

===Diet===
The role of [[Chemistry:Vitamin D|vitamin D]] on atopic dermatitis is not clear, but vitamin D supplementation may improve its symptoms.<ref name="DebinskaSikorskaSzaflik2015">{{cite journal | vauthors = Dębińska A, Sikorska-Szaflik H, Urbanik M, Boznański A | title = The role of vitamin D in atopic dermatitis | journal = Dermatitis | volume = 26 | issue = 4 | pages = 155–161 | year = 2015 | pmid = 26172483 | doi = 10.1097/DER.0000000000000128 | type = Review | s2cid = 35345939 }}</ref><ref name="KimBae2016">{{cite journal | vauthors = Kim G, Bae JH | title = Vitamin D and atopic dermatitis: A systematic review and meta-analysis | journal = Nutrition | volume = 32 | issue = 9 | pages = 913–920 | date = September 2016 | pmid = 27061361 | doi = 10.1016/j.nut.2016.01.023 | type = Systematic Review and Meta-Analysis }}</ref><ref>{{cite journal | vauthors = Hattangdi-Haridas SR, Lanham-New SA, Wong WH, Ho MH, Darling AL | title = Vitamin D Deficiency and Effects of Vitamin D Supplementation on Disease Severity in Patients with Atopic Dermatitis: A Systematic Review and Meta-Analysis in Adults and Children | journal = Nutrients | volume = 11 | issue = 8 | pages = 1854 | date = August 2019 | pmid = 31405041 | pmc = 6722944 | doi = 10.3390/nu11081854 | doi-access = free }}</ref>

There is no clear benefit for pregnant mothers taking [[Chemistry:Omega-3 fatty acid|omega 3 long-chain polyunsaturated fatty acid]] (LCPUFA) in preventing the development of AD in their child.<ref>{{cite journal | vauthors = Venter C, Agostoni C, Arshad SH, Ben-Abdallah M, Du Toit G, Fleischer DM, Greenhawt M, Glueck DH, Groetch M, Lunjani N, Maslin K, Maiorella A, Meyer R, Antonella M, Netting MJ, Ibeabughichi Nwaru B, Palmer DJ, Palumbo MP, Roberts G, Roduit C, Smith P, Untersmayr E, Vanderlinden LA, O'Mahony L | display-authors = 6 | title = Dietary factors during pregnancy and atopic outcomes in childhood: A systematic review from the European Academy of Allergy and Clinical Immunology | journal = Pediatric Allergy and Immunology | volume = 31 | issue = 8 | pages = 889–912 | date = November 2020 | pmid = 32524677 | pmc = 9588404 | doi = 10.1111/pai.13303 | veditors = Peters R }}</ref><ref>{{cite journal | vauthors = Trikamjee T, Comberiati P, D'Auria E, Peroni D, Zuccotti GV | title = Nutritional Factors in the Prevention of Atopic Dermatitis in Children | journal = Frontiers in Pediatrics | volume = 8 | pages = 577413 | date = 2021-01-12 | pmid = 33585361 | pmc = 7874114 | doi = 10.3389/fped.2020.577413 | doi-access = free }}</ref>

Several probiotics seem to have a positive effect, with a roughly 20% reduction in the rate of AD.<ref>{{cite journal | vauthors = Makrgeorgou A, Leonardi-Bee J, Bath-Hextall FJ, Murrell DF, Tang ML, Roberts A, Boyle RJ | title = Probiotics for treating eczema | journal = The Cochrane Database of Systematic Reviews | volume = 2018 | issue = 11 | pages = CD006135 | date = November 2018 | pmid = 30480774 | pmc = 6517242 | doi = 10.1002/14651858.CD006135.pub3 }}</ref><ref>{{cite journal | vauthors = Rusu E, Enache G, Cursaru R, Alexescu A, Radu R, Onila O, Cavallioti T, Rusu F, Posea M, Jinga M, Radulian G | display-authors = 6 | title = Prebiotics and probiotics in atopic dermatitis | journal = Experimental and Therapeutic Medicine | volume = 18 | issue = 2 | pages = 926–931 | date = August 2019 | pmid = 31384325 | pmc = 6639913 | doi = 10.3892/etm.2019.7678 }}</ref><ref>{{cite journal | vauthors = Umborowati MA, Damayanti D, Anggraeni S, Endaryanto A, Surono IS, Effendy I, Prakoeswa CR | title = The role of probiotics in the treatment of adult atopic dermatitis: a meta-analysis of randomized controlled trials | journal = Journal of Health, Population, and Nutrition | volume = 41 | issue = 1 | pages = 37 | date = August 2022 | pmid = 35978397 | pmc = 9386980 | doi = 10.1186/s41043-022-00318-6 | doi-access = free }}</ref> Probiotics containing multiple [[Biology:Strain|strains]] of bacteria seem to work the best.<ref>{{cite journal | vauthors = Chang YS, Trivedi MK, Jha A, Lin YF, Dimaano L, García-Romero MT | title = Synbiotics for Prevention and Treatment of Atopic Dermatitis: A Meta-analysis of Randomized Clinical Trials | journal = JAMA Pediatrics | volume = 170 | issue = 3 | pages = 236–242 | date = March 2016 | pmid = 26810481 | doi = 10.1001/jamapediatrics.2015.3943 | doi-access = free }}</ref>

In people with celiac disease or nonceliac gluten sensitivity, a gluten-free diet improves their symptoms and prevents the occurrence of new outbreaks.<ref name="FasanoSapone2015" /><ref name="MansuetoSeidita2014" />

Use of blood specific [[Biology:Immunoglobulin E|IgE]] or skin prick tests to guide dietary exclusions with the aim of improving disease severity or control is controversial. Clinicians vary in their use of these tests for this purpose and there are very limited evidence of any benefit.<ref>{{cite journal | vauthors = Roberts K, Gilbertson A, Dawson S, Turner N, Ridd MJ | title = Test-guided dietary exclusions for treating established atopic dermatitis in children: A systematic review | journal = Clinical and Experimental Allergy | volume = 52 | issue = 3 | pages = 442–446 | date = March 2022 | pmid = 34862822 | doi = 10.1111/cea.14072 | hdl = 1983/693f4124-283d-4a11-adb3-21e1916330be | s2cid = 244872550 | url = https://research-information.bris.ac.uk/en/publications/693f4124-283d-4a11-adb3-21e1916330be | hdl-access = free }}</ref>

===Lifestyle===
Health professionals often recommend that people with AD bathe regularly in lukewarm baths, especially in salt water, to moisten their skin.<ref name="MSR" /><ref name="NP">{{cite journal | vauthors = Lio PA | title = Non-pharmacologic therapies for atopic dermatitis | journal = Current Allergy and Asthma Reports | volume = 13 | issue = 5 | pages = 528–538 | date = October 2013 | pmid = 23881511 | doi = 10.1007/s11882-013-0371-y | s2cid = 40875822 }}</ref> Dilute [[Chemistry:Sodium hypochlorite washes|bleach baths]] may be helpful for people with moderate and severe eczema, but only for patients with Staphylococcus aureus.<ref>{{cite journal | vauthors = Bakaa L, Pernica JM, Couban RJ, Tackett KJ, Burkhart CN, Leins L, Smart J, Garcia-Romero MT, Elizalde-Jiménez IG, Herd M, Asiniwasis RN, Boguniewicz M, De Benedetto A, Chen L, Ellison K, Frazier W, Greenhawt M, Huynh J, LeBovidge J, Lind ML, Lio P, O'Brien M, Ong PY, Silverberg JI, Spergel JM, Wang J, Begolka WS, Schneider L, Chu DK | display-authors = 6 | title = Bleach baths for atopic dermatitis: A systematic review and meta-analysis including unpublished data, Bayesian interpretation, and GRADE | journal = Annals of Allergy, Asthma & Immunology | volume = 128 | issue = 6 | pages = 660–668.e9 | date = June 2022 | pmid = 35367346 | doi = 10.1016/j.anai.2022.03.024 | s2cid = 247847598 | doi-access = free }}</ref>

Avoiding [[Physics:Woolen|woolen]] clothing or scratchy fibres is usually recommended for people with AD as they can trigger a flare.<ref>{{cite journal | vauthors = Jaros J, Wilson C, Shi VY | title = Fabric Selection in Atopic Dermatitis: An Evidence-Based Review | journal = American Journal of Clinical Dermatology | volume = 21 | issue = 4 | pages = 467–482 | date = August 2020 | pmid = 32440827 | doi = 10.1007/s40257-020-00516-0 | s2cid = 218761019 }}</ref><ref>{{Cite web |date=2020-02-11 |title=Clothing and eczema |url=https://eczema.org/information-and-advice/triggers-for-eczema/clothing-and-eczema/ |access-date=2023-04-10 |website=National Eczema Society |language=en}}</ref>

=== Self-management ===
Treatment regimens can be confusing and written action plans may support people to know what treatments to use where and when.<ref>{{Cite journal | vauthors = Thandi CS, Constantinou S, Vincent R, Ridd MJ |date=2023-03-22 |title=Where and how have written action plans for atopic eczema/dermatitis been developed and evaluated? Systematic review |journal=Skin Health and Disease |volume=3 |issue=3 |pages=e213 |language=en |doi=10.1002/ski2.213 |pmid=37275422 |pmc=10233085 |s2cid=257729897 |issn=2690-442X}}</ref>

A website supporting self-management has been shown to improve AD symptoms for parents, children, adolescents and young adults.<ref>{{Cite journal |date=2023-04-11 |title=Online support improved eczema symptoms in children and young people |url=https://evidence.nihr.ac.uk/alert/online-support-improved-eczema-symptoms-in-children-and-young-people/ |journal=NIHR Evidence |type=Plain English summary |language=en |publisher=National Institute for Health and Care Research |doi=10.3310/nihrevidence_57579|s2cid=258094184 }}</ref><ref>{{cite journal | vauthors = Santer M, Muller I, Becque T, Stuart B, Hooper J, Steele M, Wilczynska S, Sach TH, Ridd MJ, Roberts A, Ahmed A, Yardley L, Little P, Greenwell K, Sivyer K, Nuttall J, Griffiths G, Lawton S, Langan SM, Howells LM, Leighton P, Williams HC, Thomas KS | display-authors = 6 | title = Eczema Care Online behavioural interventions to support self-care for children and young people: two independent, pragmatic, randomised controlled trials | journal = BMJ | volume = 379 | pages = e072007 | date = December 2022 | pmid = 36740888 | doi = 10.1136/bmj-2022-072007 | s2cid = 254367009 | hdl = 1983/6003736c-fa64-47a6-9ca7-984ba6a3bad1 | hdl-access = free }}</ref>

===Light===
Phototherapic treatment involves exposure to broad- or narrow-band [[Physics:Ultraviolet|ultraviolet]] (UV) light. UV radiation exposure has been found to have a localized immunomodulatory effect on affected tissues and may be used to decrease the severity and frequency of flares.<ref>{{cite journal | vauthors = Tintle S, Shemer A, Suárez-Fariñas M, Fujita H, Gilleaudeau P, Sullivan-Whalen M, Johnson-Huang L, Chiricozzi A, Cardinale I, Duan S, Bowcock A, Krueger JG, Guttman-Yassky E | display-authors = 6 | title = Reversal of atopic dermatitis with narrow-band UVB phototherapy and biomarkers for therapeutic response | journal = The Journal of Allergy and Clinical Immunology | volume = 128 | issue = 3 | pages = 583–93.e1–4 | date = September 2011 | pmid = 21762976 | pmc = 3448950 | doi = 10.1016/j.jaci.2011.05.042 }}</ref><ref>{{cite journal | vauthors = Beattie PE, Finlan LE, Kernohan NM, Thomson G, Hupp TR, Ibbotson SH | title = The effect of ultraviolet (UV) A1, UVB and solar-simulated radiation on p53 activation and p21 | journal = The British Journal of Dermatology | volume = 152 | issue = 5 | pages = 1001–1008 | date = May 2005 | pmid = 15888160 | doi = 10.1111/j.1365-2133.2005.06557.x | s2cid = 22191753 }}</ref> Among the different types of phototherapies only narrowband (NB) ultraviolet B (UVB) exposure might help with the severity of AD and ease itching.<ref name=":12" /><ref>{{cite journal | vauthors = Musters AH, Mashayekhi S, Harvey J, Axon E, Lax SJ, Flohr C, Drucker AM, Gerbens L, Ferguson J, Ibbotson S, Dawe RS, Garritsen F, Brouwer M, Limpens J, Prescott LE, Boyle RJ, Spuls PI | display-authors = 6 | title = Phototherapy for atopic eczema | journal = The Cochrane Database of Systematic Reviews | volume = 10 | issue = 10 | pages = CD013870 | date = October 2021 | pmid = 34709669 | pmc = 8552896 | doi = 10.1002/14651858.CD013870.pub2 | collaboration = Cochrane Skin Group }}</ref> However, UV radiation has also been implicated in various types of skin cancer, and thus UV treatment is not without risk.<ref>{{cite journal | vauthors = Jans J, Garinis GA, Schul W, van Oudenaren A, Moorhouse M, Smid M, Sert YG, van der Velde A, Rijksen Y, de Gruijl FR, van der Spek PJ, Yasui A, Hoeijmakers JH, Leenen PJ, van der Horst GT | display-authors = 6 | title = Differential role of basal keratinocytes in UV-induced immunosuppression and skin cancer | journal = Molecular and Cellular Biology | volume = 26 | issue = 22 | pages = 8515–8526 | date = November 2006 | pmid = 16966369 | pmc = 1636796 | doi = 10.1128/MCB.00807-06 }}</ref> UV phototherapy is not indicated in young adults and children due to this risk of skin cancer with prolonged use or exposure.<ref name="Stander" />

=== Alternative medicine ===
While several Chinese herbal medicines are intended for treating atopic eczema, no conclusive evidence shows that these treatments, taken by mouth or applied topically, reduce the severity of eczema in children or adults.<ref>{{cite journal | vauthors = Gu S, Yang AW, Xue CC, Li CG, Pang C, Zhang W, Williams HC | title = Chinese herbal medicine for atopic eczema | journal = The Cochrane Database of Systematic Reviews | issue = 9 | pages = CD008642 | date = September 2013 | volume = 2015 | pmid = 24018636 | doi = 10.1002/14651858.CD008642.pub2 | pmc = 10639001 }}</ref>

== Burden of Disease ==
Atopic Dermatitis (AD), commonly known as atopic eczema, is a chronic skin condition that significantly impairs the quality of life (QoL) of affected individuals. Although AD was previously considered primarily a childhood disease, it is now recognized as highly prevalent in adults, with an estimated adult prevalence of 3-5% globally.<ref name=":13">{{Cite journal |last1=Fasseeh |first1=Ahmad N. |last2=Elezbawy |first2=Baher |last3=Korra |first3=Nada |last4=Tannira |first4=Mohamed |last5=Dalle |first5=Hala |last6=Aderian |first6=Sandrine |last7=Abaza |first7=Sherif |last8=Kaló |first8=Zoltán |date=2022-12-01 |title=Burden of Atopic Dermatitis in Adults and Adolescents: a Systematic Literature Review |url=https://doi.org/10.1007/s13555-022-00819-6 |journal=Dermatology and Therapy |language=en |volume=12 |issue=12 |pages=2653–2668 |doi=10.1007/s13555-022-00819-6 |issn=2190-9172 |pmc=9674816 |pmid=36197589}}</ref><ref name=":14">{{Cite journal |last1=Page |first1=Matthew J. |last2=McKenzie |first2=Joanne E. |last3=Bossuyt |first3=Patrick M. |last4=Boutron |first4=Isabelle |last5=Hoffmann |first5=Tammy C. |last6=Mulrow |first6=Cynthia D. |last7=Shamseer |first7=Larissa |last8=Tetzlaff |first8=Jennifer M. |last9=Akl |first9=Elie A. |last10=Brennan |first10=Sue E. |last11=Chou |first11=Roger |last12=Glanville |first12=Julie |last13=Grimshaw |first13=Jeremy M. |last14=Hróbjartsson |first14=Asbjørn |last15=Lalu |first15=Manoj M. |date=2021-03-29 |title=The PRISMA 2020 statement: an updated guideline for reporting systematic reviews |journal=BMJ (Clinical Research Ed.) |volume=372 |pages=n71 |doi=10.1136/bmj.n71 |issn=1756-1833 |pmc=8005924 |pmid=33782057}}</ref>

The impact of AD extends beyond physical symptoms, encompassing substantial humanistic and psychosocial effects. Its burden is significant, especially given the high indirect costs and psychological impacts on quality of life.<ref name=":13" /><ref>{{Cite journal |last1=Marron |first1=S. E. |last2=Cebrian-Rodriguez |first2=J. |last3=Alcalde-Herrero |first3=V. M. |last4=Garcia-Latasa de Aranibar |first4=F. J. |last5=Tomas-Aragones |first5=L. |date=2020-07-01 |title=Impacto psicosocial en adultos con dermatitis atópica: estudio cualitativo |url=https://www.sciencedirect.com/science/article/pii/S0001731020301289 |journal=Actas Dermo-Sifiliográficas |volume=111 |issue=6 |pages=513–517 |doi=10.1016/j.ad.2019.03.018 |pmid=32401725 |issn=0001-7310}}</ref>

According to the Global Burden of Disease study, AD is the skin disease with the highest disability-adjusted life-year (DALY) burden and ranks in the top 15 of all nonfatal diseases. In comparison with other dermatological conditions like psoriasis and urticaria, AD presents a significantly higher burden.<ref name=":14" />

While AD remains incurable, reducing its severity can significantly alleviate its burden. Understanding the extent of the burden of AD can aid in better resource allocation and prioritization of interventions, benefiting both patients and healthcare systems.<ref>{{Cite journal |last1=Silverwood |first1=Richard J. |last2=Mansfield |first2=Kathryn E. |last3=Mulick |first3=Amy |last4=Wong |first4=Angel Y.S. |last5=Schmidt |first5=Sigrún A.J. |last6=Roberts |first6=Amanda |last7=Smeeth |first7=Liam |last8=Abuabara |first8=Katrina |last9=Langan |first9=Sinéad M. |date=May 2021 |title=Atopic eczema in adulthood and mortality: UK population–based cohort study, 1998-2016 |url=https://doi.org/10.1016/j.jaci.2020.12.001 |journal=Journal of Allergy and Clinical Immunology |volume=147 |issue=5 |pages=1753–1763 |doi=10.1016/j.jaci.2020.12.001 |issn=0091-6749 |pmc=8098860 |pmid=33516523}}</ref>

=== Clinical and Economic Burden ===
AD is associated with various symptoms, including pruritis, depression, and anxiety. The prevalence of itching in AD patients ranges from 21% to 100%,<ref name=":13" /> with the median severity of itch averaging around 6 on a 0-10 numerical rating scale.<ref name=":13" /><ref>{{Cite journal |last1=Sheary |first1=Belinda |last2=Harris |first2=Mark Fort |date=October 2020 |title=Cessation of Long-term Topical Steroids in Adult Atopic Dermatitis: A Prospective Cohort Study |url=https://www.liebertpub.com/doi/10.1097/DER.0000000000000602 |journal=Dermatitis |volume=31 |issue=5 |pages=316–320 |doi=10.1097/DER.0000000000000602|pmid=32404621 |doi-access=free }}</ref>

Economically, AD imposes a substantial burden, with the average direct cost per patient estimated at 4411 USD and the average indirect cost reaching 9068 USD annually.<ref name=":13" /> These figures highlight the considerable financial impact of the disease on healthcare systems and patients.<ref>{{Cite journal |last1=Pedersen |first1=Courtney J. |last2=Uddin |first2=Mohammad J. |last3=Saha |first3=Samir K. |last4=Darmstadt |first4=Gary L. |date=2021-04-16 |title=Prevalence and psychosocial impact of atopic dermatitis in Bangladeshi children and families |journal=PLOS ONE |language=en |volume=16 |issue=4 |pages=e0249824 |doi=10.1371/journal.pone.0249824 |doi-access=free |issn=1932-6203 |pmc=8051797 |pmid=33861780|bibcode=2021PLoSO..1649824P }}</ref><ref>{{Cite web |title=World Bank Country and Lending Groups – World Bank Data Help Desk |url=https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups |access-date=2024-01-14 |website=datahelpdesk.worldbank.org}}</ref>

=== Humanistic Burden ===
AD significantly decreases the quality of life by affecting various aspects of patients' lives. The psychological impact, often resulting in conditions like depression and anxiety, is a major factor leading to decreased quality of life. Sleep disturbances, commonly reported in AD patients, further contribute to the humanistic burden, affecting daily productivity and concentration.<ref name=":13" /><ref>{{Cite journal |last1=Guyatt |first1=Gordon H. |last2=Oxman |first2=Andrew D. |last3=Vist |first3=Gunn E. |last4=Kunz |first4=Regina |last5=Falck-Ytter |first5=Yngve |last6=Alonso-Coello |first6=Pablo |last7=Schünemann |first7=Holger J. |date=2008-04-24 |title=GRADE: an emerging consensus on rating quality of evidence and strength of recommendations |url=https://www.bmj.com/content/336/7650/924 |journal=BMJ |language=en |volume=336 |issue=7650 |pages=924–926 |doi=10.1136/bmj.39489.470347.AD |issn=0959-8138 |pmc=2335261 |pmid=18436948}}</ref>

The average utility value for the general AD population is approximately 0.779, with a gradual decrease in health-related quality of life (HRQoL) correlating with increasing severity of the disease.<ref name=":13" /><ref>{{Cite journal |last1=Grant |first1=Laura |last2=Seiding Larsen |first2=Lotte |last3=Trennery |first3=Claire |last4=Silverberg |first4=Jonathan I. |last5=Abramovits |first5=William |last6=Simpson |first6=Eric L. |last7=Stalder |first7=Jean-Francois |last8=Paty |first8=Jean |last9=Hahn-Pedersen |first9=Julie |last10=Kragh |first10=Nana |last11=Bang |first11=Bo |last12=Arbuckle |first12=Rob |date=August 2019 |title=Conceptual Model to Illustrate the Symptom Experience and Humanistic Burden Associated With Atopic Dermatitis in Adults and Adolescents |journal=Dermatitis |volume=30 |issue=4 |pages=247–254 |doi=10.1097/DER.0000000000000486 |pmc=6641086 |pmid=31261226}}</ref>

=== Productivity Loss ===
AD also has a marked impact on productivity. The total number of days lost annually due to these factors is about 68.8 days for the unstratified AD population, with presenteeism accounting for the majority of these days.<ref name=":13" /> The impact on productivity varies significantly with the severity of AD, with more severe cases resulting in higher numbers of days lost.<ref name=":13" /><ref>{{Cite journal |last=Avena-Woods |first=Carmela |date=June 2017 |title=Overview of atopic dermatitis |url=https://pubmed.ncbi.nlm.nih.gov/28978208/?dopt=Abstract |journal=The American Journal of Managed Care |volume=23 |issue=8 Suppl |pages=S115–S123 |issn=1936-2692 |pmid=28978208}}</ref>

=== Burden of Disease in the Middle East and Africa ===
Atopic Dermatitis leads to the highest loss in disability-adjusted life years (DALYs) compared to other skin diseases in the Middle East and Africa.<ref name=":15">{{Cite journal |last1=Elezbawy |first1=Baher |last2=Fasseeh |first2=Ahmad Nader |last3=Fouly |first3=Essam |last4=Tannira |first4=Mohamed |last5=Dalle |first5=Hala |last6=Aderian |first6=Sandrine |last7=Abu Esba |first7=Laila Carolina |last8=Al Abdulkarim |first8=Hana |last9=Ammoury |first9=Alfred |last10=Altawil |first10=Esraa |last11=Al Turaiki |first11=Abdulrahman |last12=Albreiki |first12=Fatima |last13=Al-Haddab |first13=Mohammed |last14=Al-Lafi |first14=Atlal |last15=Alowayesh |first15=Maryam |date=2023-01-01 |title=Humanistic and Economic Burden of Atopic Dermatitis for Adults and Adolescents in the Middle East and Africa Region |url=https://doi.org/10.1007/s13555-022-00857-0 |journal=Dermatology and Therapy |language=en |volume=13 |issue=1 |pages=131–146 |doi=10.1007/s13555-022-00857-0 |issn=2190-9172 |pmc=9823172 |pmid=36445612}}</ref> Patients with AD in these regions lose approximately 0.19 [[Medicine:Quality-adjusted life year|quality-adjusted life year]]s (QALYs) annually due to the disease. Egypt experiences the highest QALY loss and Kuwait the lowest. The estimated utility value for an average patient with AD ranges from 0.54 to 0.77.<ref name=":15" />

The average annual healthcare cost per patient varies is highest in the United Arab Emirates, estimated at US $3569, and lowest in Algeria at US $312. These costs are influenced by the economic status of each country and the cost of healthcare. Advanced treatments like targeted therapies and phototherapy are among the main cost drivers.<ref name=":15" />

Indirect costs, primarily due to productivity loss from absenteeism and presenteeism average about 67% in these countries. Indirect costs in Saudi Arabia are the highest in the area, estimated at US $364 million.<ref name=":15" /> Factors like mental health impact, side effects of treatments, and other indirect costs such as personal care products are not fully accounted for in these estimates, suggesting that the actual burden might be even higher.<ref name=":15" />

== Epidemiology ==

Since the beginning of the 20th century, many inflammatory skin disorders have become more common; AD is a classic example of such a disease. It now affects 15–30% of children and 2–10% of adults in developed countries, and in the United States has nearly tripled in the past 30–40 years.<ref name = MSR/><ref name=saito>{{cite journal | vauthors = Saito H | title = Much atopy about the skin: genome-wide molecular analysis of atopic eczema | journal = International Archives of Allergy and Immunology | volume = 137 | issue = 4 | pages = 319–325 | date = August 2005 | pmid = 15970641 | doi = 10.1159/000086464 | s2cid = 20040720 }}</ref> Over 15 million American adults and children have AD.<ref>{{cite web | url = http://www.uchospitals.edu/online-library/content=P01675 | title = Atopic Dermatitis | date = 1 January 2015 | work = www.uchospitals.edu | access-date = 2 April 2015 | archive-url = https://web.archive.org/web/20150408150538/http://www.uchospitals.edu/online-library/content%3DP01675 | archive-date = 2015-04-08 }}</ref>

== Society and culture ==

=== Conspiracy theories ===
A number of false and conspiratorial claims about AD have emerged on the internet and have been amplified by social media. These conspiracy theories include, among others, claims that AD is caused by [[5G|5G]], [[Physics:Formaldehyde|formaldehyde]] in food, [[Biology:Vaccine|vaccine]]s, and topical steroids. Various unproven theories also claim that vegan diets, [[Unsolved:Apple cider vinegar|apple cider vinegar]], [[Biology:Calendula|calendula]], and [[Biology:Witch-hazel|witch hazel]] can cure AD and that [[Physics:Air purifier|air purifier]]s reduce the risk of developing AD.<ref>{{cite journal | vauthors = O'Connor C, Murphy M | title = Scratching the surface: a review of online misinformation and conspiracy theories in atopic dermatitis | journal = Clinical and Experimental Dermatology | volume = 46 | issue = 8 | pages = 1545–1547 | date = December 2021 | pmid = 33864398 | doi = 10.1111/ced.14679 | s2cid = 233278383 | hdl = 10468/11402 | hdl-access = free }}</ref>

==Research==
''[[Medicine:Staphylococcus aureus|Staphylococcus aureus]]'' may have a role in producing atopic dermatitis by [[Biology:Colony|colonizing]] on the skin.<ref>{{cite journal | vauthors = Totté JE, van der Feltz WT, Hennekam M, van Belkum A, van Zuuren EJ, Pasmans SG | title = Prevalence and odds of ''Staphylococcus aureus'' carriage in atopic dermatitis: a systematic review and meta-analysis | journal = The British Journal of Dermatology | volume = 175 | issue = 4 | pages = 687–695 | date = October 2016 | pmid = 26994362 | doi = 10.1111/bjd.14566 | s2cid = 23617550 }}</ref>

== See also ==
* [[Medicine:Sweat allergy|Sweat allergy]]

== References ==

{{Reflist}}

== External links ==
{{Medical resources
|   ICD10          = {{ICD10|L|20||l|20}}
|   ICD9           = {{ICD9|691.8}}
|   ICDO           =
| DiseasesDB=4113
|   OMIM           = 603165
|   MedlinePlus    = 000853
|   eMedicineSubj  = emerg
|   eMedicineTopic = 130
|   eMedicine_mult = {{eMedicine2|derm|38}} {{eMedicine2|ped|2567}} {{eMedicine2|oph|479}}
|   MeshID         = D003876
}}

* [http://www.niams.nih.gov/Health_Info/Atopic_Dermatitis/default.asp NIH Handout on Health: Atopic Dermatitis]
* [https://www.eczemacareonline.org.uk/ Eczema Care Online]. Toolkit for managing eczema.
* [https://isad.org/ International Society of Atopic Dermatitis].
* [https://www.bristol.ac.uk/primaryhealthcare/resources/moisturiser-decision-aid/#d.en.592367 Moisturiser Decision Aid] . University of Bristol.

{{Hypersensitivity and autoimmune diseases}}


{{DEFAULTSORT:Atopic Dermatitis}}
[[Category:Wikipedia medicine articles ready to translate]]

{{Sourceattribution|Atopic dermatitis}}