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InflammatoryVery commonICD-10 L20.x

Atopic eczema

Atopic dermatitis ยท AD ยท eczema

Atopic eczema is the commonest chronic inflammatory skin disease in the UK, affecting up to 20% of children and ~10% of adults. It is characterised by pruritic, ill-defined eczematous patches with a relapsing-remitting course and a typical age-related morphology. Filaggrin loss-of-function mutations, Th2-Th22 immune polarisation and skin-barrier dysfunction underpin pathogenesis. Importantly in skin-oncology practice it is the principal background for eczema herpeticum, a frequent DDx for irritant / ICI-related dermatitis, and a setting for development of cutaneous T-cell lymphoma in long-standing recalcitrant disease.

CurrentLast reviewed 18 May 2026
Clinical image of Atopic eczema
Atopic eczema. Image sourced from DermNet New Zealand. Used under CC BY-NC-ND 4.0. No endorsement implied.

Pathogenesis

  • Skin-barrier dysfunction: filaggrin (FLG) loss-of-function variants in ~30%; reduced natural moisturising factor; impaired lipid lamellae.
  • Type-2 immune dysregulation: IL-4 / IL-13 / IL-31 / IL-22 drive itch, inflammation and barrier disruption.
  • Microbiome dysbiosis: Staphylococcus aureus over-colonisation; reduced biodiversity.
  • Atopic march: eczema โ†’ food allergy โ†’ asthma โ†’ allergic rhinitis.
  • Genetic + environmental: hard water, climate, hygiene-hypothesis exposure.

Clinical features

  • Pruritic erythematous patches; ill-defined; chronic-relapsing course.
  • Age-related morphology:
    • Infantile (0-2 years): cheeks, scalp, extensor limbs.
    • Childhood (2-12 years): flexures, antecubital, popliteal, neck.
    • Adult: flexures, face, neck, hands, eyelids; lichenification chronic; head-and-neck variant in young adults.
  • Hanifin and Rajka diagnostic criteria; UK Working Party diagnostic criteria for prevalence studies.
  • Atopic stigmata: Dennie-Morgan fold, allergic shiners, hyperlinear palms, white dermographism, pityriasis alba, keratosis pilaris.
  • Complications:
    • Bacterial superinfection (S. aureus) โ€” impetiginised eczema.
    • Eczema herpeticum (HSV).
    • Eczema vaccinatum (rare).
    • Erythroderma.

Severity assessment

  • EASI (Eczema Area and Severity Index) โ€” area + severity by body region.
  • SCORAD (Scoring Atopic Dermatitis) โ€” extent + intensity + subjective symptoms.
  • POEM (Patient-Oriented Eczema Measure) โ€” patient-reported.
  • IGA (Investigator Global Assessment) โ€” five-point.
  • DLQI / CDLQI for quality of life impact.

Differential diagnosis

  • Contact dermatitis (allergic / irritant) โ€” geometric, specific exposure.
  • Seborrhoeic dermatitis โ€” greasy scale; nasolabial, scalp, central chest.
  • Psoriasis โ€” silvery scale; extensor; Auspitz sign.
  • Mycosis fungoides (patch / plaque stage) โ€” asymmetric, sun-protected, recalcitrant; biopsy + TCR.
  • Scabies โ€” burrow; web spaces; itch worse at night.
  • Cutaneous T-cell lymphoma in chronic atopic patients with new fixed plaques.
  • ICI-related eczematous dermatitis โ€” drug history.
  • Tinea, candidiasis, pediculosis, perioral dermatitis.

Management

  • General: liberal emollients (daily, โ‰ฅ250 g/week adult); soap substitutes; lukewarm baths; cotton clothing; trigger avoidance.
  • Topical first-line (NICE CG57 [under 12s] / CKS):
    • Topical corticosteroids โ€” potency stepped to disease severity and site.
    • Topical calcineurin inhibitors (tacrolimus 0.03% / 0.1%; pimecrolimus 1%) โ€” steroid-sparing; face / flexure use.
    • Topical PDE4 inhibitor (crisaborole โ€” limited UK access).
    • Topical JAK inhibitor (ruxolitinib cream โ€” limited UK).
  • Phototherapy: narrowband UVB; PUVA second-line.
  • Systemic (moderate-severe disease):
    • Ciclosporin 2.5-5 mg/kg/day; short-medium term.
    • Methotrexate, azathioprine, mycophenolate mofetil โ€” steroid-sparing.
    • Short-course oral corticosteroids โ€” flares only.
  • Biologics / small molecules (UK NICE):
    • Dupilumab (anti-IL-4Rฮฑ) โ€” NICE TA534 for adults with moderate-to-severe atopic dermatitis; paediatric access should be checked against current NICE / local commissioning wording.
    • Tralokinumab (anti-IL-13) โ€” NICE TA814.
    • Lebrikizumab (anti-IL-13) โ€” NICE TA986.
    • Baricitinib (JAK1/2 inhibitor) โ€” NICE TA681.
    • Upadacitinib (JAK1 inhibitor) โ€” NICE TA814.
    • Abrocitinib (JAK1 inhibitor) โ€” NICE TA814.
  • Complication management:
    • Bacterial superinfection: oral flucloxacillin / topical fusidic acid (avoid long courses for resistance).
    • Eczema herpeticum: empirical oral / IV aciclovir.
    • Education on signs of secondary infection.

References

  1. NICE CG57. Atopic eczema in under 12s: diagnosis and management. London: NICE; 2007 (last updated 22 September 2025).
  2. Wollenberg A et al. European guideline (EuroGuiDerm) on atopic eczema 2022. J Eur Acad Dermatol Venereol. 2022;36:1409-1431.
  3. Simpson EL et al. Two phase 3 trials of dupilumab versus placebo in atopic dermatitis (SOLO 1 / SOLO 2). N Engl J Med. 2016;375:2335-2348.
  4. NICE TA534. Dupilumab for treating moderate to severe atopic dermatitis. London: NICE; 2018.
  5. NICE TA814. Abrocitinib, tralokinumab or upadacitinib for treating moderate to severe atopic dermatitis. London: NICE; 2022.
  6. Brown SJ, McLean WH. One remarkable molecule: filaggrin. J Invest Dermatol. 2012;132:751-762.

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