Eczema and atopic dermatitis
Two opposite mistakes dominate eczema care: using potent steroids indefinitely without supervision, and refusing to use any steroid at all. Both cause harm. The way through is understanding what is actually broken.
Atopic dermatitis is a chronic, relapsing inflammatory condition with three components: a genetically weak skin barrier, an overactive immune response, and an altered skin microbiome. It commonly runs alongside asthma and allergic rhinitis — the "atopic triad" — and often clusters in families.
Understanding it as a barrier disease is the single most useful shift, because it explains why moisturiser is treatment rather than comfort.
Recognising it
- Itch is the defining symptom. No itch, probably not eczema.
- Infants: cheeks, scalp, outer arms and legs.
- Children: elbow creases, behind the knees, wrists, ankles, neck.
- Adults: hands, eyelids, neck, flexures; often thickened, leathery patches (lichenification) from years of scratching.
- Course: flares and remissions, worse in extremes of weather and with stress.
The itch-scratch cycle
Itching leads to scratching. Scratching damages the barrier and releases inflammatory mediators, which causes more itching. Breaking this cycle is the practical goal of most treatment, and it is why controlling itch aggressively early is not indulgent — it prevents the thickening and pigmentation that follow years of scratching.
Treatment that works
1. Moisturiser — the foundation, not an optional extra
How to actually use emollients
- Quantity matters. An adult with widespread eczema needs roughly 250–500 g per week. Most people use a fraction of that. If a tube lasts a month, you are under-treating.
- Apply within three minutes of bathing, on skin that is still slightly damp, to trap water.
- Twice daily minimum, and more often on hands.
- Choose by climate. In Kerala's humidity a heavy ointment can feel intolerable and cause heat rash — a cream or lotion base is often more realistic, and something you will actually apply beats a technically superior one you abandon.
- Fragrance-free. Fragrance is a common trigger in eczema-prone skin.
- Look for ceramides, glycerin, urea or colloidal oatmeal.
2. Topical steroids — used correctly, they are safe
Steroid phobia is now one of the biggest obstacles to good eczema care, and it is partly our own profession's fault for not explaining properly. Let me be clear about both sides.
The genuine risks come from using potent steroids on the face or in folds, for long unsupervised periods: skin thinning, stretch marks, visible capillaries, and steroid-induced rosacea. These are real, and I treat their consequences regularly — usually from combination creams bought over the counter.
Used correctly, they are safe and necessary. Correctly means: the right potency for the site — mild (hydrocortisone) for face and folds, moderate to potent for limbs and trunk; applied to active eczema only; for short bursts of one to two weeks; then stepped down or stopped while continuing moisturiser. Under-treating a flare because of fear leads to prolonged inflammation, infection, sleep loss and long-term skin thickening — which is its own harm.
The fingertip unit is a useful guide: the amount squeezed onto the last segment of an adult index finger treats an area the size of two adult palms.
3. Other prescription options
- Topical calcineurin inhibitors (tacrolimus, pimecrolimus) — steroid-free, particularly useful for face, eyelids and long-term maintenance.
- Antihistamines — sedating ones at night help sleep more than they help itch directly.
- Antibiotics — only where there is genuine secondary infection (weeping, golden crusts, sudden worsening).
- Phototherapy (narrowband UVB) — effective for extensive disease.
- Systemic treatment — ciclosporin, methotrexate, or newer biologics such as dupilumab for severe refractory disease. These have transformed outcomes for the worst-affected patients.
- Wet wrap therapy — very effective for severe flares, especially in children.
Identifying and reducing triggers
Common triggers here: heat and sweat (a major one in our climate), harsh soaps and detergents, wool and synthetic fabrics, dust mites, hard water, stress, and sudden temperature change from air conditioning. Practical adjustments: lukewarm short showers, a soap substitute or syndet bar, loose cotton clothing, keeping nails short, and using a fan rather than letting sweat sit on the skin.
About food allergy
Parents are often told to eliminate milk, eggs, wheat and more. In truth, food allergy is a genuine trigger in only a minority of children with eczema, and unnecessary elimination diets cause real nutritional harm and family stress. Do not remove major food groups from a child's diet without proper allergy assessment. Treating the skin properly helps far more than restricting food in most cases.
When to see a doctor
See a dermatologist if the eczema is widespread or not settling with moisturiser and a mild steroid, if sleep is being disturbed, if there is weeping or golden crusting suggesting infection, if there are painful clustered blisters (possible herpes infection, which needs urgent treatment in eczema), or if you have been using an unlabelled or potent steroid cream for months.
One reassurance for parents: most childhood eczema improves substantially with age, and a majority of children see significant improvement by adolescence. The goal in the meantime is good control — not a cure — so that the child sleeps, grows and lives normally.
Frequently asked questions
Used correctly, yes, and they are often necessary. Correct use means matching potency to the site (mild on face and folds), applying only to active eczema, in short bursts of one to two weeks, alongside regular moisturiser. The harm comes from potent steroids used on the face or for long unsupervised periods — and from under-treating flares out of fear.
Far more than most people do — roughly 250 to 500 g per week for an adult with widespread eczema. Apply within three minutes of bathing while skin is still damp, at least twice daily. If a tube lasts a month, the eczema is being under-treated.
Only in a minority of children. Unnecessary elimination diets cause real nutritional harm and family stress, so major food groups should never be removed without proper allergy assessment. Treating the skin barrier properly helps far more in most cases.
Most childhood eczema improves substantially with age, and a majority of children see significant improvement by adolescence. The aim in the meantime is good control so the child sleeps and grows normally, rather than waiting for a cure.
Heat and sweat are major triggers, and sweat sitting on the skin irritates a weakened barrier. Heavy ointments can also cause heat rash here, so a lighter cream base, lukewarm short showers, loose cotton clothing and a fan often help more than switching products.
Control the inflammation with appropriate topical treatment, moisturise generously before bed, keep nails short, keep the room cool, and consider a sedating antihistamine at night — it helps sleep more than it stops itch directly. Persistent night itch is a reason to see a dermatologist rather than endure it.
