The skin condition known as eczema, or atopic dermatitis (AD), is a chronic inflammatory disorder that causes intense itching, redness, and dry patches. While it is most commonly associated with infancy and childhood, it is possible to experience the first signs of this condition in adulthood. Developing eczema after the age of 18 is referred to as Adult-Onset Atopic Dermatitis (AOAD).
Adult-Onset Atopic Dermatitis
Atopic dermatitis is typically viewed as a pediatric disease, with approximately 80% of affected individuals developing it before the age of six. However, a significant proportion of people experience the condition’s onset in adulthood. Adult-Onset Atopic Dermatitis accounts for a substantial percentage of new AD cases, with some studies suggesting that one in four adults with eczema report their symptoms began after childhood.
The prevalence of AD in the United States adult population is estimated to be around 7%. It is important to distinguish AOAD from persistent AD, which describes eczema that began in childhood and continued into adulthood. The emergence of symptoms for the first time in an adult, sometimes even after the age of 50, suggests a differently timed interaction between genetic predisposition and environmental factors.
How Adult Eczema Manifests
The physical presentation of eczema in adults often differs from the classic rashes seen in children, making diagnosis more challenging. Adult eczema frequently appears as extremely dry, scaly patches that can be thicker and more leathery than the lesions of childhood AD. This thickening, known as lichenification, is a result of chronic scratching and rubbing.
While childhood eczema often affects the creases of the elbows and knees, adult AD frequently targets the hands, eyelids, neck, and face. Adults may also present with nummular, or coin-shaped, lesions or small, intensely itchy bumps known as prurigo-like nodules, which are less common in younger patients. The intense, persistent itch, or chronic pruritus, is a hallmark of adult eczema and can severely disrupt sleep.
Unlike the typically “weepy” or oozing acute patches seen in infants, adult lesions are frequently drier and may take on a muted or dusky tone due to prolonged inflammation. The skin around the eyes is particularly susceptible in adults, often displaying thickening and darkening.
Factors Contributing to Late Appearance
The emergence of eczema in adulthood involves a complex interplay between genetic susceptibility and various adult-specific triggers. Many individuals with AOAD may possess a genetic predisposition, such as mutations in the Filaggrin protein, but this vulnerability only becomes clinically apparent later in life. Filaggrin is a protein that helps maintain the skin barrier, and a defect can lead to increased water loss and susceptibility to irritants.
Occupational exposure to irritants like chemicals, solvents, or the need for frequent hand washing can severely damage the skin barrier, leading to irritant hand dermatitis that progresses to eczema. Psychological stress is a significant contributor, as it triggers the release of hormones like cortisol, which can heighten the body’s inflammatory response.
Hormonal fluctuations are another factor, particularly in women, where declining estrogen levels, such as during menopause, can compromise the skin’s barrier function. Changes in climate, exposure to air pollutants, and smoking have also been linked to the onset of AD in adults.
Medical Management of Adult Eczema
The initial step in managing adult-onset eczema is a careful diagnostic process to ensure the condition is not a different type of dermatitis, such as allergic contact dermatitis. Clinicians may use patch testing to rule out an allergic reaction. Once confirmed, treatment aims to reduce inflammation, repair the skin barrier, and control the intense itching.
The foundational treatment involves consistent use of emollients, which are moisturizing creams or ointments applied multiple times daily and immediately after bathing to lock in moisture. For active flare-ups, topical anti-inflammatory therapies are utilized, including prescription topical corticosteroids of varying strengths and topical calcineurin inhibitors, which can be safely used on delicate areas like the face and eyelids. Newer topical options include phosphodiesterase-4 (PDE-4) and Janus kinase (JAK) inhibitors, which target specific inflammatory pathways.
For moderate to severe cases that do not respond sufficiently to topical treatments, systemic therapies are often necessary. These advanced options include traditional immunosuppressant medications, phototherapy (light treatment), and a growing class of biologic medications. Biologics are injectable antibodies that precisely target the immune messengers, such as interleukin-4 and interleukin-13, that drive the inflammation in AD. Managing stress and avoiding identified environmental triggers remain important supporting strategies for long-term control.