BACKGROUND Atopic dermatitis is associated with skin and blood eosinophilia, but the role of eosinophils in the pathogenesis of the skin lesions is poorly understood. METHODS To determine whether eosinophils play a role in the pathogenesis of the skin lesions in atopic dermatitis, we studied the relationship between the severity of the disease and both the number and the extent of activation of eosinophils in 15 patients with food-sensitive atopic dermatitis. Furthermore, this relationship was re-evaluated in eight of these patients who, after a period of elemental diet or total parenteral nutrition, showed significant clinical improvement. RESULTS A clear relationship was found between the number of light-density eosinophils and the severity of the disease both during the active disease and after clinical improvement. Furthermore, we describe an adhesion-stimulating activity for eosinophils in patients' plasma, which does not change after recovery. CONCLUSIONS Taken together, these observations strongly indicate that eosinophils play a pivotal role in the pathogenesis of the skin lesions in atopic dermatitis. In particular, the light-density phenotype seems to be an essential feature of eosinophils involved in this process. The adhesion-promoting activity that we observed in the patients' plasma could be important in the recruitment of eosinophils from the blood into the skin.