#293 Bath Time: Atopic Dermatitis and Bathing
CLINICAL QUESTION
Can atopic dermatitis (AD) be improved with more baths/showers, bleach baths, or bath additives?
BOTTOM LINE
In AD, more frequent baths (and likely showers), 1-2 times/day, improve symptoms meaningfully (≥30%) for about 40% more patients than less frequent bathing (with moisturizers after bath/showers). Despite advocacy, research does not support bleach baths, bath additives or water softeners for AD symptoms. Offer simple advice for frequent plain-water bathing and application of moisturizers immediately afterward.
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EVIDENCE
- Statistically significant differences unless noted.
- Frequency:
- Cross-over randomized controlled trial (RCT)1 of 42 children with moderate-severe AD. Two-week treatments of twice-daily versus twice-weekly baths (moisturizers applied after baths but otherwise twice-daily):
- Patients with ≥30% symptom improvement: 58% twice-daily baths versus 15% twice-weekly, number needed to treat (NNT)=3.
- Mean symptom score (0-103, higher worse): Baseline 42, twice-daily baths improved 21 points more than twice-weekly.
- Cross-over randomized controlled trial (RCT)1 of 42 children with moderate-severe AD. Two-week treatments of twice-daily versus twice-weekly baths (moisturizers applied after baths but otherwise twice-daily):
- Showers versus Baths:
- No RCTs.
- 1 non-randomized trial2 and 1 intervention cohort3: Children who added a shower daily at school had improved AD scores.
- Bleach Baths:
- General AD: Systematic Review4 (4 RCTs, 116 patients) of moderate-severe AD, bleach bath (5-10 mins, 2x/week) versus regular bath, at 4 weeks:
- No significant difference in AD scores, surface area with AD, or staphylococcal colonization.
- Limitations: Trials small/short/heterogeneous.
- Others find similar.5 No increased adverse events.
- AD with clinical bacterial infection:
- RCT (22 patients): Reduction in score of submerged sites.
- Bleach bath group also got nasal mupirocin and were more severe at start.6
- Cross-over RCT (40 patients): No difference in AD severity.7
- RCT (22 patients): Reduction in score of submerged sites.
- General AD: Systematic Review4 (4 RCTs, 116 patients) of moderate-severe AD, bleach bath (5-10 mins, 2x/week) versus regular bath, at 4 weeks:
- Additives (like Oilatum™ or Aveeno™):
- Systematic review (5 RCTs, 111 patients):8 inconsistent reporting, high risk of bias.
- RCT (482 children):9 generally moderate AD, assigned to bath additive (clinician/patient choice) versus no additive, after 1 year: No benefit.
- Water Softener:
- RCT (336 children):10 moderate-severe AD living in hard-water area (≥200 mg/l calcium carbonate), ion-filter water softener versus none, after 12 weeks: No difference.
- Guidelines/reviews recommend regular bathing and apply moisturizers (ointment or thick-creams) immediately after, while skin is still damp.11-14
- Advocacy for bath alterations, like bleach baths, persists11-14 but some acknowledge the evidence does not support benefit.13
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