Tools for Practice


#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.
  • 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
  • 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.
Context
  • 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
June 28, 2021

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Author(s):

  • Christina Korownyk MD CCFP
  • G. Michael Allan MD CCFP
  • Rodger Craig MPH

1. Cardona ID, Kempe EE, Lary C, et al. J Allergy Clin Immunol Pract. 2020 Mar; 8(3):1014-1021.

2. Kameyoshi Y, Tanaka T, Mochizuki M, et al. Arerugi 2008; 57(2):130-7

3. Mochizuki H, Muramatsu R, Tadaki H, et al. Pediatr Dermatol Mar-Apr 2009; 26(2):223-5.

4. Chopra R, Vakharia PP, Sacotte R, et al. Ann Allergy Asthma Immunol. 2017 Nov; 119(5):435-440.

5. George SM, Karanovic S, Harrison DA, et al. Cochrane Database Syst Rev. 2019; 2019(10):CD003871.

6. Huang JT, Abrams M, Tlougan B, et al. Pediatrics. 2009; 123:e808-e814.

7. Hon KL, Tsang YC, Lee VW, et al. J Dermatolg Treat. 2016; 27:156-162.

8. Maarouf M, Hendricks AJ, Shi VY. Dermatitis. 2019 May/Jun; 30(3):191-197.

9. Santer M, Ridd MJ, Francis NA, et al. BMJ. 2018 May 3; 361:k1332.

10. Thomas KS, Dean T, O'Leary C, et al. PLoS Med. 2011 Feb 15;8(2):e1000395.

11. Frazier W, Bhardwaj N. Am Fam Physician. 2020 May 15; 101(10):590-8.

12. Lynde C, Barber K, Claveau J, et al. J Cutan Med Surg. 2005; 8 Suppl 5:1-9. Weston WL, Howe W. Treatment of Atopic Dermatitis (eczema). UptoDate. www.uptodate.com Accessed May 9, 2021.

13. Katoh N, Ohya Y, Ikeda M, et al. Clinical practice guidelines for the management of atopic dermatitis 2018. J Dermatol. 2019 Dec; 46(12):1053-1101

Authors do not have any conflicts of interest to declare.