Skip to main content
NCBI home page
Canadian Family Physician logoLink to Canadian Family Physician
. 2021 Oct;67(10):758. doi: 10.46747/cfp.6710758

Atopic dermatitis and bathing

G Michael Allan 1, Rodger Craig 2, Christina S Korownyk 3
PMCID: PMC8516174  PMID: 34649901

Clinical question

Can atopic dermatitis (AD) be improved with more baths or showers, bleach baths, or bath additives?

Bottom line

More frequent bathing (and likely showers) (ie, 1 to 2 times/day) improves symptoms meaningfully (≥ 30%) for about 40% more patients than less frequent bathing (with moisturizers afterward). Research does not support bleach baths, bath additives, or water softeners. Frequent plain-water bathing (mild soap as needed) and immediate application of moisturizers are advised.

Evidence

Differences are statistically significant unless noted.

  • Frequency: In a crossover RCT (N = 42), children with moderate-severe AD were treated with 2-week treatments of either twice-daily or twice-weekly baths (moisturizers applied after baths but otherwise twice daily).1
    • - Patients with symptom improvement (≥ 30%): 58% twice-daily baths versus 15% twice weekly; number needed to treat = 3.
    • - Mean symptom score (0 to 103, higher score worse): baseline score of 42; twice-daily baths improved 21 points more than twice weekly.

  • Showers versus baths: No RCTs were found; only 1 non-RCT2 and 1 intervention cohort.3 Children who added a shower daily at school had improved AD scores.

  • Bleach baths for general AD: A systematic review4 (4 RCTs, 116 patients) of those with moderate-severe AD compared bleach bath (5 to 10 min, 2 times/week) to regular bath. At 4 weeks, there was no significant difference in AD scores, surface area with AD, or staphylococcal colonization. Limitations included the trials being small, short, or heterogeneous. Other studies had similar findings.5 There were no increased adverse events.

  • Bleach baths for AD with clinical bacterial infection: An RCT found a reduction in score of submerged sites in bleach bath (N = 22); this group was also treated with nasal mupirocin and was more severe at start.6 In a crossover RCT (N = 40), there was no difference in AD severity.7

  • Additives: A systematic review (5 RCTs, N = 111) had inconsistent reporting and high risk of bias.8 An RCT (N = 482) assigned children with moderate AD to either a bath additive group (clinician or patient choice) or a no additive group; after 1 year, no benefit was found.9

  • Water softener: An RCT (N = 336) randomized children with moderate-severe AD living in a hard-water area (≥ 200 mg/L calcium carbonate) to either an ion-filter water softener group or placebo; after 12 weeks, no difference was found.10

Context

  • Guidelines and reviews recommend regular bathing and application of moisturizers (ointment or thick creams) immediately after, while skin is still damp.11-13

  • Advocacy for bath alterations, like bleach baths, persists,11-13 but evidence does not support benefit.12

Implementation

There is inadequate evidence for an optimal bathing technique for eczema. While daily short baths in lukewarm water are recommended,11 there is no high-level evidence for temperature or duration. An RCT of children with eczema compared washing one side of the body with either soap or water alone, but there was no statistical or clinical difference in eczema outcome.14

Tools for Practice articles in Canadian Family Physician are adapted from peer-reviewed articles at www.toolsforpractice.ca and summarize practice-changing medical evidence for primary care. Coordinated by Dr. G. Michael Allan and Dr Adrienne J. Lindblad, articles are developed by the Patients, Experience, Evidence, Research (PEER) team and supported by the College of Family Physicians of Canada and its Alberta, Ontario, and Saskatchewan Chapters. Feedback is welcome and can be sent to toolsforpractice@cfpc.ca.

Footnotes

Competing interests

None declared

The opinions expressed in Tools for Practice articles are those of the authors and do not necessarily mirror the perspective and policy of the College of Family Physicians of Canada.

References

  • 1.Cardona ID, Kempe EE, Lary C, Ginder JH, Jain N.. Frequent versus infrequent bathing in pediatric atopic dermatitis: a randomized clinical trial. J Allergy Clin Immunol Pract 2020;8(3):1014-21. [DOI] [PubMed] [Google Scholar]
  • 2.Kameyoshi Y, Tanaka T, Mochizuki M, Koro O, Mihara S, Hiragun T, et al. Taking showers at school is beneficial for children with severer atopic dermatitis [article in Japanese]. Arerugi 2008;57(2):130-7. [PubMed] [Google Scholar]
  • 3.Mochizuki H, Muramatsu R, Tadaki H, Mizuno T, Arakawa H, Morikawa A.. Effects of skin care with shower therapy on children with atopic dermatitis in elementary schools. Pediatr Dermatol 2009;26(2):223-5. [DOI] [PubMed] [Google Scholar]
  • 4.Chopra R, Vakharia PP, Sacotte R, Silverberg JI.. Efficacy of bleach baths in reducing severity of atopic dermatitis: a systematic review and meta-analysis. Ann Allergy Asthma Immunol 2017;119(5):435-40. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.George SM, Karanovic S, Harrison DA, Rani A, Birnie AJ, Bath-Hextall FJ, et al. Interventions to reduce Staphylococcus aureus in the management of eczema. Cochrane Database Syst Rev 2019;(10):CD003871. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Huang JT, Abrams M, Tlougan B, Rademaker A, Paller AS.. Treatment of Staphylococcus aureus colonization in atopic dermatitis decreases disease severity. Pediatrics 2009;123(5):e808-14. [DOI] [PubMed] [Google Scholar]
  • 7.Hon KL, Tsang YC, Lee VW, Pong NH, Ha G, Lee ST, et al. Efficacy of sodium hypochlorite (bleach) baths to reduce Staphylococcus aureus colonization in childhood onset moderate-to-severe eczema: a randomized, placebo-controlled cross-over trial. J Dermatolog Treat 2016;27(2):156-62. [DOI] [PubMed] [Google Scholar]
  • 8.Maarouf M, Hendricks AJ, Shi VY.. Bathing additives for atopic dermatitis—a systematic review. Dermatitis 2019;30(3):191-7. [DOI] [PubMed] [Google Scholar]
  • 9.Santer M, Ridd MJ, Francis NA, Stuart B, Rumsby K, Chorozoglou M, et al. Emollient bath additives for the treatment of childhood eczema (BATHE): multicentre pragmatic parallel group randomised controlled trial of clinical and cost effectiveness. BMJ 2018;361:k1332. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Thomas KS, Dean T, O’Leary C, Sach TH, Koller K, Frost A, et al. A randomised controlled trial of ion-exchange water softeners for the treatment of eczema in children. PLoS Med 2011;8(2):e1000395. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Frazier W, Bhardwaj N.. Atopic dermatitis: diagnosis and treatment. Am Fam Physician 2020;101(10):590-8. [PubMed] [Google Scholar]
  • 12.Weston WL, Howe W.. Treatment of atopic dermatitis (eczema). Waltham, MA: UpToDate; 2021. [Google Scholar]
  • 13.Katoh N, Ohya Y, Ikeda M, Ebihara T, Katayama I, Saeki H, et al. Clinical practice guidelines for the management of atopic dermatitis 2018. J Dermatol 2019;46(12):1053-101. Epub 2019 Oct 9. [DOI] [PubMed] [Google Scholar]
  • 14.Inuzuka Y, Natsume O, Matsunaga M, Monna Y, Okada E, Kato Y, et al. Washing with water alone versus soap in maintaining remission of eczema. Pediatr Int 2020;62(6):663-8. [DOI] [PubMed] [Google Scholar]

Articles from Canadian Family Physician are provided here courtesy of College of Family Physicians of Canada

RESOURCES