Step-Wise Treatment of Atopic Dermatitis: Basics and Beyond

Noreen Heer Nicol, PhD, RN, FNP, NEA-BC

Disclosures

Pediatr Nurs. 2020;46(2):92-98. 

In This Article

Hydration and Bathing

Bathing plays a key role in hygiene and an important role in AD treatment. The debate about the clinical role of bathing in AD treatment has been ongoing for more than a century. The argument comes from the notation that water can be "good" or "bad" depending on how water is used. Generally accepted explanations are that evaporation and micro fissuring occur when wet skin is not immediately covered by a protective layer of moisturizer, occlusive, or medication, further damaging the skin. Some clinicians believe that avoiding water altogether leads to better outcomes rather than trying to ensure proper use of an appropriate sealer. In contrast, the proper "soak-and-seal" method leads to re-hydration, sealing in of moisture, and repair of the damaged epidermal barrier (Cardona et al., 2016). Bathing may also remove allergens and irritants from the skin surface and reduce general colonization or serous crusts by S. aureus.

"Soak and seal" has consistently been used as a fundamental concept for bathing techniques over more than three decades at a leading AD care center (Boguniewicz & Nicol, 2002; Boguniewicz et al., 2008; Brar et al., 2019; Nicol, 1987; Nicol & Boguniewicz, 2008). This multidisciplinary AD center stresses teaching proper skin care emphasizing use of hydration, moisturizers, cleansers, topicals, and medications to help maintain an intact skin barrier. Other centers have described this technique as "soak and smear" (Gutman et al., 2005). Both terms are frequently seen in the AD literature.

Different recommendations for bathing practice may vary based on the specialty of health care practices where the patient is treated. Inconsistencies in AD treatment recommendations between primary care practitioners and specialists contribute to a high degree of frustration and confusion among families (Kempe et al., 2013). One study published data that highlighted this debate; primary care physicians more often recommend infrequent or less than daily bathing, whereas allergists and pediatric dermatologists recommend frequent, at least daily bathing (Cardona et al., 2015). Another review found that among parents who have seen multiple providers for their child's AD, more than 75% reported a significant amount of confusion and frustration owing to conflicting advice on bathing frequency (Kempe et al., 2013). This highlights the need for consistent messaging and practice among specialists.

There is no clear standard for the frequency or duration of bathing of patients with AD. A literature review revealed the few studies published on bathing frequency were limited by design flaws, but suggest a slight advantage favoring frequent bathing (Cardona et al., 2016). This review defined 'frequent bathing' as bathing at least once a day and 'infrequent bathing' as bathing less than once a day.

Clinical studies evaluating bathing frequency or duration of the bath in AD are limited. A recent randomized controlled trial in children with AD evaluated bathing in AD (Cardona et al., 2019). The study evaluated a 'wet method' of care for efficacy, which included twice-daily soaking baths lasting 15 to 20 minutes followed by immediate application of an occlusive moisturizer compared with the 'dry method' of care that included twice-weekly baths lasting 10 minutes or less in the acute management of pediatric AD. Both groups received the same moisturizer (Vanicream®), same cleanser (Vanicream® Free & Clear Liquid Cleanser) and use of the low-potency topical corticosteroid (TCS), desonide, and the primary differences were frequency of baths and length of baths. The researchers concluded as an acute treatment intervention more frequent bathing with the 'wet method' is superior to 'dry method' at improving disease severity in moderate-to-severe pediatric AD.

Not every AD guideline previously listed has clear information on bathing specifics. However, it has become general consensus, and most guidelines now recommend daily bathing or soaking in warm water for 10 to 20 minutes initially without soap or shampoo to avoid residue and unnecessary irritation. In routine care, cleaners are recommended at least once per day with the bath. Cleansers may be of benefit in infection-prone individuals, and this should be a discussion between provider and patient to determine best cleanser selection. Sensitive cleanser formulations that are dye-free, fragrance-free, and pH neutral are generally desired and well-tolerated. Overuse of soaps, detergents, and other cleansers can contribute to skin barrier breakdown by increasing the stratum corneum pH. Water temperature of a bath should feel warm and comfortable to the patient; the often recommended 'tepid' is usually too cool for most patients. After bathing, the skin should be patted down, not wiped completely dry, with a towel and not an abrasive washcloth. Showers are an acceptable alternative to bathing during the maintenance phase of therapy; however, they should be avoided during AD flares.

A study demonstrated that moisturizers should be applied soon after bathing and drying to reduce transepidermal water loss (TEWL) caused by wet skin. Thus, applying moisturizers within 2 to 3 minutes is recommended (Chiang & Eichenfield, 2009).

Another important reason noted for avoidance of bathing may be with more severe AD, the patient may initially complain of discomfort or pain when initiating bathing with severely dry and/or excoriated skin. This avoidance of bathing often results in progressive worsening of the atopic dermatitis. If dermatitis is limited to areas such as face, hands, or feet, rather than bathing, a basin of water can be used for soaking an extremity or a washcloth soaked in warm water to the face. For pain and discomfort, the patient or caregiver should be taught to avoid any irritating additives to the bath and to consider premedication or activities for pain management. Distraction or other means of comforting children or adults are preferred. To encourage bath time, adding age-appropriate toys will help young children or soothing music for the adolescent or adult. Young children must be supervised during baths.

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