Step-Wise Treatment of Atopic Dermatitis: Basics and Beyond

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


Pediatr Nurs. 2020;46(2):92-98. 

In This Article

Bath Additives and Bleach Baths

Additives to the bath remain at times unproven or controversial. Bath oils, acidic spring water, and water softeners should also be avoided as a general rule (Fleischer et al., 2017). Addition of oatmeal to the bath water may be soothing to patients but does not promote skin hydration, while bath oils may give the patient a false sense of lubrication and can make the tub slippery. Antibacterial skin cleansers may dry and aggravate the skin, so less irritating and moisturizing cleansers should be used after initial soaking.

There are several current recommended guidelines. Bleach (sodium hypochlorite) baths are easy to perform and inexpensive intervention, although their efficacy in treating AD has been questioned. The ease and low cost has likely contributed to their being frequently recommended adjuvant therapy in patients with AD. Bleach baths are thought to reduce skin inflammation and thereby decrease colonization of S. aureus bacteria on the skin. This can be beneficial because Staphylococcal exotoxins are known to exacerbate AD, and severity of AD correlates with S. aureus density on the skin. A systematic review found that the addition of bleach as a disinfectant did not provide further clinical benefit than bath water alone (Chopra et al., 2017). However, there are limitations with all current available studies. For instance, one primary study showing efficacy in clinically improving moderate-to-severe AD in children with the addition of dilute sodium hypochlorite in bath water (bleach baths) also used intermittent applications of intranasal mupirocin as part of the study (Huang et al., 2009).

The amount of bleach per volume of water and the frequency of baths has also not been well-studied. Generally, patients prepare a bleach bath with only one-quarter to one-half of a cup of 6% sodium hypochlorite (chlorine bleach) to a tub of water. How much water constitutes a "tub" has been debated, which adds to the confusion. Common side-effects of bleach baths include increased xerosis and irritation of skin and nasal passages. Regardless of the vague instructions and lack of evidentiary support, multiple clinicians still feel that patients with more moderate-to-severe AD disease and those frequently infected, especially with methicillin-resistant S. aureus infections, may benefit from a trial of once- or twice-weekly dilute bleach baths. Future larger scale randomized controlled trials are needed to address the known limitations.