For children with eczema, daily bathing and moisturizing is best

Daily bathing followed by moisturizing—known as “soak and smear”—controls children’s atopic dermatitis better than less frequent bathing, allergy specialists concluded in the July 2016 issue of the journal Annals of Allergy, Asthma and Immunology.

It’s been a question that has dogged allergists for more than a century: How often should a child with eczema be bathed?

“A number of medical groups have commented on the general role of bathing in eczema. But they don’t all agree on the best bathing practices,” said lead author Ivan D. Cardona, MD, an allergist and immunologist in Portland, ME.

In a 2014 study, Dr. Cardona and colleagues found that primary care physicians recommended daily bathing less than 50% of the time for children with atopic dermatitis, while specialists (dermatologists, allergists, and immunologists) recommended daily bathing more than 50% of the time. 

Such mixed messages leave parents perplexed—more than 75% of parents reported being confused and frustrated with this kind of conflicting advice from their child’s doctors, the researchers found in an earlier study.

“Because parents are confused, and because they often take their questions to their allergist, we wanted to examine the studies that have been published on the topic, and see if there was agreement on just how often children with eczema should be bathed,” Dr. Cardona explained.

Confusion about the frequency of bathing stems from the paradox that water can be good and bad for skin. This had led to two differing schools of thought about the issue.

In one corner are physicians who think infrequent bathing (defined as less than once a day) is the best way to avoid irritating the skin. They believe infrequent bathing helps keep skin hydrated because it avoids evaporative water loss, which can dry out the skin. Less frequent bathing also means less use of the soaps that increase stratum corneum pH and contribute to skin barrier breakdown.

In the other corner are those who favor of frequent bathing—at least once a day. These physicians argue that the presence of xerosis requires rehydration with daily baths. They believe in limited use of pH balanced skin cleansers, along with gentle patting dry, followed by the immediate application of an emollient to “seal” in moisture—a process dubbed “soak and smear.”

“The smear part is really the most important element, because unless moisturizer is applied immediately, then the skin is likely to dry out even more,” said co-author Neal Jain, MD, an allergist and immunologist in Phoenix, AZ.

The authors explained that a better understanding of skin barrier defects that contribute to transepidermal water loss—such as increased skin protease activity in the stratum corneum, ceramide deficiency, and filaggrin deficiency—support their recommendation for frequent bathing.

“The weight of the evidence in the literature we reviewed and our experience in caring for these patients suggests daily bathing with ‘soak and smear’ is more effective for soothing dry skin from eczema,” Dr. Jain concluded.