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Bleach Baths for Atopic Dermatitis

Combined treatment with sodium hypochlorite and nasal mupirocin improved eczema severity, but we don’t yet know how or why.

Staphylococcus aureus colonization and infection is a common complication of atopic dermatitis (AD), due in part to defective epidermal barrier function and decreased antimicrobial peptides. In turn, S. aureus superantigens worsen the inflammation of AD. Dilute bleach baths are sometimes recommended to decrease bacterial colonization, but formal studies have been lacking. These authors performed a randomized, controlled study to determine whether bleach baths decrease eczema severity.

Thirty-one children (age range, 6 months–17 years) with moderate-to-severe AD and clinical signs of bacterial skin infection received 2 weeks of oral cephalexin before randomization. The treatment group bathed twice weekly in dilute bleach (0.5 cup of bleach to 40 gallons of bathwater) for 5 to 10 minutes, and patients and family members applied mupirocin to the nares twice daily for 5 consecutive days of each month. The control group used plain bathwater and applied petroleum jelly to the nares.

At baseline, S. aureus was cultured from 87% of skin and 81% of nares (7% of skin bacteria and 4% of nares bacteria were methicillin resistant [MRSA]; all were susceptible to mupirocin). Bleach baths were well tolerated. On the primary endpoint, compared with the control group, the treatment group had significantly improved Eczema Area Severity Index (EASI) scores at 1- and 3-month visits. In the treatment group, the mean EASI score was not improved in the head and neck area but was improved in the submerged body sites. At 3 months, the frequency of isolating S. aureus from skin and nares was unchanged, although quantitative cultures were not done to determine if the concentration of the bacteria had decreased.

Comment: Irrigation with dilute bleach was first used for infected wounds and as a perioperative antiseptic during World War I. The concentration used in this study was only 0.005%, more dilute than swimming pool water but apparently effective for reducing eczema severity. Antimicrobial therapy, including nasal mupirocin, has not been very successful in reducing atopic dermatitis severity, as the authors concede. Therefore, the bleach baths were likely the critical component and could have beneficial action independent of antimicrobial effects. Further study is needed to explore the mechanisms of benefit and to determine the optimal regimen. In the meantime, bleach baths are worth trying for patients with significant AD.

— Mary Wu Chang, MD, and Jan V. Hirschmann, MD

Published in Journal Watch Dermatology June 5, 2009

Citation(s):

Huang JT et al. Treatment of Staphylococcus aureus colonization in atopic dermatitis decreases disease severity. Pediatrics 2009 May; 123:e808. (http://dx.doi.org/10.1542/peds.2008-2217)

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