Guidelines on the Management of Atopic Dermatitis ... - Dermatology

Bathing practices [1+; A]
Although salt has been used for centuries for treating skin diseases – including dermatitis –
according to a systematic review 5 there is little evidence to support the use of salt baths for
treating atopic dermatitis. Contrary to this practice, hard water has been thought to play a
role in triggering atopic dermatitis. In a randomised controlled study done in the United
Kingdom, there were no benefits demonstrated when ion exchange water softeners were
used. 6 These softeners removed predominantly calcium, but not other contaminants.
The use of emollients is a cornerstone of atopic dermatitis management, but in a systematic
review of randomised controlled studies, Tarr et al reported little evidence for the addition of
emollients to the bath water. 7
Infections are accepted as triggers for atopic dermatitis and have been implicated as the
cause in those with poor control. Previous reviews have shown no benefit 5 and an updated
Cochrane systematic review confirmed lack of benefit for the use of bath antiseptics for
infected or non-infected atopic dermatitis patients. 8
Further study is required to determine the efficacy of various cleansers used in bathing, the
role of bathing as a steroid-sparing modality, and the optimal duration of bathing. Emollients
applied during or after bathing provide a surface lipid film retarding evaporative water loss
from the epidermis.
Table 5: The current recommendations for bathing:
Regular bathing to hydrate the skin and debride crust – useful for most patients for
both cleansing and hydrating the skin;
Bathe once daily for several minutes in warm (not hot) water;
Use a moisturising cleanser;
Avoid antibacterial cleansers (may lead to bacterial resistance);
After bathing, pat dry; and
Emollients should be applied immediately after bathing.
Antiseptics and antimicrobials [1+; A]
Although secondary infection and colonisation of damaged skin by bacteria is
understandable, the role of bacteria in the pathogenesis of atopic dermatitis is not clear. 9
Evidence for the regular use of antimicrobial and antiseptic agents in the control of
uninfected dermatitis has been reported in a systematic review 5 of trials that included
children, adolescents and adults. There was little evidence to support the use of antiseptics
in either bath water or if applied directly to the skin. The intermittent use of short-term
mupirocin was of benefit for relapsing atopic dermatitis that was not overtly infected, but
there is concern for emerging resistant organisms. There were no randomised control trials
supporting the use of oral antibiotics.
No benefits for the regular use of topical antifungals in addition to topical steroids were found
for 60 adult patients with head and neck involvement, although yeast colonisation fell
significantly.
In a more recent review of the subject of antimicrobial use in atopic dermatitis control, no
benefit when used as a topical agent or bath additive was found. 8