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Year : 2017  |  Volume : 18  |  Issue : 3  |  Page : 176-179

Atopic dermatitis: General care of the skin

1 Department of Pediatric Dermatology, Institute of Child Health, Kolkata, West Bengal, India
2 Department of Pediatric Dermatology, Wadia Children Hospital, Mumbai, Maharashtra, India
3 Consultant Pediatric Dermatologist, Kanchi Kamakoti Childs Trust Hospital, Chennai, Tamil Nadu, India
4 Consultant Pediatric Dermatologist, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
5 Department of DVL-1, CMC, Vellore, Tamil Nadu, India
6 Department of Dermatology, Sri B M Patil Medical College, BLDE University, Bijapur, Karnataka, India
7 Hon. Pediatric Dermatologist, Wadia Hospital for Children, Mumbai, Maharashtra, India
8 Professor of Dermatology, Vivekananda Institute of Medical Science, Kolkata, West Bengal, India
9 Department of Dermatology, Sharda Hospital, Greater Noida, Uttar Pradesh, India
10 Department of Dermatology, Lady Hardinge Medical College, Delhi, India
11 Department of Dermatology, MAMC and Associated LNGP Hospital, New Delhi, India
12 Consultant, Dermatologist, S D M Hospital, Jaipur, Rajasthan, India

Date of Web Publication7-Jun-2017

Correspondence Address:
Sandipan Dhar
Flat 9C, Palazzo, 35, Panditia Road, Kolkata - 700 029
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Source of Support: None, Conflict of Interest: None

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How to cite this article:
Dhar S, Parikh D, Rammoorthy R, Srinivas S, Sarkar R, Inamadar A, Shah M, Banerjee R, Kanwar AJ, Mendiratta V, George R, Gulati R. Atopic dermatitis: General care of the skin. Indian J Paediatr Dermatol 2017;18:176-9

How to cite this URL:
Dhar S, Parikh D, Rammoorthy R, Srinivas S, Sarkar R, Inamadar A, Shah M, Banerjee R, Kanwar AJ, Mendiratta V, George R, Gulati R. Atopic dermatitis: General care of the skin. Indian J Paediatr Dermatol [serial online] 2017 [cited 2021 Jan 16];18:176-9. Available from: https://www.ijpd.in/text.asp?2017/18/3/176/207610

Various factors can aggravate AD and trigger itching. Modifying these factors will often help in better control of AD and diminish the need of pharmacologic agents.


Bathing can help hydrate the skin and help remove crusts, irritants such as sweat, allergens and mechanically eliminate bacterial contaminants in the case of bacterial superinfection. The duration of the bath should not exceed 5–10 min. Longer exposure can disrupt the structural integrity of the skin barrier.[1] Water should be lukewarm or cool, as temperature extremes can trigger off itch.[2] Bathing at least once a day is recommended.[3] Applying a moisturizer immediately after bathing is recommended to maintain skin hydration.[4] After bathing, it is advisable to pat the skin dry and avoid strong scrubbing or rubbing.[5] Alkaline soaps and surfactant-based cleansers should be avoided because they can worsen dryness, and cause irritant and allergic contact dermatitis.[6],[7] Syndets or non-soap cleansers with a pH of 5.5 are preferable. Antiseptic-containing cleansers are not recommended due to the limited duration of action and lack of sufficient data for efficacy.[8]

Bleach baths decrease staphylococcal colonization and decrease AD severity.[9],[10],[11],[12] Staphylococcus aureus colonization is present in most of the cases of AD exacerbation and correlates with disease severity. This involves soaking the body neck down in a tub filled with water (about 150 L) in which half a cup of 6% household bleach has been added. Given the lack of space in most Indian households, most parents would find it difficult to administer bleach tub baths to their children. In such a situation, 1 teaspoonful (around 5 ml) of bleach can be added to a bucket of around 15 L of water. A soft cloth soaked into this well-mixed solution can be used for compresses on the skin for around 10 min. Use of shampoos, especially during winters has been associated with AD flares.[2] It appears logical to rinse off soap and shampoo residue from regions such as the hairline, retroauricular region, side of the nose, and jawline.[13]

Exposure of atopic skin to scum produced due to exposure to hard water has been thought to be an aggravating factor. A cohort study of 1638 Spanish cohorts did not find any association between eczema and water hardness at home or bathing exposure during the first 4 years of life.[14] A more recent study of 1303 3-month-old infants concluded that high domestic calcium carbonate levels were associated with an increased risk of AD.[15] In a randomized controlled trial of 336 children with moderate to severe AD, the use of ion-exchange water softeners did not significantly improve the Six Area Six Sign Atopic Dermatitis score.[16] (Strength of recommendation A, Level of evidence 1).


Coarse irritating fabrics and fibers cause primary skin irritation and are preferably avoided. Occlusive clothing that can induce heat sensation is not appropriate. We recommend smooth, soft, loose, full-sleeved cotton clothes to patients with AD. Woollen garments if worn, should have an inner layer of cotton.


Low humidity and low environmental temperature lead to a general decrease in skin barrier function and increased susceptibility to mechanical stress.[17] Hot humid climate and sweating can aggravate AD.[2] In hot weather, using air conditioning or use of desert coolers during summer can be very helpful. For dry climates, humidifiers have been used for AD patients, but no systematic studies have been done. In patients who cannot afford air conditioning, one can recommend bathing twice a day and being under the fan and well-ventilated areas.

Some patients with AD develop dry skin or increased cutaneous inflammation with frequent swimming in public pools. The amount of free residual chlorine may impact the skin barrier and contribute to AD exacerbation.[18]


House dust mites (HDMs) are ubiquitous organisms that accompany homes and are most commonly present in dust from mattresses and flooring. HDMs live in a complex ecosystem comprising humidity, ambient temperature, and organic matter. The rate of AD patients sensitized to house dust can be quite high.[19] The severity of AD in children without sensitization to HDM appears to be related to indoor concentrations HDMs, and this concentration probably acts as a nonspecific irritant as well as an allergen.[20] Various interventions have been attempted to minimize house dust exposure, notably covers for bedding and mattresses, high-quality vacuuming of mattresses and carpets and sprays that kill HDMs. A Cochrane review found implications of these in clinical practice of questionable significance (Strength of recommendation B, Level of evidence 2).[21]

Recommendations for general skin care

  • Bathe at least once a day. Avoid very hot and cold water baths and restrict bathing time to 5–10 min (Strength of recommendation C, Level of evidence 3)
  • Cleanse the skin before application of topical medications (Strength of recommendation C, Level of evidence 3)
  • Apply moisturizers after bath to slightly damp skin as soon as possible (Strength of recommendation C, Level of evidence 3)
  • Use syndets or non-soap cleansers with pH 5.5 (Strength of recommendation C, Level of evidence 3)
  • Soaps and shampoos should be rinsed off thoroughly. Shampooing away from the body will minimize contact with atopic skin. We recommend pH balanced mild shampoo (Strength of recommendation C, Level of evidence 3)
  • Bleach baths may be advised in moderate or severe AD with crusted lesions and patients with recurrent staphylococcal infection. We recommend bleach baths 1–2 times a week for at least 6–8 weeks (Strength of recommendation B, Level of evidence 2)
  • Soft, loose, full-sleeved cotton clothes with a smooth texture are recommended (Strength of recommendation C, Level of evidence 3)
  • During summer months, air conditioning/desert coolers in patients when feasible can be useful (Strength of recommendation C, Level of evidence 3)
  • In patients for whom air conditioning is not feasible, measures to minimize sweating like use of fans and to improve ventilation are helpful (Strength of recommendation C, Level of evidence 3)
  • Avoid swimming in acute flares (Strength of recommendation C, Level of evidence 3)
  • Damp dusting, wet mopping, and vacuuming for HDM control can be useful adjuncts (Strength of recommendation C, Level of evidence 3)
  • Avoid furred soft toys. Prefer washable cotton soft toys (Strength of recommendation C, Level of evidence 3)
  • Trimming child's nails is important to reinforce (Strength of recommendation C, Level of evidence 3)
  • Gentle oil massage using bland oils such as coconut and sunflower oil (not against the direction of hair follicles) in the absence of active dermatitis is permissible (Strength of recommendation C, Level of evidence 3)
  • We recommend delaying ear piercing as much as possible, preferably to around 8 years of age (Strength of recommendation C, Level of evidence 3).

Financial Support and Sponsorship

This activity was sponsored by Curatio Health Care (I)Pvt. Ltd. from their unlimited Educational Grant.

Conflicts of Interest

There are no conflicts of interest.

  References Top

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Langan SM, Bourke JF, Silcocks P, Williams HC. An exploratory prospective observational study of environmental factors exacerbating atopic eczema in children. Br J Dermatol 2006;154:979-80.  Back to cited text no. 2
Eichenfield LF, Tom WL, Berger TG, Krol A, Paller AS, Schwarzenberger K, et al. Guidelines of care for the management of atopic dermatitis: Section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol 2014;71:116-32.  Back to cited text no. 3
Simpson E, Trookman NS, Rizer RL, Preston N, Colón LE, Johnson LA, et al. Safety and tolerability of a body wash and moisturizer when applied to infants and toddlers with a history of atopic dermatitis: Results from an open-label study. Pediatr Dermatol 2012;29:590-7.  Back to cited text no. 4
Kim JE, Kim HJ, Lew BL, Lee KH, Hong SP, Jang YH, et al. Consensus Guidelines for the treatment of atopic dermatitis in Korea (Part I): General management and topical treatment. Ann Dermatol 2015;27:563-77.  Back to cited text no. 5
Shukuwa T, Kligman AM. Disaggregation of corneocytes from surfactant-treated sheets of stratum corneum in hyperkeratosis on psoriasis, ichthyosis vulgaris and atopic dermatitis. J Dermatol 1997;24:361-9.  Back to cited text no. 6
Shaughnessy CN, Malajian D, Belsito DV. Cutaneous delayed-type hypersensitivity in patients with atopic dermatitis: Reactivity to surfactants. J Am Acad Dermatol 2014;70:704-8.  Back to cited text no. 7
Sidbury R, Tom WL, Bergman JN, Cooper KD, Silverman RA, Berger TG, et al. Guidelines of care for the management of atopic dermatitis: Section 4. Prevention of disease flares and use of adjunctive therapies and approaches. J Am Acad Dermatol 2014;71:1218-33.  Back to cited text no. 8
Huang JT, Abrams M, Tlougan B, Rademaker A, Paller AS. Treatment of Staphylococcus aureus colonization in atopic dermatitis decreases disease severity. Pediatrics 2009;123:e808-14.  Back to cited text no. 9
Huang JT, Rademaker A, Paller AS. Dilute bleach baths for Staphylococcus aureus colonization in atopic dermatitis to decrease disease severity. Arch Dermatol 2011;147:246-7.  Back to cited text no. 10
Barnes TM, Greive KA. Use of bleach baths for the treatment of infected atopic eczema. Australas J Dermatol 2013;54:251-8.  Back to cited text no. 11
Wong SM, Ng TG, Baba R. Efficacy and safety of sodium hypochlorite (bleach) baths in patients with moderate to severe atopic dermatitis in Malaysia. J Dermatol 2013;40:874-80.  Back to cited text no. 12
Katayama I, Kohno Y, Akiyama K, Aihara M, Kondo N, Saeki H, et al. Japanese Guideline for Atopic Dermatitis 2014. Allergol Int 2014;63:377-98.  Back to cited text no. 13
Font-Ribera L, Gracia-Lavedan E, Esplugues A, Ballester F, Jiménez Zabala A, Santa Marina L, et al. Water hardness and eczema at 1 and 4 y of age in the INMA birth cohort. Environ Res 2015;142:579-85.  Back to cited text no. 14
Perkin MR, Craven J, Logan K, Strachan D, Marrs T, Radulovic S, et al. Association between domestic water hardness, chlorine, and atopic dermatitis risk in early life: A population-based cross-sectional study. J Allergy Clin Immunol 2016;138:509-16.  Back to cited text no. 15
Thomas KS, Koller K, Dean T, O'Leary CJ, Sach TH, Frost A, et al. A multicentre randomised controlled trial and economic evaluation of ion-exchange water softeners for the treatment of eczema in children: The Softened Water Eczema Trial (SWET). Health Technol Assess 2011;15:v-vi, 1-156.  Back to cited text no. 16
Engebretsen KA, Johansen JD, Kezic S, Linneberg A, Thyssen JP. The effect of environmental humidity and temperature on skin barrier function and dermatitis. J Eur Acad Dermatol Venereol 2016;30:223-49.  Back to cited text no. 17
Seki T, Morimatsu S, Nagahori H, Morohashi M. Free residual chlorine in bathing water reduces the water-holding capacity of the stratum corneum in atopic skin. J Dermatol 2003;30:196-202.  Back to cited text no. 18
Jeong KY, Park JW, Hong CS. House dust mite allergy in Korea: The most important inhalant allergen in current and future. Allergy Asthma Immunol Res 2012;4:313-25.  Back to cited text no. 19
Kim J, Lee S, Woo SY, Han Y, Lee JH, Lee IY, et al. The indoor level of house dust mite allergen is associated with severity of atopic dermatitis in children. J Korean Med Sci 2013;28:74-9.  Back to cited text no. 20
Nankervis H, Pynn EV, Boyle RJ, Rushton L, Williams HC, Hewson DM, et al. House dust mite reduction and avoidance measures for treating eczema. Cochrane Database Syst Rev 2015;1:CD008426.  Back to cited text no. 21


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