Research letter

Comparing the effect of bleach and water water or 0
005% dilute hypochlorite solution bath expo-
baths on skin barrier function in atopic sure.3,12,13 The randomization was performed prior to recruit-
dermatitis: a split-body randomized controlled ment by the study coordinator, and stored in sealed envelopes
trial that were not opened until the patient was recruited by the
investigators. Participants remained blinded to the water or
DOI: 10.1111/bjd.14483 dilute hypochlorite immersion. Each arm was immersed for
10 min. None of the patients bathed or applied topical mois-
turizers or medications for 12 h prior to the study session.
DEAR EDITOR, Atopic dermatitis (AD) is a chronic inflammatory
Skin barrier function parameters, including hydration (Mois-
skin disease associated with defective epidermal barrier func-
tureMeter SC; Delfin Technologies, Stamford, CT, U.S.A.),
tion, characterized by decreased stratum corneum (SC) hydra-
TEWL (Tewameter; Courage and Khazaka, Cologne, Germany)
tion, and increased transepidermal water loss (TEWL) and pH.
and pH (Dry Skin pH Meter; Hanna Instruments, Woonsocket,
Staphylococcus aureus skin colonization is present in nearly all
RI, U.S.A.), were measured at baseline, immediately postim-
cases of AD exacerbation and correlates with disease severity,1
mersion, and 15, 30 and 60 min postimmersion. Patients
suggesting an infection–inflammation cycle. The use of a
were asked to report skin discomfort, including itching, burn-
sodium hypochlorite (bleach) bath alone and as an adjunct to
ing or pain during the 10-min immersion and throughout the
intranasal mupirocin ointment is associated with a reduction
postimmersion period. All recruited patients completed the
in AD severity,2,3 and decreases annual skin infection cases
study. A priori power analysis showed that evaluation of 10
10-fold.4 In a Cochrane review on various interventions to
patients with AD and 10 healthy controls would yield > 90%
reduce S. aureus colonization, including oral antibiotics, topical
power at a = 0
05 to detect a difference of 15% in TEWL
steroids and antibiotic ointments, only bleach bath showed a
(primary end point) after bleach immersion compared with
significant improvement in AD severity.5 Bleach bath appears
water immersion. Intra- and interindividual comparisons were
to be a low-cost and effective adjuvant treatment for AD, and
performed by ANOVA with a paired analysis performed for
is recommended by the American Academy of Dermatology
intraindividual comparisons.
and American Academy of Allergy, Asthma and Immunol-
ogy,6,7 particularly for patients with moderate-to-severe AD
and frequent bacterial infections. Although bleach bath is gen- Table 1 Demographic data of study participants
erally well-tolerated, with no existing report on skin irritation,
it may be difficult to convince patients and parents that a Healthy
potential irritant is beneficial for the sensitive skin of patients participants Patients with AD
with AD.8 The goal of this study was to compare the effect of Upper
bleach bath vs. water bath exposure on skin barrier function Age Age GLOBAL limb Overall
by measuring SC hydration, TEWL and pH in patients with (years) Sex (years) Sex EASI11 EASIa severity
AD and healthy subjects. 27 F 32 M 55
0 11
0 Severe
The study was approved by the institutional review board 31 M 24 F 6
1 1
6 Mild
of University of California, Davis (# 523979). The study was 33 M 13 F 15
2 3
2 Mild
registered on ClinicalTrials.gov (NCT02594969). Ten patients 22 M 45 F 22
0 6
4 Moderate
with concurrent AD (mean age 26
3 years, range 12
0–45
0) 31 F 18 M 16
4 4
2 Mild
25 F 12 F 6
4 0 Mild
and 10 healthy subjects (mean age 28
5 years, range 22
0–
27 M 28 F 4
8 1
2 Mild
34
0) were enrolled between 2014 and 2015. The entire 25 M 43 M 60
0 12
0 Severe
study was performed at University of California, Davis. Demo- 34 F 27 M 34
9 12
8 Moderate
graphic data are summarized in Table 1. Testing was con- 30 M 21 M 50
0 19
2 Moderate
ducted on the volar surfaces of the forearms, a commonly
AD, atopic dermatitis; EASI, eczema area severity index; F,
used study site for topical applications.9,10 AD severity was
female; M, male. a(Erythema + induration/population + excoria-
determined by the global eczema area severity index (EASI)
tion + lichenification) 9 0
2 (area is defined on a 7-point ordi-
and modified local EASI for upper limbs.11 Each patient served nal scale: 0 = no eruption; 1 = 1–9% eruption; 2 = ≤ 10–29%;
as their own control and a priori binary randomization was 3 = ≤ 30–49%; 4 = ≤ 50–69%; 5 = ≤ 70–89%; 6 = 90–100%).
performed to determine which forearm would receive tap

© 2016 British Association of Dermatologists British Journal of Dermatology (2016) 1

2 Research letter
Outcome measures are presented in Figure 1. Strikingly,
bleach bath exposure did not disrupt barrier function any
more than exposure to tap water. There was no statistical dif-
ference in mean hydration, TEWL and pH status between tap
water and bleach bath exposures in patients with AD and
healthy participants at all time points measured. In patients
with AD, bleach and water baths resulted in an immediate and
drastic increase in mean SC hydration (285% for bleach and
313% for water bath), TEWL (328% for bleach and 427% for
water bath) and pH (107% for both bleach and water baths),
followed by recovery to near baseline levels by 15 min
postimmersion, and maintained for 60 min. Healthy partici-
pants had very similar trends. None of the participants
reported discomfort. The investigators did not observe
increased erythema or signs of irritation in any of the partici-
pants.
This study indicated no statistical change in skin barrier
function between bleach bath and water bath. Bathing tem-
porarily introduces moisture to the skin, presented by a peak
in hydration status immediately postimmersion. TEWL and pH
status peaked at 15 min, likely due to increased local water
concentration and evaporation. None of the participants
reported irritation associated with bleach baths.
(a)
(c)
Fig 1. Changes in skin barrier function due to bleach and water baths. Hydration and transepidermal water loss (TEWL) Values are normalized to
baseline reading. Percentage baseline, (a) hydration, (b) TEWL and (c) pH vs. time are graphed for patients with atopic dermatitis (AD) and
healthy participants. All three parameters were measured three times to achieve an average value with SD. pH values for patients 1–3 were not
obtained owing to equipment malfunction.
British Journal of Dermatology (2016)
This study attempted to understand the evidence of the
safety for the recommendation of bleach bath use for patients
with AD. The study clearly showed that bleach baths are well
tolerated, safe and pose no negative effect on SC hydration,
TEWL or pH. Practitioners can educate patients that a bleach
bath provides antimicrobial benefits without damaging the
skin barrier any more than bathing with water alone. As
bleach baths are typically taken more than once weekly, the
effect of repeated bleach bath exposure on skin barrier func-
tion is unknown. This study did not rinse off the dilute
hypochlorite water prior to testing. However, it would be use-
ful to study the effect of bleach baths followed by rinsing
with tap water, as recommended in real-life practice. There-
fore, our methodology has higher potential for irritation and,
despite this, the protocol was well tolerated. Exposure to 1%
sodium hypochlorite can cause immediate contact urticaria;8
therefore, patients should be counselled on proper bleach
dilution techniques to achieve approximately 0
005% sodium
hypochlorite [1/2 cup (0
36 L) of common household bleach
into a standard 40-gallon (150 L) bathtub full of water] in
order to prevent skin irritation and hypersensitivity reaction
that may develop with higher bleach concentrations. Emollient
use after bathing has been demonstrated to improve skin
(b)
© 2016 British Association of Dermatologists

hydration.10 Future studies are needed to examine the effect
of emollient application after water and bleach bath on skin
barrier function.
1 1
Department of Dermatology, University of V.Y. SHI
California, Davis, Sacramento, CA, U.S.A. N. FOOLAD1
2
University of California, Davis, School of J.N. ORNELAS2
Medicine, Sacramento, CA, U.S.A. L.A. HASSOUN2
3
Departments of Pediatrics and Dermatology, G. MONICO2
University of California, San Diego, School N. TAKEDA2
of Medicine, San Diego, CA, U.S.A. S. SARIC2
4 2016).
Pediatric and Adolescent Dermatology, Rady N. PRAKASH1
Children’s Hospital, San Diego, CA, U.S.A. L.F. EICHENFIELD3,4
E-mail: rksivamani@ucdavis.edu R.K. SIVAMANI1
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© 2016 British Association of Dermatologists
Research letter 3
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Funding sources: none.
Conflicts of interest: none declared.
British Journal of Dermatology (2016)