Dr. Joseph Lam (biography and disclosure)
What I did before
Atopic dermatitis (AD) is a chronic relapsing disease which involves pruritus and eczematous lesions, affecting 15% to 20% of the childhood population (1). Staphylococcus aureus infection is the most common complication of AD.
Patients with AD have a very high rate of S aureus colonization (76-100%) as compared to healthy controls (2-25%) (2, 3). Even when the S aureus is not causing a bacterial superinfection, its presence can exacerbate AD through superantigens which induce the release of proinflammatory cytokines.
While S aureus can be treated with topical and/or systemic antibiotics, it is preferable to avoid frequent antibiotic use on patients, especially with the emergence of community-acquired methicillin-resistant S aureus (CA-MRSA).
What changed my practice
In 2009, Huang et al published a study looking at whether or not suppression of S aureus growth with sodium hypochlorite (bleach) baths and intranasal mupirocin improves AD severity (4). In this study, they took 31 patients (aged 6 months to 17 years) with moderate to severe AD and evidence of bacterial infection and randomized them to receive active treatment versus placebo (they did not do bleach-only or no mupirocin group). After treating all with a 2 week course of cephalexin, participants were instructed to add 1/2 cup (0.12 L) of 6% bleach (treatment group) or water (placebo group) to a full bath of water and to bathe in this solution twice weekly for 3 months. Participants were also asked to apply mupirocin ointment (treatment group) or petroleum ointment (placebo group) intranasally for 5 consecutive days, once per month for 3 months.
After 3 months, the treatment group had a dramatic difference in their Eczema Area and Severity Index (EASI) score compared with placebo. As well, participants in the treatment group also showed a greater mean reduction in the proportion of BSA (body surface area) affected at both 1 and 3 month. Interestingly, these differences were only seen in the submerged areas, and not in the head and neck areas.
What I do now
Although the hallmark of AD treatment is education, avoidance of triggers, moisturization and topical anti-inflammatory medications (topical corticosteroids or topical calcineurin inhibitors), dilute bleach baths are an effective adjuvant antiinfective treatment that can help decrease the number of local skin infections and reduce the need for systemic antibiotics for patients with AD with heavily colonized and/or superinfected skin. I usually recommend 1/2 cup of 6% bleach for 1/3 to 1/2 of an adult bathtub. Earlier studies looking at the concentration needed to kill a resistant bacteria known as methicillin-resistant Staph aureus (MRSA) used higher concentrations (5). In general, I recommend to avoid getting this in the eyes and to use caution in those with a known allergy to bleach. However, practically, there are no significant side-effects. This concentration of dilute bleach is similar to what was used in the past to sterilize water.
References (Note: Article requests might require a login ID with CPSBC or UBC)
1. Eichenfield LF. Consensus guidelines in diagnosis and treatment of atopic dermatitis. Allergy. 2004;59(suppl 78):86–92 (View article with CPSBC or UBC)
2. Higaki S, Morohasi M, Yamagishi T, Hasegawa Y. Comparative study of staphylococci from the skin of atopic dermatitis patients and from healthy subjects. Int J Dermatol. 1999;38(4): 265–269 9. (View article with CPSBC or UBC)
3. Abeck D, Mempel M. Staphylococcus aureus colonization in atopic dermatitis and its therapeutic implications. Br J Dermatol. 1998;139(suppl 53):13–16. (View article with CPSBC or UBC)
4. Huang JT, Abrams M, Tlougan B, Rademaker A, Paller AS. Treatment of Staphylococcus aureus colonization in atopic dermatitis decreases disease severity. Pediatrics. 2009 May;123(5):e808-14. (View article with CPSBC or UBC)
5. Fisher RG, Chain RL, Hair PS, Cunnion KM.Hypochlorite killing of community-associated methicillin-resistant Staphylococcus aureus. Pediatr Infect Dis J. 2008 Oct;27(10):934-5 (Abstract, or view with CPSBC or UBC)
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Was using this in practice at 1/4 cup per tub. Hard to say what a full tub is and with a small child the tendency would be to use less water in the tub.
very informative
I look after a population that is heavily colonized with MRSA.
No access to bathtubs and water is rationed.
Would like to see results on affected head and neck from washing that area at the same time as bathing the rest of the body. Closure of the eyes should be sufficient for protection from irritation.
Interesting approach. Will give it a try with next patient
will try on my resistant atopic dermatitis patients and will inform after use.
A larger sample size with perhaps a cross-over approach would be important to add strength to this small study and make more general recommendations. Double-blind would be difficult.
Is this study so strongly positive that a larger one is not needed?
I have a number of treatment resistent patients with AD. There are multiple factors but I do like this very basic approach – certainly as an adjunct to usual tx.
Its intresting.will start doing this approach.
this is a simple adjunct for those difficult cases-good to see the research (and experience)supports use of bleach.
This is an old practice that has come around again. Years ago Dettol was used in the same way and with the same efficacy.
Good information to try on at risk population especially if there is minimal side effects.
What about nasal mupirocin administration (dose, frequency, duration), effect on AD and effect on bacterial resistance?
Sounds so simple but is there no danger from splashes into the eyes by accident?
Great suggestion-as significant AD is distressing to families.
This info is too “loose”. What does a full bathtub mean?. The fact that participants were also given another treatment, i.e. intanasal bactroban, totally confounds the study. Moreover, I thought there recently was an advisory not to use bactroban intranasally.
Nevertheless, it is interesting information and I may wnat to try using bleach.
Replies by Dr. Joseph Lam:
In practice, I add 1/4 to 1/2 cup to an adult tub that is anywhere from 1/3 to 1/2 full. In fact, earlier studies looking at the concentration needed to kill methicillin-resistant Staph aureus (MRSA) used higher concentrations (1/2 cup in 1/4 adult tub of water) (see Fisher et al below). For facial eczema, I advise patients to soak a washcloth in the bathwater to apply to the face (and ensure they rinse). However, this is not addressed by the study.
Fisher RG, Chain RL, Hair PS, Cunnion KM.Hypochlorite killing of community-associated methicillin-resistant Staphylococcus aureus. Pediatr Infect Dis J. 2008 Oct;27(10):934-5. (http://www.ncbi.nlm.nih.gov/pubmed/18756186)
This is not a new practice, and has been done by many practitioners, most often pediatric dermatologists and dermatologists. However, the study adds some support (and renewed interest) in bleach (a cheap and effective adjunct to treatment).
The study itself, however, isn’t perfect. The intervention group used both nasal mupirocin and bleach baths. There was no bleach bath arm alone. As well, although the study arms were blinded in theory, in reality, the smell of bleach will give away which group the patients were randomized to.
With regards to the nasal mupirocin, this was applied intranasally twice daily for 5 consecutive days of each month. However, the role of the nasal mupirocin is unclear (as suggested by the differential improvement in only the submerged areas).
I think that this is worth trying out in my patients with AD. I would appreciate more specifics re exact amount of household bleach to what size tub, and how long to soak. I would think the facecloth soaked in the bath water applied to the face neck or scalp would be a helpful tip.
What role does treating for two weeks with Cephalexin prior to the baths play?
very interesting, worth a try especially on these really severe cases of AD
I hope that more studies with a larger sample size and cross-over design would be done to confirm this interesting treatment approach. If truly effective, it would be a very helpful adjunct for treatment-resistant AD due to its inexpensive ingredients.
I have doubts about the intranasal mupiricin being contributory.
I would certainly try it on some of my patients.
Might also help in severe cases where parental anxiety & avoidance of “high dose” topical corticosteroids may be contributing/exacerbating the problem.