Can Salt Solution Bathing and Education Improve Skin Care for Atopic Dermatitis?

Case Report

J Pediatr & Child Health Care. 2020; 5(1): 1029.

Can Salt Solution Bathing and Education Improve Skin Care for Atopic Dermatitis?

Peroni DG1*, Mazloum DE2, Pecoraro L2, Pigozzi R² and Cicco MED1

1Department of Clinical and Experimental Medicine, University of Pisa, Italy

2Department of Surgical Sciences, University of Verona, Italy

*Corresponding author: Diego Peroni, Professor of Pediatrics, Department of Clinical and Experimental Medicine, Section of Paediatrics, University of Pisa, Italy

Received: January 20, 2020; Accepted: February 11, 2020; Published: February 18, 2020


Atopic dermatitis (AD) is a multifactorial, chronic inflammatory skin disorder resulting from disruption of the epithelial barrier and inflammation. A wide range of treatments are currently available for AD, aimed to restore impaired skin barrier and control inflammation. In order to avoid systemic therapy, the soak and smear technique, the Wet-Wrap Treatment (WWT) with physiologic lipid-based barrier repair therapy and proactive use of topical corticosteroids, can represent an alternative and excellent option, with encouraging results. We report this strategy (“global topical approach”) in a 12-year-old girl with severe AD, with no longer satisfactory response to topical therapy. We discuss the utility of bathing and evaluated the Hill’s criteria for causation for the use of a new salts’ composition to be added to water during soaking.

Keywords: Atopic eczema; Atopic dermatitis; Bath; Children; Salt solution; Treatment


Bathing is suggested as an advantageous non-pharmacologic intervention for the regular skin care of patients with Atopic Dermatitis (AD) in the latest guidelines of the American Academy of Dermatology [1]. Indeed, regular bathing with water can not only hydrate the skin, but also remove scale, crust, irritants, and allergens [2], enhance penetration of topical agents and give emotional and social benefits to patients [3]. However, those effects can be different depending on the bathing practices, and currently there is no appropriate standard for the frequency or duration of bathing for patients with AD. Moreover, it is still unclear whether the addition of oils, emollients, and other additives to bath water may produce further benefits for management of AD. Therefore, the role of bathing as a complementary treatment strategy for AD remains a matter of debate [1].

Colloidal grain suspensions added to bath have been used for decades as adjuncts in the treatment of AD. Nevertheless, oat and wheat ingredients in cosmetics and personal care products may increase the risks of sensitization to these grains through the skin, and may result in immediate- and delayed-type hypersensitivity reactions [4]. Therefore, it has been suggested to avoid topical application of oat proteins in infants with AD [5].

Dilute bleach baths have been proposed to suppress epidermal Staphylococcus aureus load in patients with AD, but a recent metaanalysis suggested that although bleach baths are effective in decreasing AD severity, they do not appear to be more effective than water baths alone [6].

Bath oil can be added to the tube after the patient has soaked for 15-20 minutes in order to seal the moisture in the hydrated skin. However, patients usually add bath oil before entering the tube and this creates a film of oil over the skin, which can reduce the penetration of water into the stratum corneum and decrease the effectiveness of the soak and smear technique [7]. In line with this observation, a recent pragmatic open label trial, which randomized 483 children (aged 1-11 years) with atopic dermatitis to regular use for 12 months oily or oat-based emollient bath additives versus no bath additives, found no evidence of clinical benefit from including emollient bath additives in addition to standard topical eczema management strategy [8].

The question whether the addition of salts and non-irritating, non-sensitizing substances to water baths can improve skin care and long-term maintenance in children with AD remains unanswered.

Clinical Scenario

A 12-year-old Nigerian girl with eczema since infancy, diagnosed with Atopic Dermatitis (AD) associated with asthma and allergy to multiple inhalant allergens. Due to a progressive worsening eczema her sleep was seriously disturbed with consequent compromised school attendance. She was admitted to our Clinic for “progressively worsening of atopic dermatitis and severely quality of life disturbing itching”.

At physical examination, she presented with dry skin all over her body and lichenification on the flexor surface of both elbows and knee joints, as well as on the inguinal and lumbar regions. The mean Scoring Atopic Dermatitis (SCORAD) score at baseline was 82 (severe diseases if SCORAD > 50). As long as the home run treatment with moisturizers and topical corticosteroid had not raised any results, we decided to start a soak and smear treatment7 and the wet-wrap therapy in addition to the topical treatment [9].

In practice, prior to any topical treatment we decided to bath the girl in a tube for 15-20 minutes using a dose of plane water sufficient to cover the entire body surface with the addition of 60 g of a new salt solution containing MgCl, MgSO4, NaCl, urea, and allantoin (Idrocristalli Envicon®, Envicon Medical Italy).

Without drying the skin we than used the wet-wrap therapy [9]. This consisted first in the application on flared skin areas for 2 times a day of a topical corticosteroid (0.05% fluticasone cream, Flixoderm®., GSK) together with a the correct amount [10] of a physiologic lipidbased barrier repair emollient [11] containing an equimolar ratio of ceramide, cholesterol and ≥1 fatty acids, as well as hyaluronic acid, plus another emollient containing glycyrrhetinic acid and vitis vinifera (Envicer3® and Enviplus®, Envicon Medical Italy). Secondly, we cutted the tubular bandages (cotton wool-Envitube®, Envicon Medical Italy) to fit arms, legs, and trunk (Figure 1) and moistened them in the same warmed saline water used for the bath before application onto the patient’s skin. Two other layers of dry tubular bandages were then fitted over the previous layer and kept in place for 11-12 hours. This “global topical strategy” resulted in an evident clinical improvement of the lesions confirmed by a mean SCORAD of 37 one week later (Figure 2a, 2b).