526980

research-article2014
CPJXXX10.1177/0009922814526980Clinical PediatricsKoutroulis et al

Article
Clinical Pediatrics

Frequency of Bathing in the 2014, Vol. 53(7) 677­–681

© The Author(s) 2014
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DOI: 10.1177/0009922814526980

To Bathe or Not to Bathe? cpj.sagepub.com

Ioannis Koutroulis, MD1,2, Katrina Petrova, MS2,

Panagiotis Kratimenos, MD1,2, and John Gaughan, MS, PhD, MBA3

Abstract
Background. Atopic dermatitis prevalence has increased in the developed world in recent decades, and effective
management is vital to improve patients’ quality of life. Methods. A prospective, randomized, case-control study
with a purposive sample of 28 children, aged 6 months to 10 years, diagnosed with atopic dermatitis. Participants
received bathing instructions to be followed either daily or twice a week, with a follow-up duration of 2 weeks.
Improvement of symptoms over time was measured using the SCORAD (SCORing Atopic Dermatitis) tool. Results.
Overall symptoms decreased significantly at follow-up compared with baseline (difference = 5.0938, confidence
interval = 0.2116 to 9.9759) but the differences in scores before and after interventions were not statistically
significant between the groups (difference = −1.0937, confidence interval = −5.9759 to 3.7884). Conclusions. The
frequency of bathing did not seem to play an important role in the management of atopic dermatitis. Clinicians
should focus on the need for adequate skin hydration.

Keywords
atopic dermatitis, bathing, frequency, eczema

Introduction disease and treatment. Disease management includes

Atopic dermatitis (also referred as atopic eczema) is a
common condition that dermatologists, pediatricians,
and primary care providers treat daily. As the prevalence
of atopic dermatitis in the developed world has increased
in recent decades,1 effective management is vital to
improve patients’ quality of life.2 Atopic dermatitis
directly influences not only a child’s physical and social
wellbeing but also that of the entire family.3 The disease
often presents with severe lifestyle limitations and finan-
cial burdens with which families must cope.4 Some of the
ways that atopic dermatitis can affect patients include
physical appearance, pain, reduced activity, and occa-
sionally loss of schooling, as well as low self-esteem,
embarrassment, and decreased social interaction.5 The
quality of life of affected children is impaired in a man-
ner similar to, and sometimes worse than, that of children
with diabetes and asthma, though children with atopic
dermatitis receive significantly less support.6 Without the
guidance of an informed physician, patients become
frustrated with the chronic course of this condition,
which leads to lower rates of treatment compliance.7 In
order to increase compliance, physicians must also be
sensitive to parents’ anxiety as it pertains to both the
monitoring for flares and a stepwise treatment approach
tailored for transition from acute to long-term therapy.
Such close monitoring will not only improve disease
response but may also help to promote compliance.8
The role of emollients has been shown to be signifi-
cant and multiple trials have documented the efficacy of
low- and mid-potency topical corticosteroids in the man-
agement of atopic dermatitis in children. As skin hydra-
tion is an important factor in the pathogenesis of atopic
dermatitis, bathing plays an essential role in manage-
ment.2 To prevent skin drying due to evaporation, it is
critical to apply emollient or topical medication immedi-
ately after bathing.9 However, to date no studies have
been conducted to show whether frequent bathing has
benefits over less frequent bathing. Recommendations
1
St Christopher’s Hospital for Children, Philadelphia, PA, USA
2
Drexel University College of Medicine, Philadelphia, PA, USA
3
Temple University School of Medicine, Philadelphia, PA, USA
Corresponding Author:
Ioannis Koutroulis, Department of Emergency Medicine, St
Christopher’s Hospital for Children, 3601 A Street, Philadelphia, PA
19134, USA.
Email: ioannis.koutroulis@drexelmed.edu

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678 Clinical Pediatrics 53(7)

Table 1.  Descriptive Statistics for 12 Children With Atopic Dermatitis Instructed to Bathe Daily (Group 1).a

Minimum Maximum Mean SD Skewness

Age, years 1 9 4.33 2.605 0.487 (SE 0.637)
Score 1 20 56 33.75 10.922 0.574 (SE 0.637)
Severity 1 1 3 1.83 0.577 −0.063 (SE 0.637)
Score 2 20 43 29.25 8.433 0.416 (SE 0.637)
Severity 2 1 2 1.67 0.492 −0.812 (SE 0.637)
Years from diagnosis 0 6 1.92 1.676 1.267 (SE 0.637)
a
SCORing Atopic Dermatitis (SCORAD) scores were ranked as mild (0-24), moderate (25-49), or severe (50-103).

Table 2.  Descriptive Statistics for 16 Children With Atopic Dermatitis Instructed to Bathe on Mondays and Thursdays Only
(Group 2).a

Minimum Maximum Mean SD Skewness

Age, years 2 10 4.81 2.639 0.928 (SE 0.564)
Score 1 19 54 35.44 9.550 0.338 (SE 0.564)
Severity 1 1 3 2.00 0.365 0.000 (SE 0.564)
Score 2 19 45 29.75 7.113 0.940 (SE 0.564)
Severity 2 1 2 1.81 0.403 −1.772 (SE 0.564)
Years from diagnosis 1 9 2.25 2.082 2.559 (SE 0.564)
a
SCORing Atopic Dermatitis (SCORAD) scores were ranked as mild (0-24), moderate (25-49), or severe (50-103).

from American, Canadian, and European dermatologi-
cal societies have not clarified the role of bathing and its
effects in the prognosis of atopic dermatitis.10 Because
recommendations are unclear, parents often receive
mixed messages, making faulty bathing and moisturiza-
tion more likely to occur and leading to disease flares in
otherwise stable patients.11 This uncertainty about opti-
mal bathing is a major barrier to treatment and often
leads to persistent atopic dermatitis.12
We aimed to evaluate the relationship between the
frequency of bathing in school-aged children with dif-
ferent degrees of severity of atopic dermatitis and the
progression of atopic dermatitis. Our goal was to deter-
mine whether bathing frequency significantly affected
the progression of atopic dermatitis, as an independent
variable from pharmacological treatments.
Methods
We conducted a prospective, randomized, case-control
study enrolling 28 subjects treated at Flushing Hospital
Medical Center general pediatric and allergy/immunol-
ogy clinics or at a private pediatric office in Queens,
New York, between August and October 2011. Our
inclusion criteria were children 6 months to 10 years
old, diagnosed with atopic dermatitis. Exclusion criteria
were as follows: children whose parents reported going
swimming in the prior month; children who were on
vacation or away from home (presuming they might
have difficulty following specific bathing instructions
without parents’ help); children with immunologic dis-
orders; and children with parents not fluent in either
English or Spanish. Written informed consent was
obtained from the parents of children younger than 7
years and written assent was obtained from children
older than 7 years. Consent was obtained in either
English or Spanish, depending on the language(s) spo-
ken by the child and family.
On initial assessment, we recorded the following
parameters: age, gender, history of asthma, allergies, and
use of medications and/or emollients. An initial score
(S1) was obtained for each subject using the SCORAD
tool (SCORing Atopic Dermatitis at http://adserver.
sante.univ-nantes.fr/Scorad.html), which we used to
assess the severity of symptoms more objectively. Scores
were ranked as mild (0-24), moderate (25-49), or severe
(50-103). Subjects were then randomly assigned to group
1 (n = 12) or group 2 (n = 16). Both groups were pro-
vided with bathing instructions in either English or
Spanish. Subjects in group 1 (G1; Table 1) were directed
to bathe once a day, 7 days a week, and subjects in group
2 (G2; Table 2) were directed to bathe once a day only on
Mondays and Thursdays. Any medications or bathing
products used prior to our intervention remained
unchanged, and every medication used had to be admin-
istered at least 2 months prior to the first scoring.

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Koutroulis et al 679
Subjects were reexamined and scored (S2) with the
SCORAD tool 2 weeks after the initial visit. SAS v9.2
software (SAS Institute, Cary, NC) was used for statisti-
cal analyses. When considering the outcomes, score and
severity, the data for both failed the test of normality
(Shapiro–Wilk test); therefore the data were transformed
to ranks before analysis, making the analysis nonpara-
metric. We then analyzed the 2 groups using the Fisher
exact test. We compared group means using analysis of
variance on the rank-transformed data in order to deter-
mine whether there was a significant change in symp-
toms between time points and whether the degree of
symptoms over time was similar between groups.
As previously stated, informed consent was obtained
from patients older than 7 years and assent for patients
younger than 7 years, both in writing. None of the par-
ticipants received a stipend for participating and there
were no missing data at the end of the study to account
for. Institutional review board approval was granted for
Flushing Hospital Medical Center.
Results
Twenty-eight subjects were enrolled in the study and
randomly assigned to G1 (daily bathing, n = 12) or G2
(Monday- and Thursday-only bathing, n = 16). A t test
and Fisher’s exact test demonstrated no significant dif-
ferences between the groups with respect to age, gen-
der, use of medications and severity of atopic dermatitis,
but the presence of asthma was used as a covariate
because this variable differed significantly between
groups (P = .04).
Mean S1 (initial score) was 33.7 (standard deviation
[SD] ±10.9) in G1 and 35.4 (SD ±9.5) in G2. Overall,
symptoms decreased significantly at follow-up as com-
pared with baseline. Group 1 had a difference of 4.5000
between period 1 and period 2 (before and after inter-
vention) with a confidence interval (CI) of −2.8811 to
11.8811. Group 2 had a difference of 5.6875 between
period 1 and period 2, with a CI of −0.7048 to 12.0798.
The overall difference in symptoms for both groups
from period 1 to period 2 was 5.0938, with a CI of
0.2116 to 9.9759. However, the frequency of bathing did
not seem to play an important role in the management of
atopic dermatitis, as the differences in scores before and
after intervention were not statistically significant
between the 2 groups (Table 3). The difference in symp-
toms between G1 and G2 during period 1 was −1.6875
(CI −8.5919 to 5.2169) and during period 2 it was
−0.5000 (CI −7.4044 to 6.4044). The presence of asthma
was also not statistically significant after analysis of
variance was performed (Fisher’s exact test, P = .0882;
Figure 1).
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Table 3.  Mean Scores at Initial Visit and at 2-Week Follow-
up Among 28 Children With Atopic Dermatitis Bathing Daily
(Group 1) or Twice Weekly (Group 2).
Score 1 SD Score 2 SD Difference SD
Group 1 33.75 10.92 29.25 8.43 4.50 5.63
Group 2 35.44 9.55 29.75 7.11 5.69 7.46
Figure 1.  Asthma as a covariate in children with atopic
dermatitis. Children in group 1 were instructed to bathe
daily and children in group 2 were instructed to bathe
only on Mondays and Thursdays. The presence of asthma
between the 2 groups was not statistically significant.
Discussion
Atopic dermatitis is a chronic, highly pruritic inflamma-
tory skin disease that results from a complex interplay of
genetic, immune, metabolic, infectious, neuroendocrine,
and environmental factors.13 Defective epidermal bar-
rier function, one of the hallmarks of atopic dermatitis,
is thought to be related to the downregulation of corni-
fied envelope genes such as the filament-aggregating
protein, filaggrin, reduced ceramide levels, increased
levels of endogenous proteolytic enzymes, and enhanced
transepidermal water loss.8 This water loss correlates
with the severity of atopic dermatitis and is compro-
mised even in normal-appearing skin.14 This loss of
water leads to very dry skin, which is a hallmark of
atopic dermatitis.15 In addition, T-helper type 2 response
to viral and bacterial stimuli is upregulated, whereas
T-helper type 1 response is downregulated, which results
in an inadequate immune response.16 This compromised
immune defense is correlated with the lifelong risk asso-
ciated with vaccination in patients with atopic dermati-
tis.17 Patients can enter an itch–scratch cycle, which
further damages the epidermal barrier, leading to more
transepidermal water loss, xerosis, and microbial infec-
tion.18 Affected patients have a predisposition to both
colonization and infection by organisms such as
Staphylococcus aureus and herpes simplex virus, much
higher than that of the general population.19 In patients
680 Clinical Pediatrics 53(7)
with atopic dermatitis, even skin that appears normal has
a compromised epidermal barrier and is immunologi-
cally abnormal, emphasizing the need to treat the patient
as a whole rather than just individual lesions.20
Diagnosis is generally clinical, and the Eczema Area
and Severity Index (EASI) and the SCORAD systems
are 2 systems that appear to be the most reliable and
user-friendly and share the advantage that they are most
commonly used in contemporary clinical trials. Both
systems generate quantifiable data that are amenable to
analysis. SCORAD is a verified scoring system that
assesses the extent, intensity, and subjective symptoms
of atopic dermatitis based on clinical examination and
history as provided by the parent.13 Diagnostic criteria
include itchy skin, as well as asthma, allergic rhinitis,
involvement of flexural surfaces, generalized dry skin,
onset of rash prior to the age of 2 years, and visible flex-
ural dermatitis.21 Atopic dermatitis has a broad differen-
tial diagnosis, so it is vital to exclude other diagnoses as
treatment options can vary greatly.22
Successful management of atopic dermatitis involves
educating patients and parents about the condition, as
well as recognizing and reducing symptoms using phar-
macologic and nonpharmacologic measures.8 The
avoidance of irritants and allergens can help decrease
inflammation of the skin, lessening the need for medica-
tions.19 An interesting new development is the role of
vitamin D deficiency in allergic diseases. In one small
study, children with atopic dermatitis were successfully
treated with oral vitamin D.23 Supplementation with
vitamin D may also help improve innate immunity.15
Larger oral vitamin D trials are in progress that could
shed light on a possible new treatment. Some biologic
medications, such as efalizumab, which targets T cells,
have been found to be mildly effective.24 Somewhat
more promising is tacrolimus (FK506), an immunosup-
pressant often used for solid organ transplantation. In a
small, randomized, double-blind study, tacrolimus either
completely resolved or markedly alleviated symptoms.25
Although many of these therapies are not yet widely
used, they nonetheless provide an avenue for future
treatment and better understanding of the disease.
Current practice incorporates skin hydration as part
of the treatment plan, with an emphasis on proper bath-
ing and drying techniques. However, we have no defini-
tive knowledge of what the appropriate bathing
frequency is. We aimed to determine whether bathing
more or less often would have an effect on disease con-
trol, and we found that although both groups showed
improvement, the frequency of bathing did not seem to
affect progression of atopic dermatitis. The two groups
showed a similar amount of symptom improvement,
suggesting that the overall maintenance of hydration
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plays a more important role than the frequency of wash-
ing in managing atopic dermatitis. Clinicians should
thus focus on the need for adequate skin hydration in
compliance with the current recommendations. Change
in frequency of bathing should not be considered as part
of the treatment of atopic dermatitis.
Limitations of our study include the small number of
subjects, and further investigation with a larger subject
pool is warranted. Individual subjects were also scored
by different physicians, and although we tried to equal-
ize ratings by using data sheets, differences are possible
in the physical examinations conducted on the same
subjects on different occasions. Results could also have
been confounded by parental noncompliance or by med-
ication effects.
Future prospective studies should include accurate
measurements of skin hydration status using more
advanced techniques (eg, by determining the electrical
capacitance and conductance of the skin). This approach
would provide more precise data about the importance
of frequency of bathing in the progression of atopic
dermatitis.
Acknowledgments
The authors would like to thank Drs Fernanda Kupferman,
Susana Rapaport, Won Baik-Han, and Ashley Hiza, and Ms
Kelly Cervellione.
Authors’ Note
Poster presentations of the study have been at PAS 2012,
ESPR 2012, and during the pediatric grand rounds at Flushing
Hospital Medical Center in New York. There was also a poster
presentation at the Chinese-American Doctors’ Association
conference in 2012 held at Flushing, New York.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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