COli tact Derlllatitis. 1999. 41.

3 11- 314 Copyright CI Mu" ksgaard 1999

Prill/ed ill Delllllark , All rights reserved
CONTACT DERMATITIS
ISSN 0105·1873

Review Article

How irritant is water? An overview

TSEN-FANG TSAI 1•2 AND HOWARD I. MAIBACH 1
IDepartment of Dermatology, University of California, San Francisco, California and
2Na tional Taiwan University Hospital, Taipei, Taiwan, ROC

Water is a skin irritant which deserves attention because of its ubiqujty. During the Vietnam
war, soldiers suffered from painful swollen feet, so-called tropical immersion foot. In occupational
dermatology, the importance of water as a skin irritant is especially appreciated. The irritancy of
water has been demonstrated by occlusion experiments; occlusion with either closed chambers or
water-soaked patches has been shown to produce clinical and histopathological inflammation .
Functional damage, as revealed by increased transepidermal water loss, bas also been shown.
Repeated water exposure without occlusion caused an increase in blood flow on irritated skin;
however, clinical evaluation did not show a difference in dryness or scaling. Several mechanisms
such as osmolarity, pH, hardness and temperature might account for the irritancy of water. Extrac-
tion or dilution of natural moisturizing factors in the stratum corneum is another po sible expla-
nation. Occlusion per se also changes the physiology of skin and may trigger the activation of
potentially active substances. However, much remains to be done to clarify the risk factors and
mechanisms of water-induced irritation .
Key lVords: water; cumulative irritation; occlusion; irritant contact dermatitis; tropical immersion
foot; occupational; wet work; natural moisturizing factors ; stratum corneum. © Munk gaard.
1999.
Accepted for publication 2 June 1999

When and how is water detrimental to skin? Pro-
longed warm water immersion resulted in painful
swollen feet, so-called tropical-immersion-foot, in
Vietnam (1). Repeated water immersion with
periods of drying in between was implicated as a
cause of juvenile plantar dermatosis (2). Frequent
or prolonged bathing and showering, even without
the use of soap, i often discouraged for the care
of dry and senile skin (3). Wet workers such as
hairdre er, hospital cleaners, cannery workers
and bartenders have an increased incidence of
hand eczema (4-7). Water may be an irritant in
patients with hand eczema, especially in atopic pa-
tient (8, 9). Rarely, water may produce pruritus
(la, 11) or urticaria (12, 13). In view of the ap-
parent potential detrimental effect of water, the ir-
ritancy of tepid water has been tudied , but much
remain to be elucidated in terms of risk factors
and mechanism .
Occlu ive studie have produced most of the ex-
perimental data on water irritancy. Willis demon-
strated the development of clinical and patholog-
ical effects after closed water cup occlusion for 72-
144 h. Buffered water (4 ml/4.0 cm 2 at pH 7.5
showed stronger reaction as compared to water at
pH 3.5. Empty cups were u ed as a control, and
showed milder changes (14). Kligman occluded
normal skin with water-soaked patche (volume
not provided) of unwoven cloth, for up to 2 weeks
with changes every 2 days, and induced "hydration
dermatitis" characterized by vasodilation periven-
ular lymphocytic infiltration, edema, mast cell
degradation and fibroblast proliferation. Damage
to epidermal cell occurred quickly and wa fully
developed by 2 days. Occlusion with a water-per-
meable membrane or a water-ab orbent dre ing
for 3 weeks was, however, relati ely innocuous
(15).
Agner & Serup (16) tudied kin reaction after
clo ed patche and showed tran ient water damage
312 TSAI & MAIBACH
as demonstrated by increased transepidermal
water loss after occlusion for 24 h. However, the
irritancy of water under occlusion can result from
water per se or from retention of sweat, which is
more irritant than the water per se (17). Notwith-
standing, after prolonged occlusion, anhidrosis re-
sults (18- 20). Occlusion modifies reactive events in
Langerhans cells (21, 22), and has a profound ef-
fect on cytokine production (23). Not all physio-
logical changes from occlusion are damaging to
the skin. Occlusive dressings alone have been used
as effective adjuvant therapy (24-26). The alleged
healing power of silicon gel sheet on keloids is con-
sidered to be through its occlusiveness (27) and oc-
clusion has also been used to treat psoriasis (28)
and periungual verrucae (29).
To separate the influence of occlusion from the
influence of water, Ramsing & Agner (30) studied
the effect of water on experimentally irritated skin
in healthy volunteers, to evaluate water as a cumu-
lative irritant. Volunteers exposed one hand to
water IS min 2Xdaily for 2 weeks, while the other
hand served as control. Water did not significantly
influence transepidermal water loss, but caused a
significant increase in skin blood flow, as evaluated
by laser Doppler flowmetry. However, clinical
evaluation did not show a difference in .dryness or
scaling (30), and erythema alone does not equate
to irritancy.
An irritant is any agent, physical or chemical,
capable of producing cell damage if applied for
sufficient time and in sufficient concentration. Im-
munological processes are not involved. Strong ir-
ritants will induce a clinical reaction witb a single
application, whereas with less potent irritants, the
response may be subclinical and require repeated
or prolonged application (31). Weaker irritants in-
duce damage by gradually exhausting the horny
layer, denaturing the keratin, removing stratum
corneum lipids and altering the water-holding ca-
pacity of the skin (32). Such damage results in a
drier, less pliable surface, which might result in
cracks and fissures. Water is considered a weak ir-
ritant. Theoretically, water can exert detrimental
effects on the skin through several mechanisms.
Hydration of the stratum corneum may facilitate
the penetration of foreign substances, and contrib-
ute to the development of allergic and irritant con-
tact dermatitis (33). The same principle is also
used in occlusive dressing therapy to enhance the
therapeutic effects of topical preparations such as
corticosteroids (34). Brief wash ing enhances re-
sponse to some non-immunologic contact urt-
icants and some other materials. This phenom-
enon is relevant to the use of soap and water in
routine cosmetic skin care (3S). Persistent hy-
dration of the skin surface may also change the
ecological environment and support the over-
growth of pathological organisms on the skin (36-
38).
Extraction of water-soluble substances, or
natural moisturizing factors (NMFs), from the
skin is another mechanism. NMFs are a group
of water-extractable substances, including sodium
pyrrolidone carboxylic acid, sodium calcium lac-
tate, amino acids, urea and a sugar-protein com-
plex. These substances can bind 3 to 4 x their
own weight of water (39). Water is the main plas-
ticizing factor of the horny layer (40), and the
presence of water in the stratum corneum de-
pends on an intercellular bilayer membrane that
encloses the NMFs as in an envelope. Water con-
tent of the stratum corneum decreases when the
NMFs are reduced, and superficial cracks may
develop. The amino acid content of senile skin is
decreased, and frequent showering combined with
a delay in the replenishment of NMF may
further aggravate this situation (4 1, 42). How-
ever, intercellular lipids have been identified as
the major factors in maintaining water content of
the stratum corneum, and the significa nce of
NMFs is not indisputable (43).
The irritancy of water could theoretically also
result from the neutral pH 7.0, which is alkaline
compared to normal skin pH (4.2 to 6.0). The
neutralization capacity of lesional skin in hand ec-
zema appears to be defective (44). However, since
water has no buffering capacity, the irritancy of
water pH is somewhat doubtful. Besides, the sig-
nificance of skin surface acidity is under dispute
(4S). Hypotonicity of pure water may be irritant
on abraded skin (46), and change of water pressure
gradient acro s the stratum corneum, which may
trigger the release of cytokines (47, 48), may also
playa role in the irritancy of water. Kligman sug-
gested that the skin may also contain several po-
tentially active substance that may become active
when hydrated (49). Clearly, contam inants and
hardness of water (SO), as well as osmolarity (SI)
and temperature (S2), are also important to the
irritancy of water.
In conclusion, water can be an irritant and the
dictum of Kligman that "almost any substance
can be an irritant under some circumstances"
(S3) also applie to plain water. Water exposure
can modify physiologic functions of the skin and
produces skin disease. But most of the reported
irritancy of water may result mainly from oc-
clusion or from occlusion as an additive fa ctor.
However, ince water expo ure is ubiquitous,
more studies are warranted to elucidate the
mechanisms of its irritancy. Patient care should
improve when we know better the biology of
water and kin.
 THE IRRITANCY OF WATER
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Address:
Howard I. Maibach
Box 0989, Surge 110
UCSF Medical Center
CA 94143, USA