Trans-epidermal water loss plays a key role in the pathophysiology of pediatric atopic dermatitis (AD). We hypothesized that in moderate-to-severe AD, twice daily soak-and-seal baths would be associated with improved AD severity scores, versus twice weekly soak-and-seal baths.
We enrolled 63 and randomized 42 children between the ages of 6 months and 11 years of age, with moderate-to-severe AD, for a randomized single-blinded prospective cross-over controlled trial. Patients received the same moisturizer, cleanser, and class VI topical corticosteroid (TCS), and only bathing varied. After a run-in week, patients were randomized into 2 groups: twice weekly soak-and-seal baths for 2 weeks (“dry”) followed by twice daily soak-and-seal baths (“wet”) for 2 weeks, or the converse. Primary endpoint was severity of AD using the SCORing Atopic Dermatitis (SCORAD) tool. Secondary endpoints included AD Quickscore (ADQ), quality of life, S. aureus colonization, skin hydration, and usage of moisturizer and TCS.
The effect estimate for the difference in SCORAD improvement for wet versus dry treatments was 13.6, 95% CI (8.7, 18.4), p =1.5e-06, using a Welch t-test for the primary analysis. A McNemar’s chi-squared test for 30% SCORAD improvement for wet versus dry was also significant (Χ2=12.0, df=1, p=0.00052) for a secondary analysis. SCORAD correlated with parental assessment of eczema severity (ADQ), which also showed a significant effect of 4.6, 95% CI (1.4, 7.8), p=0.0064. No other secondary endpoints showed significance.
In pediatric moderate-to-severe AD, aggressive skin hydration, with twice daily soak-and-seal baths, improves eczema severity more than restricting baths.