Sodium hypochlorite body wash in the management of Staphylococcus aureus-colonized moderate-to-severe atopic dermatitis in infants, children, and adolescents.

Sara Majewski,Manuela Asztalos,Amy S. Paller,Benjamin Bohaty,Tanya Bhattacharya,Adelaide A. Hebert,Katherine C. Durham,Dennis P. West

doi:10.1111/pde.13842

Abstract

ObjectivesA cleansing body wash containing diluted sodium hypochlorite (0.006% NaOCl) was evaluated for management of moderate‐to‐severe Staphylococcus aureus–colonized, atopic dermatitis in children.MethodsA 6‐week, prospective, open‐label study was conducted with 50 evaluable participants (ages 6 months to 17 years) who had moderate‐to‐severe atopic dermatitis with S aureus skin colonization documented by culture. Participants were instructed to continue using their current medications while using the study product, 0.006% NaOCl body wash, once daily to affected areas for 6 weeks. Primary outcome measures were Investigator's Global Assessment, Eczema Area and Severity Index, and Body Surface Area scores. Secondary outcome measures were the Visual Analog Scale for pruritus, Family Dermatology Life Quality Index, and Patient Satisfaction Questionnaire for Problem Areas. A subject daily diary and a six‐item subject questionnaire that provided information on preferences for bleach bath vs body wash were secondary outcome measures.ResultsDaily use of the 0.006% NaOCl body wash led to improvement for all outcome measures comparing baseline to 2‐week and to 6‐week evaluations. Of the 50 skin S aureus‐positive subjects, 32/50 (64%) were still positive at 2 weeks. A 36.5% decrease in subject's daily record of topical corticosteroid application at end of study compared to baseline was found. Participant surveys indicated preferences for the body wash over bleach baths.ConclusionsSodium hypochlorite (NaOCl) body wash improved all outcome measures for moderate‐to‐severe S aureus–colonized AD in infants, children, and adolescents. The limited reduction in S aureus further suggests that sodium hypochlorite has ameliorative effects other than antimicrobial actions.

Highlights

Up to 90% of patients with atopic dermatitis (AD) have colonization by Staphylococcus aureus (SA) of lesional skin and often nares and nonlesional skin, even when overt clinical signs of infection are lacking.[1,2,3,4,5,6] SA has been shown to promote skin inflammation and exacerbate AD
In a 3-month trial, twice-weekly bleach baths plus intranasal mupirocin led to greater reduction in AD severity and body surface area involvement than plain water baths plus intranasal petrolatum in 31 children with moderate-to-severe AD who had an initial skin infection treated with cephalexin.[10,11,13]
Two shorter studies and a meta-analysis based on only the first 4 weeks of therapy have disputed the effect of dilute NaOCl; given that bleach baths are primarily used as maintenance therapy, 4 weeks may be an insufficient time to effect significant change.[14,15,16]

Summary

Introduction

Up to 90% of patients with atopic dermatitis (AD) have colonization by Staphylococcus aureus (SA) of lesional skin and often nares and nonlesional skin, even when overt clinical signs of infection are lacking.[1,2,3,4,5,6] SA has been shown to promote skin inflammation and exacerbate AD. The purported role of SA in exacerbating AD was a major impetus for the original use of 0.005%-0.006% NaOCl (dilute bleach), considered a bactericidal agent with very low potential toxicity.[9,10,11,12] Early studies provided evidence that dilute NaOCl improved AD severity in children with moderate-to-severe AD.[9,10] In a 3-month trial, twice-weekly bleach baths plus intranasal mupirocin led to greater reduction in AD severity and body surface area involvement than plain water baths plus intranasal petrolatum in 31 children with moderate-to-severe AD who had an initial skin infection treated with cephalexin.[10,11,13] The greater effect of dilute NaOCl in bleach baths at 1 month and 3 months was seen only in submerged body parts, suggesting the requirement for exposure to the treated bathwater for efficacy. Two shorter studies and a meta-analysis based on only the first 4 weeks of therapy have disputed the effect of dilute NaOCl; given that bleach baths are primarily used as maintenance therapy, 4 weeks may be an insufficient time to effect significant change.[14,15,16] Despite a small increase in pH by adding bleach to water, no reduction in skin barrier function based on skin hydration, pH, and tewametry has been shown with use of bleach baths for AD.[17]

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