Bathing in Atopic Dermatitis in Pediatric Age: Why, How and When

Round 1

Reviewer 1 Report

The paper is full of inaccuracies due to the fact that is not written  by dermatologists

Concepts of atopy and allergy are always overlapped. The opposite should be clarified in the introduction

Authors Often refer to emollients which are not the subject of the paper

Sentence line 44-45 is ambiguous as it suggests an obligatory link between atopy and allergy

line 49 xerosi is better than dryness

overall this paper must be more balanced by clarifying in the introduction and discussion that the cleansing is not "the cure"but one of the many processes to be acted upon care AD

Author Response

Comment: The paper is full of inaccuracies due to the fact that is not written by dermatologists

We regret the disappointment of the reviewer. We aimed to deepen this interesting topic through a pediatric perspective.

Comment: Concepts of atopy and allergy are always overlapped. The opposite should be clarified in the introduction.

We agree with the reviewer. We have modified the text.

Comment: Authors often refer to emollients which are not the subject of the paper

We agree with the reviewer. We have modified the text.

Comment: line 49 xerosi is better than dryness

We agree with the reviewer, and we have modified it. 

Comment: overall this paper must be more balanced by clarifying in the introduction and discussion that the cleansing is not "the cure"but one of the many processes to be acted upon care AD.

We have revised the manuscript according to the reviewer's suggestion.

Reviewer 2 Report

Overall this review by Pagliaro et al does a good job of summarizing the controversies of bathing practices in infants with atopic dermatitis. Considering how there is a great deal of uncertainty on this topic, it may help to add a discussion(s) of how future research may be better designed to provide more conclusive results.

Other minor comments:

-It may help to add a sentence discussing the use of TEWL for monitoring AD in the Introduction. While TEWL is currently mentioned, its use for monitoring AD is only implied.

Author Response

Comment: Overall this review by Pagliaro et al does a good job of summarizing the controversies of bathing practices in infants with atopic dermatitis. Considering how there is a great deal of uncertainty on this topic, it may help to add a discussion(s) of how future research may be better designed to provide more conclusive results.

We agree with the reviewer. We have modified the text.

Comment: It may help to add a sentence discussing the use of TEWL for monitoring AD in the introduction. While TEWL is currently mentioned, its use for monitoring AD is only implied.

We agree with the reviewer. We have modified the text.

Reviewer 3 Report

The authors provided an important publication on bathing in AD prone children. It is an important and interesting review and many aspects have been discussed and most important studies have been citied.

Remarks and questions:

A very important point is missing: Skin bathing is not sufficient for skin care in AD, daily use of emollients in AD is necessary, especially after bathing. The use of oil or emollients in a bath solution is not sufficient for the treatment of dry skin a hallmark of AD. Emollients are emulsions of oil in water or water in oil and need an emulsifier. Emulsifiers are the same or related to detergents.  Too much detergent may lead to dry skin and irritation. A recent study for the use of emollients to prevent AD showed that daily bathing plus twice daily use of emollient was too much and less effective as daily bathing plus once daily use of an emollient (Inuzuka et al. Prevention of atopic dermatitis in high-risk neonates…. J Eur Acad Dermatol Venereol. 2023;00,1-11). In my opinion daily bathing especially with a detergent or oil bath solution is not necessary and not advisable for AD prone skin.  For critical parts of the body in babies, children and adults the use of a wash cloth is sufficient.  Also, a short shower with lukewarm water and little detergent may be advisable to avoid dry skin inAD (plus the use of an emollient thereafter).

A bleach bath using sodium hypochlorite has an alkaline pH and may irritate the skin. Nevertheless, a few studies showed positive results in AD. Interesting, “Bleach baths enhance skin barrier, reduce itch but do not normalize skin dysbiosis in atopic dermatitis” or reduce Staph. aureus (Stolarczyk A, Archiv Dermatol Res. https://0-doi-org.brum.beds.ac.uk/10.1007/s00403-023-02723-1).

The effect of bath oils on skin barrier function is very limited, because they don’t create a continuous film on the surface. After bathing in a bath oil, the use of emollients is necessary.

Unsaturated fatty acids in an emollient bath and in bath oils may irritate the skin. Especially oleic acid is an irritant and a well-known penetration enhancer.

It is well known, that bathing in the high salt containing Dead Sea improves psoriasis and AD (if it doesn’t burn too much). The high concentrations of the salt cannot be obtained in private, because it needs several kilograms of salt for every bath. This leads to corrosion of the bath tub and the wastewater pipe and it is bad for the environment.

Author Response

Comment: A very important point is missing: Skin bathing is not sufficient for skin care in AD, daily use of emollients in AD is necessary, especially after bathing. The use of oil or emollients in a bath solution is not sufficient for the treatment of dry skin a hallmark of AD. Emollients are emulsions of oil in water or water in oil and need an emulsifier. Emulsifiers are the same or related to detergents.  Too much detergent may lead to dry skin and irritation. A recent study for the use of emollients to prevent AD showed that daily bathing plus twice daily use of emollient was too much and less effective as daily bathing plus once daily use of an emollient (Inuzuka et al. Prevention of atopic dermatitis in high-risk neonates…. J Eur Acad Dermatol Venereol. 2023;00,1-11). In my opinion, daily bathing especially with a detergent or oil bath solution is not necessary and not advisable for AD prone skin.  The use of a wash cloth is sufficient for critical parts of the body in babies, children and adults.  Also, a short shower with lukewarm water and little detergent may be advisable to avoid dry skin in AD (plus the use of an emollient thereafter).

We thank the reviewer for his/her suggestion. We have deepened the role of emollients and specified that bath is a support in AD management. 

A bleach bath using sodium hypochlorite has an alkaline pH and may irritate the skin. Nevertheless, a few studies showed positive results in AD. Interesting, “Bleach baths enhance skin barrier, reduce itch but do not normalize skin dysbiosis in atopic dermatitis” or reduce Staph. aureus (Stolarczyk A, Archiv Dermatol Res. https://0-doi-org.brum.beds.ac.uk/10.1007/s00403-023-02723-1).

We agree with your comment. We reviewed the article and added this bibliographic reference.

The effect of bath oils on skin barrier function is very limited because they do not create a continuous film on the surface. After bathing in a bath oil, the use of emollients is necessary.

We agree with the reviewer. We have modified the text.

Unsaturated fatty acids in an emollient bath and in bath oils may irritate the skin. Especially oleic acid is an irritant and a well-known penetration enhancer.

We agree with your comment and reviewed the article.

It is well known, that bathing in the high salt containing Dead Sea improves psoriasis and AD (if it doesn’t burn too much). The high concentrations of the salt cannot be obtained in private, because it needs several kilograms of salt for every bath. This leads to corrosion of the bath tub and the wastewater pipe and it is bad for the environment.

We agree with your comment and reviewed the article.