Moisturizing and Bathing Tips to Help Manage and Soothe Your Eczema
Dermatology Center for Children and Young Adults
Editor’s Note: This article is an excerpt from Sandra Oehlke’s speech at the Fourth Annual National Eczema Association Patient Conference.
Minneapolis, Minnesota, is a melting pot, and you all know that atopic dermatitis does not discriminate at all. I see children who are born in Asia, I see children from Africa, and I see children whose origins are Eastern European.
In normal skin we see a beautiful glued together stratum corneum—that’s the top layer of skin. If we focus on what happens with your eczema by just magnifying that top layer, I don’t like the normal brick and mortar analogy to skin. I like the cornflake analogy. Have any of you had the cornflake bars that have peanut butter and butter and marshmallows in them? I think they are a good analogy for the top layer of your skin because you have fatty acids and cholesterol and ceramides all holding together these dead keratinocytes, which are like cornflakes. In eczema, you have this skin barrier that is leaky, it’s impaired. You’ve already learned how water goes in and out of eczematous skin, or germs and pathogens get in.
What is the skin supposed to do? It’s not there just to make us look pretty. It’s the largest organ on our whole body. It’s also the most visible organ. Therefore when it’s ill it causes us a lot of emotional, physical, and psychological stress. Simply put, some of the things that our skin does include preventing fluid loss, regulating our temperature, and protecting our skin from infection. We can also synthesize vitamin D through our skin.
So what happens with eczema? The skin barrier is impaired, fluid is lost, germs (like staph) get in, and you get infection.
Tips on Bathing
Can people with eczema bathe? Yes, yes and YES. I hope that is clear.
How often should these baths take place?
I believe the medical community is all onboard that daily bathing is recommended for people with eczema. I do have some little patients who are in the tub two or three times a day, and they do benefit from that.
Why should people with eczema bathe?
People with eczema should bathe because it can add moisture to the skin. One analogy says skin is kind of like a sponge, and it can drink up the water if you sit in the tub. You also need to wash off the allergens, some of the proteins, some of the dust, some of the pollen, the dander, any signs of exposure to your pet. You wash these things off your skin, and then you wash away the oozing and the crusting and the drying that comes with eczema. You certainly wash off the dirt from a toddler who has been at the playground; when most of these kids come in to my office and I look at their feet and I take off their shoes, I end up with a lapful of gravel. And how many of you have been told “You’re stressed, go sit in the tub”? We’re learning more about the exacerbation of disease when we’re stressed. Topical medications also penetrate easier and better when the skin is moist—so that is another reason to bathe. Bathing is also a wonderful bonding activity between parents and infants and toddlers.
What’s the best way to bathe or shower?
Well, recent research says a 20-minute bath is recommended. So, yes, your child can sit in a tub, they can play in a tub. You don’t want to bathe excessively though. You don’t want to go overboard because you’ll start to reverse the moisturizing process. When you get out of the tub, gently wipe off the drops, pat off the drops. You don’t want to press, to push, or to pull out the moisture that your skin has actually absorbed. And then there’s the 3-minute rule or the 10-minute rule for adding moisturizer. Does anybody really time it? The point is this: get your moisturizer on as quick as you can. Little kids like to run around the house naked to dry off, but they need to get slathered first.
I’m wondering how many of you have had this dilemma: you are in the pharmacy or the store or some SuperTarget or Wal*Mart or Walgreen’s, and you say to yourself, “What can I use? Well, let’s look at the history of soap. I think it’s absolutely amazing that soap was even discovered because years ago the process of making soap was intense: early settlers collected all their ashes together and poured water through them to drain out the lye and this was then mixed together with animal fat from butchering. To get pure fat, they had to cook the fat to get everything that wasn’t fat out of it. They then mixed the fat and the lye together and boiled and boiled and boiled. Do you remember the old Westerns where the woman is forever stirring a pot? I’m sure it was a pot of soap. After this process of boiling and stirring, you end up with kind of a brown, slimy soft soap, and if you add salt to the pot, then you can make hard soaps. That’s the origin of soap. It is actually a very alkaline, irritating product. Our skin is not nearly as alkaline as most soap is: our skin’s normal pH is about 4 to 5.5 and the average pH of soap is 9 to 10.5. So, you see, soap is actually not recommended.
What soap should you use?
Of course, if you want to wash with something in addition to water you certainly can use other products. Go with something with a more neutral pH, get down to basics. Dove, Cetaphil in bar form, Oil of Olay in bar form, Vanicream soap, and CeraVe cleanser are products that I recommend. Parents and patients can choose what they like.
What soap should not be used?
The lavender soaps, the strawberry scented soaps, any soap with fragrance. These and multicolored soaps contain irritants and dyes which will just make eczema worse.
What temperature should the water be?
The temperature of the bath water should not be too hot; it should not be as hot as a hot tub bath, and at the same time, it should not cause chills. It should simply be a more tepid, comfortable temperature.
What do I do when I finish my bath or shower?
Once you are done with your bath, slather on an emollient to prevent transdermal water loss. Also, drinking water helps hydrate the skin.
Tips on Moisturizing
Now you know what soaps to use, but what about moisturizers? You go into your pharmacy, your drugstore, and you see aisles of endless skin care products. They have very good things to say. They promise you will look younger and you will be soft and velvety. There are many, many choices. Which one do you use? Which ones can you use? Let’s just go back to basics.
What are moisturizers?
They’re a combination of grease and water. Ointments are pure grease. They’re the most occlusive; they hold the moisture in. Creams are more grease than water. That’s typically what we recommend to patients with atopic dermatitis—something with more grease than water. Lotions are more water than grease. When you put a lotion on, you may think your skin sucks it in quickly since it doesn’t feel sticky. Well, it’s actually evaporating into the air. Greasier ointments and creams hold in more moisture while light watery lotions evaporate. Examples of some moisturizers that are pure grease and form the best occlusive barriers include Vaseline, Aquaphor ointment, and plain Crisco (not butter flavored). I’ve had many parents look at me like I’m nuts when I say, “Go ahead and use Crisco.” If you want to go with something lighter, you might try Vanicream; it is a very mild, very bland, very boring cream—just what we want. And then there are the lotions. In the summertime when it’s hot and humid, some patients move from ointments to creams or even lotions because the ointments can actually be so occlusive that a heat rash can develop under them. Some very, very fair babies with very sensitive skin might have an exacerbation of the eczema simply because an ointment was too occlusive. If babies are sleeping in cool, dry air-conditioned air, maybe Vaseline or Crisco are in order at night, but the use of creams during the day will help. Vanicream also comes in formulation with sunscreen: there are 15 SPF, 30 SPF, 60 SPF, and sport versions.
What do moisturizers do?
Moisturizers are holding in the moisture that is already there. If you take a raisin or a prune and you put Vaseline on it, you’re still going to have a prune or a raisin that’s greasy. It would be better if you plump it up first. My background is German, so we have raisin sauce with ham every year, and to make the raisin sauce, we take these little dried up raisins and we put them in water with a whole lot of sugar to plump them up. You want your skin to be hydrated, then you put your moisturizer on to occlude and hold that moisture in.
Some creams and moisturizers have fancy things in them called humectants, which are like little sponges in the moisturizer. In a room with 70 percent humidity, they can pull water out of the air, and they can also pull it from the deeper layers of the skin. So sometimes you will find humectants in your moisturizers.
What do we need to avoid in our moisturizers?
Basically, all the fun stuff. Most of the products from specialty bath and body shops, products containing cocoa, pecan, mango, and oher crazy perfumes, are usually off limits. All that scented stuff is to be avoided, as is anything with glitter or color—all those things can cause irritation.
What are ceramides?
Ceramides are in your skin. It used to be you could buy little tubes of ceramide cream from someplace like Nordstrom for about $30 a tube. Well, I certainly wasn’t going to recommend that to any patient who was going to be going through a tube every other day! But now there are ceramide products that are not as expensive; they are much more affordable and much more reasonable to use, and perhaps you’d like to give them a try. I’ve got some patients who say ceramides make no difference for them, and some patients who swear by them, so it’s all about what works for you.
What about moisturizing and the seasons?
Just when you’ve got your moisturizing regime figured out, the seasons change. When it’s hot and moist, you may need to go lighter, meaning using creams and lotions, and when it’s cool and dry you may need to go heavier, meaning using ointments or creams to provide better moisturization.
What about all of the other products on the market?
I did what many parents do. I spent the lunch hour on the Internet and I looked up different topics about eczema, and you know, I found a cure! I’m sure you’ve all found a cure on the Internet—often something priced at $30 for two ounces.
What about bath oils and cocoa baths?
With bath oils, you end up with a slippery baby, you end up with a sticky tub. I’m not real fond of them, but I do know providers who swear by them. I’ve seen cocoa baths advertised—you can get these little cocoa sticks for a fairly large price—but I did not find any medical research or anything in our library of pediatric dermatology textbooks to support the use of cocoa baths. If you know more, let us know. I personally think these baths are a waste of cocoa, which is one of my favorite treats to eat.
How about salt baths?
When you have a horrific flare, one way to decrease the itch, is to add table salt to your bath. I’ve had some patients try sea salt, and they say it too can be beneficial.
What about bleach baths?
They just make your bathtub into a swimming pool. Bleach soaps or bleach baths can decrease the colonization of staph. We know the skin gets colonized, the barrier is impaired, and it can get infected. Some patients take bleach baths two or three times a week to keep the colonization down, thereby decreasing the need to use an oral antibiotic.
What about tar baths?
I hope you’ve learned a few tips and tricks for your bathing and moisturizing regime. It is the most important treatment of all for eczema.
And for Danielle, our NEA conference inspirational speaker, I dedicate this rubber ducky to you for all the bubble baths you missed in your life…