Title

Bleach baths for atopic dermatitis: A systematic review and meta-analysis including unpublished data, Bayesian interpretation, and GRADE

Authors

Layla Bakaa, Evidence in Allergy Group, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Jeffrey M. Pernica, Department of Pediatrics, Division of Infectious Diseases, McMaster University, Hamilton, Ontario, Canada.
Rachel J. Couban, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
Kelly Jo Tackett, Department of Dermatology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
Craig N. Burkhart, Department of Dermatology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
Liz Leins, Royal Children's Hospital, Allergy & Immunology, Victoria, Australia.
Joanne Smart, Royal Children's Hospital, Allergy & Immunology, Victoria, Australia.
Maria Teresa Garcia-Romero, Department of Dermatology, National Institute of Pediatrics, Mexico City, Mexico.
Itzel Guadalupe Elizalde-Jiménez, Department of Dermatology, National Institute of Pediatrics, Mexico City, Mexico; Ministry of Health, General Directorate of Quality and Education of Health, Mexico City, Mexico.
Michael Herd, Paediatric Department, Waitakere Hospital, Waitemata District Health Board, Auckland, New Zealand; Current location: Paediatric Department, Whakatane Hospital Bay of Plenty District Health Board, Whakatane, New Zealand.
Rachel Netahe Asiniwasis, Origins Dermatology Centre, University of Saskatchewan, Regina, Saskatchewan, Canada.
Mark Boguniewicz, National Jewish Health, Denver, Colorado.
Anna De Benedetto, University of Rochester Medical Center, Rochester, New York.
Lina Chen, University of Ottawa, Ottawa, Ontario, Canada.
Kathy Ellison, Westerville, Ohio.
Winfred Frazier, Department of Family Medicine, UPMC St. Margaret, Pittsburgh, Pennsylvania.
Matthew Greenhawt, Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado.
Joey Huynh, Orthopedic Neurological Rehabilitation, Northridge, California.
Jennifer LeBovidge, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts.
Mary Laura Lind, School for Engineering of Matter, Transport and Energy, Arizona State University, Tempe, Arizona.
Peter Lio, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Monica O'Brien, Tufts University School of Medicine, Boston, Massachusetts. Medical Student, Class of 2025.
Peck Y. Ong, Children's Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, California.
Jonathan I. Silverberg, Department of Dermatology, The George Washington University School of Medicine and Health Sciences, Washington, DC.
Jonathan M. Spergel, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
Julie Wang, Icahn School of Medicine at Mount Sinai, New York City, New York.
Wendy Smith Begolka, National Eczema Association, Novato, California.
Lynda Schneider, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts.
Derek K. Chu, Evidence in Allergy Group, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; The Research Institute of St. Joe's Hamilton, Hamilton, Ontario, Canada. Electronic address: chudk@mcmaster.ca.

Document Type

Journal Article

Publication Date

3-30-2022

Journal

Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology

DOI

10.1016/j.anai.2022.03.024

Abstract

BACKGROUND: Bleach bathing is frequently recommended to treat atopic dermatitis (AD), but its efficacy and safety are uncertain. OBJECTIVE: To systematically synthesize randomized controlled trials (RCTs) addressing bleach baths for AD. METHODS: We searched MEDLINE, EMBASE, CENTRAL, and GREAT from inception to December 29, 2021, for RCTs assigning patients with AD to bleach vs no bleach baths. Paired reviewers independently and in duplicate screened records, extracted data, and assessed risk of bias (Cochrane version 2) and GRADE quality of evidence. We obtained unpublished data, harmonized individual patient data and did Frequentist and Bayesian random-effects meta-analyses. RESULTS: There were 10 RCTs that enrolled 307 participants (median of mean age 7.2 years, Eczema Area Severity Index baseline mean of means 27.57 [median SD, 10.74]) for a median of 6 weeks (range, 4-10). We confirmed that other trials registered globally were terminated. Bleach baths probably improve AD severity (22% vs 32% improved Eczema Area Severity Index by 50% [ratio of means 0.78, 95% credible interval 0.59-0.99]; moderate certainty) and may slightly reduce skin Staphylococcal aureus colonization (risk ratio, 0.89 [95% confidence interval, 0.73-1.09]; low certainty). Adverse events, mostly dry skin and irritation, along with itch, patient-reported disease severity, sleep quality, quality of life, and risk of AD flares were not clearly different between groups and of low to very low certainty. CONCLUSION: In patients with moderate-to-severe AD, bleach baths probably improve clinician-reported severity by a relative 22%. One in 10 will likely improve severity by 50%. Changes in other patient-important outcomes are uncertain. These findings support optimal eczema care and the need for additional large clinical trials. TRIAL REGISTRATION: PROSPERO Identifier: CRD42021238486.

Department

Dermatology

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