Rewards (and Risks) of Bleach Baths
Leonard M. Milstone, M.D. (Yale University) and Peter M. Elias, M.D. (UC San Francisco)
Why do dermatologists recommend bleach baths to many of their patients with ichthyosis? Laundry bleach is quite caustic with a pH of 11. Dilute bleach (sodium hypochlorite: 1 part in 99 parts of tap water) is a potent, rapid antiseptic that has a slightly alkaline pH of 9. These two facts govern the appropriate use of bleach baths by our patients.
Many patients with ichthyosis, despite their best attempts at personal hygiene, become colonized by an overgrowth of bacteria, yeasts, or fungi. An unfortunate consequence of this colonization by these microbes can be an unpleasant odor. When these same microbes try to reside on normal skin, they encounter a much thinner, and much more acidic stratum corneum. The ‘acid mantle’ of normal skin (pH 5.0 - 5.5) resists the growth of many microbes, while selectively encouraging colonization by the microbes that normally occupy the niche of the stratum corneum. In contrast to the low pH of normal skin, the pH of ichthyotic stratum corneum rises (to pH 6-7) due in part to excess scale, inflammation, and a defective barrier. This elevated pH and the thickened stratum corneum niche favor the overgrowth of many microbes, including not only those that populate normal stratum corneum, but also pathogenic microbes, such as Staphlococcus aureus. Clearly, the chief reason we recommend bleach baths is their ability to reduce the amount of odoriferous colonization by potentially pathogenic microbes on the skin surface.
There is a second consequence of the elevated pH of ichthyotic skin, and the even more elevated pH of bleach. There are enzymes in the stratum corneum that are more active at an elevated pH, and whose activity can have two important consequences. First, some of these enzymes degrade the connections that hold the cells of the stratum corneum together, causing these cells to separate from each other, and eventually to be shed from the skin surface. Obviously, for someone who has too thick a stratum corneum, bleach baths could prove to be an advantage. It should be noted, however, that there are no experimental or clinical data proving that bleach promotes desquamation. Second, some of the enzymes that are more active at higher pH can provoke inflammation, because they activate and release pro-inflammatory cytokines, proteins that normally are stored inside stratum corneum cells and shed harmlessly. Currently, there are no studies that address whether the slightly alkaline pH of bleach baths increases inflammation in those who have inflamed skin. Somewhat surprisingly, there is one study showing that dilute bleach has the ability to reduce inflammation in an animal model of inflamed (not ichthyotic) skin. So in sum, we still have questions about the impact that bleach baths have on inflammation in our patients.
Most of us would agree that, taken together, the benefits of bleach baths in reducing microbial overgrowth, odor and infections far outweigh the uncertainties arising from its slightly alkaline pH. Yet none of us would see any advantage to prolonged exposure to the abnormally high pH of dilute bleach baths for patients with ichthyosis. Instead, it would seem prudent to follow one’s bleach bath with a generous application of a slightly acidic emollient, such as Amlactin or Lachydrin, to help restore the skin’s natural acid mantle.
Tips for the Tub: how to Enter and Exit Safely
Baths are a critical element of skin care for many people with ichthyosis. But slips and falls in the bath are common and can lead to injury. To promote independence in bathing for all ages, we recently sat down with an occupational therapist to better understand tips for bathing safely.
First, be sure to have a bathmat outside of your bathtub to reduce slipping when entering and exiting the tub. You also may want to purchase a nonslip mat for inside the bathtub, depending on your comfort and personal preference.
When entering the bathtub, use the wall to steady yourself as needed. You may also want to consider entering the bathtub sideways. Put both hands against the wall and step one leg in at a time. Depending on your level of mobility, personal comfort, and physician suggestions, you may also sit on the ledge of the bathtub, gently swing one leg over at a time, then lower yourself into the tub. For even more security, consider installing grab bars within your bathtub.
When you are ready to exit the tub, you may want to consider turning onto your knees and standing up. This promotes balance and steadiness in a slippery environment. You can also use your hands to push yourself up. If it works better for you and your personal comfort, use the ledge of the bathtub to sit on and then swing your legs out of the bathtub.
These tips from a board-certified occupational therapist are appropriate for children and adults. Please contact your physician if you have specific concerns.
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This information is provided as a service to patients and parents of patients who have ichthyosis. It is not intended to supplement appropriate medical care, but instead to complement that care with guidance in practical issues facing patients and parents. Neither FIRST, its Board of Directors, Medical & Scientific Advisory Board, Board of Medical Editors, nor Foundation staff and officials endorse any treatments or products reported here. All issues pertaining to the care of patients with ichthyosis should be discussed with a dermatologist experienced in the treatment of their skin disorder.