What is the recommended treatment regimen for patients with moderate to severe eczema using bleach baths?

Bleach Baths for Moderate to Severe Eczema

Recommended Treatment Regimen

For patients with moderate to severe eczema showing clinical signs of secondary bacterial infection, use dilute bleach baths (0.005% sodium hypochlorite) twice weekly combined with intranasal mupirocin ointment, while continuing topical corticosteroids and emollients as the foundation of treatment. 1, 2

Specific Bleach Bath Protocol

Preparation and Application

• Add ½ cup (approximately 120 mL) of regular household bleach (6% sodium hypochlorite) to a full standard 40-gallon bathtub of water to achieve 0.005% concentration 2
• Soak the affected body areas for 10 minutes, twice weekly 2
• Do not submerge the head and neck unless specifically affected 2
• Rinse with plain water after soaking and pat dry 2
• Apply emollients immediately after bathing to lock in moisture 1

Combined Intranasal Treatment

• Apply intranasal mupirocin ointment to both nostrils twice daily for 5 consecutive days each month during the 3-month treatment period 2
• This combination targets both skin surface and nasal reservoir colonization of Staphylococcus aureus 2

When to Use Bleach Baths

Primary Indications

• Moderate to severe atopic dermatitis with clinical signs of secondary bacterial infection (crusting, weeping, pustules) 1, 2
• Patients prone to recurrent skin infections despite standard topical therapy 1
• As an adjunctive antiseptic measure to reduce Staphylococcus aureus colonization 1, 2

Expected Outcomes

• Bleach baths probably improve clinician-reported eczema severity by approximately 22% relative improvement 3
• One in 10 patients will achieve 50% improvement in Eczema Area and Severity Index scores 3
• Body areas submerged in bleach baths show significantly greater improvement than non-submerged areas (particularly head and neck) 2
• Effects become apparent at 1 month and continue through 3 months of treatment 2

Critical Context and Limitations

Evidence Quality

• Recent meta-analysis shows bleach baths are effective in decreasing eczema severity, but not more effective than plain water baths alone when directly compared 1, 4
• The combination of bleach baths plus intranasal mupirocin shows superior results compared to placebo (plain water baths plus intranasal petrolatum) 2
• The benefits and risks of irritants in bleach baths should be weighed before application 1

Alternative for Homes Without Bathtubs

• Soak a cotton pajama suit in dilute bleach solution (same 0.005% concentration) and have the patient wear it for 10 minutes, 2-3 times weekly 5
• This "bleach suit" method has shown satisfactory outcomes without adverse effects in small case series 5

Essential Concurrent Treatments

Never Use Bleach Baths Alone

• Continue topical corticosteroids as the mainstay of treatment—use the least potent preparation that controls symptoms, applied twice daily 1, 6
• Apply liberal amounts of emollients regularly, even when eczema appears controlled 1, 6
• Use soap-free cleansers and dispersible cream as soap substitute 1, 6

Managing Active Infection

• If clinical signs of bacterial infection are present (increased crusting, weeping), start oral flucloxacillin or cephalexin for 14 days 7, 2
• Do not delay or withhold topical corticosteroids when infection is present—they remain primary treatment when appropriate systemic antibiotics are given concurrently 7, 6

Safety Considerations and Adverse Events

Common Side Effects

• Dry skin and irritation are the most common adverse events, occurring in approximately 1 in 10 patients 3
• These effects are generally mild and manageable with increased emollient use 3
• No significant differences in itch, patient-reported disease severity, sleep quality, or quality of life have been clearly demonstrated 3

Contraindications and Cautions

• Avoid bleach baths if open wounds or severe skin breakdown are present until initial healing occurs 1
• Do not use higher concentrations than recommended—more is not better and increases irritation risk 2
• Ensure adequate ventilation during bleach bath preparation and use 8

Common Pitfalls to Avoid

• Do not use bleach baths as monotherapy—they are adjunctive only and must be combined with topical corticosteroids and emollients 1, 2
• Do not expect dramatic superiority over plain water baths—the evidence shows bleach baths work, but water baths alone also improve eczema severity 1, 4
• Do not submerge the head and neck unless specifically treating those areas—the original study showed no benefit for non-submerged areas 2
• Do not continue indefinitely without reassessment—the studied protocol is 3 months duration 2

When to Escalate Treatment

• Failure to respond to optimized topical therapy plus bleach baths after 4 weeks warrants dermatology referral 6
• Consider topical calcineurin inhibitors (tacrolimus) as steroid-sparing agents for maintenance 6
• Phototherapy (narrow-band UVB) should be considered for recalcitrant disease after failure of first-line topical treatments 1
• Systemic immunosuppressants (cyclosporine, methotrexate, azathioprine) are reserved for severe disease refractory to topical treatments and phototherapy 1