Why bathing is essential?
In Ichthyosis the body’s ability to produce the outermost layer of skin, the stratum corneum, is defective. So there is traffic jam of cells on the skin’s surface which causes scaly skin.
The goal in treating the primary symptoms of ichthyosis is promoting exfoliation (normal shedding) of the skin’s outermost layer. Bathing is important to the shedding process. It not only cleanses skin of dirt and other external debris, it completes the natural process of desquamation, sweeping away dead epidermal cells.
For some form of ichthyosis affected people, frequent bathing is extremely important, as it is not only the best way, but the most natural way to remove dry scales and skin, and most importantly, more frequent bathing can ease the distress of ichthyosis, making day to day life much more comfortable.
Following bathing recipes can be used in a tub filled with one-third of water & soak the skin for 30 mins to an hour, as per your need. These baths should be followed by application of an emollient.
- Salt Bath : The aim is to produce 3% solution which is less than the amount of sodium chloride in the ocean. This equals 1/4 pound per gallon of water – or 5 lbs in 20 gallons or 7.5 pounds in 30 gallons. Less salt may work for some, if you soak for at least an hour. This is safe to use every day. You can add pool salt to your pool too.
- Baking Soda Bath: The aim is to have a pH of 7.9. The amount of baking soda to add may vary with the quality (pH) of your tap water. In most cases, adding one-third cup to a tub one-third full with water will raise the pH to 7.9. You can test the water after the baking soda is dissolved with pH indicator paper. You must soak for 45 minutes to one hour before starting to gently slough scale with a washcloth, loofah or other gentle mechanical desquamator. Baking soda baths can be used up to several times a week.
- Antimicrobial Bleach Bath: Measure the amount of water usually put in the tub. Add 10ml (2 teaspoons) of household bleach per gallon – i.e., about 1 cup in a half-full tub (40-50 gallons). Soak for a minimum of 15 minutes – longer if you want to remove more scale. Bleach baths once or twice a week should be adequate to reduce odor and the frequency of infections; daily for one week may be necessary for someone currently infected. Undiluted household bleach is quite irritating so be careful how you handle it.
- Post Bath Emollient: It is important to use an emollient just after bathing. If you have taken an alkaline bath (by using baking soda or bleach) it is a good idea to restore the natural acid pH of the outer layer of skin by using an emollient with a slightly acid pH, such as Lac-Hydrin or AmLactin.
(Ref: Leonard M. Milstone, MD,Yale University )
Pros & Cons of Bleach Baths
Many patients with ichthyosis, despite their best attempts at personal hygiene, become colonized by an overgrowth of bacteria, yeasts, or fungi which results in 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 pH of normal skin (pH 5.0 – 5.5) resists the growth of many microbes, while selectively encourages 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 to excess scale, inflammation, and a defective barrier. This elevated pH and the thickened stratum corneum favor the overgrowth of many microbes, including not only those that populate normal stratum corneum, but also pathogenic microbes, such as Staphlococcus aureus. In that case, bleach bath helps to:
- Decrease Odor – Bleach baths reduce the amount of odoriferous colonization by potentially pathogenic microbes on the skin surface.
- Decrease Infection – Bleach baths can decrease the risk of infection.
However, 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:
- Separation of Cells – 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.
- Inflammation – 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. 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 Lac-Hydrin or AmLactin, to help restore the skin’s natural acid mantle.
(Ref: Leonard M. Milstone, MD ,Yale University and Peter M. Elias, MD, UC San Francisco)
Travel Tips for Bathing
Traveling with children who have ichthyosis is challenging particularly when it comes to bathing.
- Bring along a blow up baby tub. It’s easy to pack and you don’t need to use the hotel tub.
- Bring a big Rubbermaid container to pack things, and then use it as a tub as well when you are at your destination.
- Cleaning sponges and bleach wipes could also do the trick for a bath.
- Bring antibacterial wipes with you when you travel. You can use them for cleaning stations and bathtubs.
- Consider switching to showers when traveling and resign yourself to the fact that kids may look a little “rough around the edges” without their same bath routines.
(tips shared by patients for coping with their ichthyosis)
Exfoliation is the act of removing the outer scales from the skin. For those individuals with hyperkeratotic ichthyosis (i.e. thickened skin) exfoliation can make you more comfortable doing day to day activities. And those with CIE, harlequin, or epidermolytic ichthyosis will find exfoliation most beneficial. However, exfoliation, while removing the scale, often brings out the underlying erythema or redness. So you may trade the scale for the redness. This is not an issue if the scale is very bothersome, but it is important to keep in mind if you do not want to be red. In other cases, such as Netherton syndrome, the skin barrier is impaired, and the skin should not be further exfoliated. Exfoliation will only lead to increased sensitivity and irritation in this case.
Tips for Exfoliation:
- After soaking in a tub for an hour or longer, use a wash cloth, pumice stone or loofah brush to gently remove the outer layer.
- After bathing, try using glycerin mixed with petroleum jelly or cream/lotion containing ammonium lactate 10% or 12% (Amylac, Lacsoft), glycolic acid (Glyco-A 6% or 12%), salicylic acid (Salicylix 6% or 12%), paraffin (Cetraben, Aquasoft), urea (Eucerin 10%, Revitaderm 20%), Mixed preparation e.g Moisturex to help soften and exfoliate the outer layer.
- For those with thick scale under their eyes, topical tazarotene (Tazret) or tretinoin cream (Retino-A 0.025% or 0.05%) can loosen the scales and allow their eyelids to close more fully.
(Ref: Dr. John Browning, Chief of Dermatology at Children’s Hospital of San Antonio)
** If the skin is sensitive, or has some areas of open skin, some of the above mentioned products will sting. Consult with your doctor before using any of these products on an infant or child.
- Use baking soda and make a paste which would be considered a mild abrasive to aid in loosening the dead skin.
- Add Vaseline Bath Beads or apple cider vinegar to the bath water to help in softening up the skin before exfoliating.
- You can try sugar scrub, sea salt or rock salt scrub which are available in body shops.
- Moisturizing soaps like dove, olay, nivea, pears etc. can be used to scrub the loose skin off gently with palms or a wash cloth. Soaps rob skin of essential oils, so should be used occasionally. You will learn with experience how much to scrub. Moderation is the key. If too much skin is removed, there will be tender (sometimes very red or even raw) skin beneath. It is especially important not to overdo scrubbing off the scale in babies. If your child is sensitive to soaps, try baking soda or oatmeal bath additives which you will get in grocery store or drugstore. If your baby has raw areas on it’s skin, put petroleum jelly on that area before bath. This will reduce the pain when comes in contact with the bath water. After shower, pat dry the body with towel to keep the skin moist. Immediately apply cream or lotion mixed with glycerin to trap that moisture while you are still in bathroom. How often should you give your child a bath depends on the condition of the skin and the weather. If you live in a climate with dry, cold weather or too hot, you may have to give your child more frequent baths. Ichthyosis becomes worse in dry season. Steam of comfortably warm shower helps to clean skin & remove toxins from the body.
- Let a loofah sponge soak in water for a few days before using, they will eventually soften up.
- When exfoliating areas such as knees, elbows and feet, if it starts to hurt, stop, and continue the next day.
- The salty ocean does wonders for the skin, and works as a natural exfoliant.
- Hydrotherapy, whereby the water and air is circulated throughout the tub, may also be a beneficial way to soften and exfoliate skin.
(tips shared by patients for coping with their ichthyosis)