Dermapixel: Swimming for atopic dermatitis: recommended or not?

It is very clear to everyone that the ability to swim is a life skill (especially if you live on an island), an activity that is also associated with improved physical and mental health. swimming may be an appropriate activity for children with atopic dermatitisBecause skin contact affects water, it is refreshing and can reduce itching at the time, as well as avoid the excessive sweating that is so bad for eczema. However, up to a third of children with atopy have limited access to swimming due to the severity of the disease or on medical advice. In addition, some children may feel embarrassed about the visual impact of their diseased skin on other people. One thing is clear: atopic dermatitis can have a very negative impact on the quality of life from these children. Forbidding these young patients to swim may be more detrimental to them than the intended benefit of such a restriction. In addition, we must not forget that drowning is the third leading cause of death from unintentional injuries, and the situation in this ranging rises in children

A child with atopic dermatitis being treated

So, I took the opportunity to review this recent article from Pediatric Dermatology (March 2023) by Cathal O’Connor and collaborators (Irish) who dedicated themselves to reviewing 20 articles published in the literature on the topic. I will just give you a translated summary of the most relevant points and conclusions that the authors reached by adapting the infographic of the article.

Current data on swimming in people with atopic dermatitis.
One of the main concerns regarding the effect of swimming in atopic dermatitis is its effect on the barrier function of the skin, since it is one of the main pathogenic factors of the disease. Transepidermal water loss (TEWL) is an indirect marker of this barrier function. A study on elite teenage swimmers showed that this figure increased after 2 hours of training in the water, but returned to normal after 30 minutes. Another study compared pH and sebum depending on whether pre-swim moisturizers were applied (with significant differences in favor of pre-swim emollients). A Spanish cohort study examined the presence of eczema in the first year of life without any difference compared to children who did not perform this activity. There are other conflicting studies in this regard that may have something to do with the fact that the diagnosis of dermatitis was self-diagnosed by the parents. There are also no studies on swimming during atopic flare-ups, so it seems reasonable to postpone swimming for more severe flare-ups. Active treatment of dermatitis is also proposed to reduce the frequency of exacerbations. On the other hand, during periods of secondary impetigo dermatitis, it is also recommended to refrain from activity until the crusts have fallen off or at least 24 hours after the start of antibiotic treatment (taking into account the antiseptic properties of chlorinated water in most swimming pools). Molluscum contagiosum is more common in atopic children and also in non-atopic children who swim, although the presence of shellfish is not a reason for these children not to swim in pools (you just have to avoid sharing towels).

Water properties.

  • hardness. Water hardness is defined as the concentration of divalent metal cations such as calcium and magnesium in a water sample. Calcium chloride is added to swimming pool water to maintain water hardness, which protects surfaces from corrosion. However, calcium in water can alter the skin’s barrier function, increasing dryness and irritation, which can be counterproductive for an atopic person.
  • pH. The pH level is the most important factor to control in any pool, as it affects the effectiveness of the chlorine. Pool water must meet stringent quality standards for swimmers to enjoy swimming, including protection from the chlorine-resistant pathogen Cryptosporidium. The ideal pH for eye comfort and prevention of corrosion or scaling is slightly alkaline in the pH range of 7.2-7.4, while the skin pH on most parts of the body is typically between 4.1 and 5.8. The acid coat of the skin is responsible for retaining essential moisture and lipids, as well as providing a barrier against pathogens, irritants, and allergens. Excessive alkalinization of the skin can make it dry and irritated, which can aggravate atopic dermatitis.
  • Temperature. For people with atopic dermatitis, cooler temperatures are preferred, as warmer water can increase TEWL and skin pH.
  • Antiseptics and other chemicals. Swimming pool water contains many chemicals that can irritate or dry out the skin. Chlorine is added to pools for antiseptic action, but exposure to chlorine can cause irritant contact dermatitis or allergic contact dermatitis. However, the antiseptic activity of dilute chlorine can reduce microbial colonization and the severity of atopic dermatitis, as has been described in bleach baths. Alternative or additional pool disinfection options include salt water chlorination, bromine (which is also not without problems), ozone, polyhexamethylene biguanide, algaecides and filter aids, flocculants and clarifiers.
  • Salty water. Most patients with atopic dermatitis experience improvement when swimming in the sea or in seawater pools (although irritation may occur in some cases). Despite everything, there is little evidence in this regard, only a Japanese study that showed the benefits of balneotherapy.

Protecting the barrier function of the skin while swimming.
Some studies have examined the benefits of using an emollient before or after swimming, and it seems that both before and after swimming can be more than beneficial, especially emollients with a higher lipid content.

Swimming accessories and atopic dermatitis.
It has been proven that residual chlorine in swimwear reduces the properties of the stratum corneum of atopic skin. If these children do not remove their bathing suits immediately after exercise, occlusion and direct irritation predispose them to folliculitis and bacterial infections. That’s why it’s important that after bathing, children take off their swimsuits and rinse off with water. In the case of swimming on the beach, you should also rinse with running water if possible.
On the other hand, contact with certain materials such as goggles, diving masks or caps may increase the sensitivity of these children to certain rubber components.

Physical exercise in children with atopic dermatitis.
There is growing concern about the link between atopic dermatitis, obesity and cardiovascular disease. For all these reasons, it is important to inculcate healthy habits from childhood, which, of course, include playing sports. In addition, sleep disturbances are a common problem in atopic patients, and exercise can improve this aspect.

Some recommendations

The authors conclude that swimming is a necessary skill for any person and that children with atopic dermatitis should not lose the opportunity to practice it due to often unfounded fears. More research needs to be done in this regard, but with a few precautions and a little common sense, these children could practice this type of activity without major problems and with no small benefit.

And since today’s post is about pediatrics, I leave you with an episode of Peppa Pig in which George learns to swim.

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