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You like tomato, I like tomahto, you soak with steroids, I use them dry…

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By Warren R. Heymann, MD
July 28, 2016

I have been a firm believer in the “Soak and Smear” approach to treating recalcitrant dermatoses, including atopic dermatitis, as detailed by Gutman et al, more than a decade ago. The authors defined soaking and smearing as soaking an affected body part or whole body bathing in plain water for 20 minutes to be followed immediately by smearing an ointment over the affected area, without drying the skin. The applied ointment is usually 0.1% triamcinolone acetonide ointment or a class 1 corticosteroid ointment for psoriatic hand involvement. Treatment includes a morning application with a cream of the same strength as the nighttime ointment. They performed a retrospective study of 28 patients (age range 24 to 84 years) with refractory chronic pruritic eruptions. Their diagnoses were atopic dermatitis (n = 15), xerotic eczema (n = 5), psoriasis (n = 4), nummular eczema (n = 2), irritant dermatitis (n = 1), and undefined dermatitis (n = 1). Intervention with a plain water 20-minute soak followed by smearing of mid-strength to high-strength corticosteroid ointment led to clearing or dramatic improvement. Presumably this approach normalizes the epidermal barrier by decreasing transepidermal water loss and allowing more effective penetration of the topical steroid (1).

This has become such a standard approach to therapy, that I was surprised to read the study by Kohn et al, who observed that application of steroids to presoaked skin works no better or worse than its application to dry skin for the treatment of atopic dermatitis (AD) in children. They performed a randomized, investigator-blinded, controlled study in children with AD. Patients were randomized to apply topical corticosteroids (TCS) either via soak and smear (SS) (n = 22) or to dry skin (n = 23) for 14 days. The primary outcome was an improvement in the Eczema Area and Severity Index score. Secondary outcomes included assessments of disease burden, pruritus, and sleep; morning cortisol levels; and adverse effects. Patients with AD severity who applied TCS via SS or to dry skin improved 84.8% and 81.4% by Eczema Area and Severity Index score, respectively. There was no statistical difference between the 2 groups (P value = .85) (2).

Is this the demise of soak and smear? Of course not, because it works! There are many considerations here, notably that Kohn’s study was performed in young patients (age 2 weeks to 18 years) with AD only. Perhaps xerosis was more of a factor in the older patients. Maybe SS is more beneficial for some inflammatory disorders compared to AD. I certainly look forward to more comparative studies to determine if there really is a difference in SS versus dry applications of corticosteroids.

Our goals in treating inflammatory dermatoses are to alleviate symptoms and restore normal barrier function. I hate to admit it, but the adage holds true: “If it’s wet dry it, if it’s dry, wet it. And if that fails, use topical steroids.” God almighty, I can’t believe I put that in writing!

1. Gutman AB, et al. Soak and smear: A standard technique revisited. Arch Dermatol 2005; 141: 1556-9.
2. Kohn LL, et al. A randomized, controlled trial comparing topical steroid application to wet versus dry skin in children with atopic dermatitis. J Am Acad Dermatol 2016; 75: 306-11.

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