The Impact of Swimming on Atopic Dermatitis Flares

Swimming may result in both positive and negative effects for patients with atopic dermatitis.

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In a recent review,¹ researchers assessed existing literature related to the topic of swimming and atopic dermatitis in order to pool data supporting the benefits and drawbacks of the activity. Additionally, they sought to analyze several factors, including components of water, exercise, skin barrier protection, and swimming gear.

Researchers performed their analysis using available data and existing literature from PubMed dated up until March 10, 2023. Their search terms included “atopic dermatitis,” “atopic eczema,” or “eczema,” and “swimming.” Of the 46 articles accumulated by researchers, 20 were selected for target review by the review authors.

“One of the key concerns relating to swimming exposure and impact on AD [atopic dermatitis] development and severity is the effect of swimming on the skin barrier, which is known to be a primary pathogenic factor in the development and persistence of AD,” review authors wrote. “Transepidermal water loss is a surrogate marker for skin barrier function, and aberrations in TEWL are known to predate the clinical development of AD.”

Multiple studies examined potential correlations between early childhood exposure to swimming and atopic dermatitis development. All related studies included in the review either found no correlation between the 2, or researchers were unable to rule out the possibility of reverse causation.

Researchers also evaluated several water constituents, including hardness, pH, temperature, antiseptics and other chemicals, type of water (saltwater or seawater), and numerous forms of skin barrier protection, such as emollient barriers and swim gear.

1 study within the review found that children who routinely applied a moisturizing emollient after swimming had stable pH and sebum levels, while children who did not experienced significant decreases in sebum and pH.

Researchers also found that calcium in hard water could lead to skin barrier damage via dryness or irritation. Furthermore, it could also predispose children to atopic dermatitis and provoke flares in those already with the condition. Water hardness and atopic dermatitis shared a linear relationship.

In cases of water with levels of high alkalinity, skin dryness and irritation can result, potentially developing into atopic dermatitis. Additionally, warmer water temperatures may increase the skin’s pH and transepidermal water loss.

Swimming and immersion in water may cool exposed eczematous lesions and skin while reducing excessive sweating. Furthermore, it can relief symptoms of itch and remove excess crusts. Certain antiseptic additives in pool water such as bleach or chlorine not only sanitize pool water, but they can also reduce microbial colonization of the skin.

However, the skin’s natural protective sebum may dilute or melt, leading to increased transepidermal water loss. While antiseptic additives can impact swimmers with atopic dermatitis positively, they can also cause irritant contact dermatitis or allergic contact dermatitis, also known as “pool dermatitis” or “pool water dermatitis” in these instances.

Researchers also found a lack of evidence supporting a correlation between salt water and atopic dermatitis outcomes, but they noted that free residual chlorine in water reduces water retaining properties of the stratum corneum. Swim gear such as goggles are also capable of producing irritation or sensitization to rubber constituents.

Currently, several atopic dermatitis and eczema organizations, including the Eczema Foundation, National Eczema Society, American Association of Dermatology, and the British Association of Dermatology, provide swimming-related recommendations. These recommendations include:

• Applying an emollient and topical corticosteroid
• Applying an emollient and/or sunscreen before swimming
• Avoidance in instances of severe flares or infections
• Avoid spending time around pool after finishing swimming due to continued exposure to chlorinated fumes
• Ensure pool showers contain fresh water, not chlorinated water
• Rinsing and patting dry skin with warm water after swimming
• Showering immediately after swimming and applying a subsequent emollient
• Try a short test period at a new pool to gauge your skin’s response
• Washing skin at home using gel containing copper and zinc

“Our work identifies significant gaps in the literature on the optimal advice on swimming for children living with AD but provides suggestions for providers based on current evidence and our opinions when evidence was lacking,” review authors wrote. “Future research should examine the impact of swimming on flares of AD using clinical severity assessment and noninvasive biomarkers and assess the role of different interventions to optimize eczema control when swimming.”

Reference

1. O'Connor C, McCarthy S, Murphy M. Pooling the evidence: A review of swimming and atopic dermatitis. Ped Dermatol. 2023. doi:10.1111/pde.15325