ORIGINAL ARTICLE

A randomized, controlled trial

comparing topical steroid application
to wet versus dry skin in children
with atopic dermatitis (AD)
Lucinda L. Kohn, MD,b Yanna Kang, PhD,b and Richard J. Antaya, MDa,b
New Haven, Connecticut

Background: Soak and smear (SS), a technique whereby a bath is followed by topical corticosteroid (TCS)
application to wet skin, is reported to be a beneficial adjunctive therapy for patients with recalcitrant atopic
dermatitis (AD).

Objective: We evaluated whether SS is of greater benefit than application of TCS to dry skin for the
treatment of childhood AD.

Methods: A randomized, investigator-blinded, controlled study was performed in children with AD.
Patients were randomized to apply TCS either via 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.

Results: Patients with AD severity who applied TCS via SS or to dry skin improved 84.8% (95% confidence
interval 77.5-92.1) and 81.4% (95% confidence interval 70.3-92.4) by Eczema Area and Severity Index score,
respectively. There was no statistical difference between the 2 groups (P value = .85).

Limitations: Small sample size limited the power of our study.

Conclusions: We did not find that application of TCS to presoaked skin works better than application to
dry skin for the treatment of AD in children. ( J Am Acad Dermatol http://dx.doi.org/10.1016/
j.jaad.2016.04.060.)

Key words: atopic dermatitis; bath; corticosteroids; eczema; hydration; soak and smear.

S oak and smear (SS) is a technique used to

increase the efficacy of topical corticosteroids
(TCS) for atopic dermatitis (AD) by the patient
soaking in lukewarm water before smearing
Abbreviations used:
AD:
EASI:
SS:
atopic dermatitis
Eczema Area and Severity Index
soak and smear
corticosteroid ointment on wet skin. Soaking TCS: topical corticosteroid
hydrates the stratum corneum, and smearing of TCS

From the Department of Dermatology and Pediatrics,a Yale
University School of Medicine.b
Supported by Yale University School of Medicine James G. Hirsch,
MD, Endowed Medical Student Research Fellowship.
Dr Antaya has been a consultant for the following: Promius, Anacor,
Astellas, Ranbaxy, Pierre Fabre, and Hoffman-Laroche Pharmaceu-
ticals. Drs Kohn and Kang have no conflicts of interest to declare.
Presented as a poster at the Yale University School of Medicine
Student Research Symposium on May 7, 2014 in New Haven,
CT, and as a poster at the Society for Pediatric Dermatology
40th Annual Meeting from July 9 to 12, 2014 in Coeur d’Alene,
ID. This study also comprises the MD thesis work of Dr Kohn,
published under the name Lucinda S. Liu.
Accepted for publication April 22, 2016.
Reprint requests: Richard J. Antaya, MD, Department of Dermatology,
Yale University School of Medicine, PO Box 208059, 333 Cedar St, LCI
501, New Haven, CT 06520-8059. E-mail: richard.antaya@yale.edu.
Published online June 1, 2016.
0190-9622/$36.00
Ó 2016 by the American Academy of Dermatology, Inc. Published
by Elsevier. All rights reserved.
http://dx.doi.org/10.1016/j.jaad.2016.04.060

1
2 Kohn, Kang, and Antaya J AM ACAD DERMATOL
n 2016

traps moisture in the stratum corneum, increases hydrocortisone 2.5% ointment twice daily. All pa-
permeability, and enhances drug absorption.1,2 tients were prescribed hydrocortisone 2.5% ointment
Previous studies have shown that SS results in for application to facial and intertriginous areas.
marked improvement or disease clearance in nearly Participants in the SS arm were instructed to use
all patients.3-5 There is limited evidence of its benefit the regimen once daily with the following instruc-
in the pediatric population; use of SS in children is tions: ‘‘Soak in a bath (not a shower) in plain,
based primarily on uncontrolled case series and lukewarm water for 10 minutes (use a timer) at night
expert opinion. This study then immediately, without
was undertaken to evaluate drying the skin, smear on
whether TCS application us- CAPSULE SUMMARY the corticosteroid ointment.’’
ing SS works better than TCS Participants in the control
d Previous uncontrolled studies suggest
applied to dry skin for the arm were instructed to
that soak and smear is a successful crisis
treatment of childhood AD. refrain from applying TCS to
intervention modality for patients with
wet skin. All participants
METHODS atopic dermatitis.
were educated regarding
Study design d Application of corticosteroid ointment maintenance and flare treat-
We conducted a random- using soak and smear was not superior ment for AD and were
ized, controlled, investigator- to application of corticosteroid ointment instructed to avoid soaps
blinded, single-center trial. to dry skin in children with atopic and cleansers.
Patients between 2 weeks dermatitis in this controlled study. Participants completed
and 18 years of age who met d In children, application of topical the treatments at home and
the clinical criteria for diag- corticosteroids for 2 weeks can result in documented progress, level
nosis of AD were eligible for greater than 80% clearance of atopic of pruritus, level of sleep
this study.6 Patients with less dermatitis if applied to wet or dry skin. deprivation, and compliance
than 5% total body surface in a daily log.
area involvement, with clini-
cally infected AD, allergy to Data collection and outcomes
triamcinolone 0.1% ointment or hydrocortisone 2.5% The main outcome was improvement in EASI on
ointment, or without access to a bathtub were day 14.7 The EASI was chosen as the objective
excluded. Participants were randomly assigned to measurement of disease, because it exhibits good
either the control or SS arm with a 1:1 allocation ratio interevaluator consistency, validity, and sensitivity to
using computer-generated permuted blocks of either change, and correlates well with other validated
4 or 6 in random order. Allocation was revealed only measures of AD severity.8 The EASI does not
after the patient had been recruited to the study. One subjectively measure AD. Therefore, we asked the
investigator was blinded and was responsible for patient or caregiver to record daily scores for itch,
evaluating patients. A separate investigator was not sleep, overall impact of disease, and compliance for
blinded and was responsible for demonstrating TCS the 14 days of treatment. Each patient or caregiver
application technique to the participants. Participants assigned a daily value to the level of pruritus (using a
initially randomized to the control arm were offered scale of 0-10 with 10 indicating severe itch); impact
the opportunity to cross over into the SS arm if their of disease defined as how much the AD affected
AD showed less than 75% clearance by Eczema Area overall quality of life (using a scale of 0-10 with 10
and Severity Index (EASI) score on day 14 (Fig 1). indicating worst quality of life); and quality of sleep
This study (protocol #1206010366) was approved (using a scale of 0-3 with 3 indicating that the patient
by the Yale IRB (Yale Human Research Protection slept poorly).
Program) on July 19, 2012 and the Yale Pediatric On day 14, participants returned for evaluation
Protocol Review Committee on June 1, 2012. Parents and were asked to report adverse effects (Fig 1).
gave written informed permission, and children older Participants had the option of participating in a
than 7 years gave written assent. The study design was 1-time blood draw to measure morning serum
posted on ClinicalTrials.gov and has the identifier cortisol level on day 14.
NCT01675232.
Statistical analysis
Study interventions Sample size calculation was based on the null
Patients 2 years of age or older were prescribed hypothesis that there would be no difference in
triamcinolone acetonide 0.1% ointment twice daily. treatment results between the 2 arms. Predicted
Patients younger than 2 years were prescribed outcomes were based on prior studies and showed
J AM ACAD DERMATOL Kohn, Kang, and Antaya 3
VOLUME jj, NUMBER j

Fig 1. Atopic dermatitis. Participant flow diagram showing randomization, study design, and
crossover design. EASI, Eczema Area and Severity Index.

a predicted improvement of 95.2% with SS and 60.5% Table I. Demographics

with TCS application to dry skin yielding a difference Control Soak and smear
in proportions of 35.3,4,9 Given that our predicted
Patients 23 24
effect size was calculated using vastly different
Age, y, mean 6 SD 3.1 6 4.0 3.2 6 3.4
studies, we chose to set it at a value that was more (range) (0.3-16) (0.3-11)
conservative than calculated. For this study to detect Gender female:male 8:15 10:12
a difference of at least 15% (by EASI) between the 2 Race
treatment arms, with an estimated SD of 20%, and White 14 12
using a 2-sided t test with a = 0.05, we required a Black 2 5
sample size of 26 participants in each arm to reach Asian 5 2
80% power. Anticipating a dropout rate of 5%, we Hispanic 0 2
calculated a need for 55 participants to reach Other 2 1
significant power. This was an intention-to-treat Recruited in summer 3 3
(June, July, August)
analysis. Two-sided Wilcoxon rank sum tests were
Initial EASI score, 15.1 6 6.9 15.8 6 9.1
performed to compare values in the 2 study arms.
mean 6 SD (range) (2.8-29.7) (4.6-34.95)

EASI, Eczema Area and Severity Index.

RESULTS
In all, 46 eligible patients with AD presented to the
Yale Pediatric Dermatology Clinic between July 2012
and July 2013, of whom 45 were enrolled in this
study (Table I). Every patient was referred from a
general pediatrician or community dermatologist. In
all, 22 patients were enrolled in the SS arm and 23 in
the control arm. All 45 patients returned on day 14 for
a follow-up visit and were included in data analysis.
Three patients were asked to cross over from the
control arm into the SS arm, and of those, 2 returned
for a second day-14 follow-up visit. The family who
did not return reported difficulty in keeping the
follow-up appointment because of work schedules
and frustration with lack of AD clearance. The data
were analyzed excluding the crossover group, and
4 Kohn, Kang, and Antaya
Fig 2. Atopic dermatitis. Eczema Area and Severity Index (EASI ) score, sleep quality, pruritus,
and overall impact of disease scores in soak and smear (SS ) and control groups on days 1, 7,
and 14.
again including the crossover group. There was
no change in statistical significance between the
2 arms with the inclusion of the crossover group.
The data presented below excludes the crossover
data.
Both SS and control arms showed improvement in
disease severity measured by EASI. The SS arm
showed an 84.8% reduction by EASI and the control
arm showed an 81.4% reduction (P = .85), demon-
strating no statistically significant difference between
the 2 arms. Both groups reported improvement in
pruritus, overall impact of disease, and sleep on days
7 and 14. There was no statistically significant
difference detected in caregiver-reported subjective
scores between the 2 treatment arms on days 7 or 14
(Fig 2 and Table II).
Compliance
Patients in the SS arm missed on average
0.67 6 1.09 days, whereas patients in the control
arm missed on average 0.48 6 0.59 days of TCS
application. There was no statistically significant
difference between compliance rates in the 2 arms
of the study (P = .8).
J AM ACAD DERMATOL
n 2016
Serum cortisol levels
Ten of 45 participants volunteered to investigate
serum morning cortisol level. Blood was drawn
between 8:15 AM and 8:45 AM. Nine patients had
serum morning cortisol levels within the normal
range, and 1 patient in the control arm had a serum
morning cortisol level of 4.75 g/dL, which was
below the lower limit of normal of 5 g/dL (Fig 3 and
Table II).
Adverse events
Three participants in the SS arm and 5 participants
in the control arm developed folliculitis. No patient
developed clinical evidence of skin atrophy or
suppression of the hypothalamic-pituitary-adrenal
axis. There were no other reported or observed
adverse events.
Early termination of the study
Because of investigator-related constraints on
time, we were not able to reach our goal sample
size of 55 participants. To assess if ending the study
before reaching our goal recruitment was a reason-
able option, we performed a futility assessment with
J AM ACAD DERMATOL Kohn, Kang, and Antaya 5
VOLUME jj, NUMBER j

Table II. Study outcomes

Control Soak and smear Wilcoxon
EASI score
Day 1 15.1 (12.1-18.1) 15.8 (11.7-19.8)
Mean (95% CI)
Day 14 2.6 (0.8-4.5) 2.5 (0.9-4.1)
Mean (95% CI)
% Difference 81.4 (70.3-92.4) 84.8 (77.5-92.1) P = .85
Mean (95% CI)
Pruritus
Day 1 5.4 (4.0-6.7) 6.3 (4.9-7.7)
Mean (95% CI)
Day 7 2.7 (1.5-4.0) 2.9 (1.7-4.0) P = .83
Mean (95% CI) 48.8 (28.0-69.7) 39.0 (e8.2 to 86.1)
% Difference (95% CI)
Day 14 1.9 (0.7-3.1) 1.6 (0.6-2.6) P = .85
Mean (95% CI) 75.8 (62.6-88.9) 77.8 (66.4-89.2)
% Difference (95% CI)
Sleep
Day 1 1.3 (0.8-1.8) 1.3 (0.8-1.9)
Mean (95% CI)
Day 7 0.7 (0.3-1.0) 0.6 (0.2-1.0) P = .9
Mean (95% CI) 54.7 (21.8-87.6) 59.0 (34.8-83.2)
% Difference (95% CI)
Day 14 0.7 (0.3-1.0) 0.5 (0.1-0.9) P = .7
Mean (95% CI) 54.4 (27.8-81.1) 62.5 (34.6-90.4)
% Difference (95% CI)
Overall impact of disease
Day 1 5.7 (4.4-7.1) 7.2 (6.1-8.2)
Mean (95% CI)
Day 7 2.9 (1.7-4.0) 3.1 (2.2-4.1) P = .8
Mean (95% CI) 54.1 (37.4-70.8) 52.3 (35.2-69.3)
% Difference (95% CI)
Day 14 2.0 (0.8-3.1) 2.2 (0.8-3.7) P = .6
Mean (95% CI) 74.0 (60.5-87.4) 64.8 (41.4-88.2)
% Difference (95% CI)
Morning cortisol, g/dL
Day 14 12.3 (6.4-18.3) 15.0 (4.5-25.5) P = .6
Mean (95% CI)

CI, Confidence interval; EASI, Eczema Area and Severity Index.

that, with the data we had accrued, there was only

5% chance of rejecting the null hypothesis.

Fig 3. Atopic dermatitis. Morning (AM ) serum cortisol
levels (g/dL) measured in volunteer participants on day
14. SS, Soak and smear.
conditional power.10,11 The calculated conditional
power was based on data gathered after accruing 45
patients and was calculated to be 0.05, which means
DISCUSSION
This study shows that twice daily application of
TCS over 2 weeks results in significant improvement
in AD severity regardless of whether the TCS is
applied to dry skin or wet skin using the SS
technique. Both groups showed remarkably
high disease clearance rates of over 80% by EASI.
There was no difference in AD improvement by
EASI, pruritus, sleep quality, or overall impact of
disease. We failed to demonstrate that SS is more
beneficial than TCS application to dry skin for AD in
children.
6 Kohn, Kang, and Antaya
These results are unexpected given the previous
literature published on SS.3-5 Three studies have
reported great benefit using SS: a retrospective study
of adults with severe, refractory dermatitis; a
prospective study of combat soldiers with severe
AD flares; and a retrospective review of children and
adults with severe or moderate AD. In both
retrospective studies, the methods of assessing AD
improvement are not well validated.12,13 Many of the
patients in the retrospective study in adults were
older individuals with associated xerosis. One could
postulate that the disease clearance observed in
these studies may be attributable to a beneficial
effect of SS in specific populations, such as older
adults with xerosis or patients with more severe
disease. A major confounder of the study
conducted by the US Army was that patients were
relocated from a combat area to a hospital.
Hospitalization alone may improve the severity of
AD.14 Because none of these studies had a control
arm, they do not show that SS is superior to standard
treatment.
The improvement in AD clearance in our patients
was most likely attributable to application of
adequate amounts of TCS. All participants were
prescribed a 454-g jar or equivalent of TCS and
were provided with an estimate of how much TCS
should have been applied by the end of the 2-week
study intervention based on age and affected body
surface area.
Our patients’ families initially presented with
varying degrees of reluctance toward applying
adequate amounts of TCS, which we addressed by
education on the benefits and adverse effects. In the
study, they were highly adherent and missed less
than 1 day of treatment on average. This may be a
result of multiple factors, including the Hawthorne
effect, use of a daily score sheet, a reminder
telephone call at 1 week, and a short follow-up
time of 2 weeks.15
The only adverse event reported was folliculitis,
although no participant reported symptoms.
Systemic absorption of TCS and effects on the
hypothalamic-pituitary-adrenal axis were negligible.
Only 1 patient in the control arm exhibited a
morning serum cortisol value below the lower limit
of normal, and he was asymptomatic.
The biggest limitation of our study was the small
number of participants. An effect may have been
seen if we had recruited more patients. However, our
futility calculations indicate that even if we reached
our intended sample size, we would not have seen a
J AM ACAD DERMATOL
n 2016
difference between the SS and control arms. With
more patients, we may have been able to capture a
subset for which SS could be a better treatment.
Another limitation is that we were unable to directly
observe the SS regimen. Lastly, our quality-of-life
assessments are not validated.
In conclusion, we did not find that application of
TCS via SS works better than applications to dry skin
for the treatment of AD in children.
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