STUDY Soak and Smear A Standard Technique Revisited Ari Benjamin Gutman, MD; Albert M. Kligman, MD, PhD; Joslyn Sciacca, MD; William D. James, MD Background: Atopic dermatitis, nummular eczema, followed by smearing of midstrength to high-strength chronic hand dermatitis, palmar plantar psoriasis, and corticosteroid ointment led to clearing or dramatic im- xerotic eczema are common inflammatory skin condi- provement. tions. They may be refractory to conventional topical and even systemic treatment. Little evidence is available that Results: Objective and symptomatic improvement was demonstrates the benefits of aggressive topical treat- obtained from aggressive topical treatment. It was well ment of patients with these disorders. accepted in this group of referral patients. Objective: To describe a simple, inexpensive, effective Conclusions: Hydration for 20 minutes before bedtime topical treatment with an accompanying patient educa- followed by ointment application to wet skin and alter- tional sheet. ation of cleansing habits is an effective method for car- ing for several common skin conditions. Prospective Design: A retrospective study of 28 patients referred to studies are needed to further validate these findings. a tertiary care center for refractory chronic pruritic erup- tions. Intervention with a plain water 20-minute soak Arch Dermatol. 2005;141:1556-1559 OME DISEASES ARE CHARACTER- volves soaking an affected body part or ized by a compromised skin whole body bathing in plain water for 20 barrier and may be associ- minutes to be followed immediately by ated with pruritus, fissur- smearing an ointment over the affected ing, or scaling. While gen- area, without drying the skin. The ap- Seral principles of moisturization and plied ointment is usually 0.1% triamcino- occlusive therapy are well appreciated, ap- lone acetonide ointment or a class 1 cor- plication of these concepts is messy and ticosteroid ointment for psoriatic hand time consuming and requires extensive pa- involvement. Treatment includes a morn- tient education for acceptance. We have ing application with a cream of the same developed a patient educational tool and strength as the nighttime ointment. a descriptive easily understood name, “soak and smear,” to treat patients expe- See also pages 1527, 1537, riencing various eczematous dermatoses. 1542, 1549, 1580, and 1589 Xerotic eczema commonly affects older individuals and can be a distressingly un- During this intensive therapy, a main- comfortable eruption. Symptoms include tenance component is initiated. Educat- Author Affiliations: University itching, a pinprick sensation, and, less com- of Pennsylvania School of ing the patient regarding the deleterious Medicine, Philadelphia monly, formications. Atopic skin is predis- effects of repeated wetting and drying, es- (Drs Gutman, Kligman, and posed to alterations in barrier function and pecially when combined with the use of James); and University of increased sensitivity to irritants. In addi- soap, is accomplished. Strategies to limit Virginia School of Medicine, tion, patients with occupations or voca- drying of the skin, such as limiting the use Charlottesville (Dr Sciacca). tions that require repeated wetting and dry- of soap to apocrine-containing sites and Dr Gutman is now with the ing of the skin, such as with routine hand adding moisturizers after any washing, are Department of Dermatology, washing, may develop chronic eczema, instituted with the initial therapy. This Albert Einstein College of painful fissures, and, at times, infection. component is continued during the main- Medicine, Bronx, New York. Clearly, many patients with the de- Dr Sciacca has changed her tenance phase of treatment. name to Dr Joslyn Kirby and scribed conditions will benefit from ag- In our experience, soaking and smear- is now with the University gressive topical therapy at a time of day ing is highly successful in treating pa- of Pennsylvania School suitable for soaking and greasy ointment tients referred to our clinics for refractory of Medicine. application. Soaking and smearing in- dermatoses. We performed a retrospec- (REPRINTED) ARCH DERMATOL/ VOL 141, DEC 2005 WWW.ARCHDERMATOL.COM 1556 ©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 tive study of 28 such patients and present 1 illustrative case in detail. Table. Soak and Smear Patient Educational An 84-year-old man was referred for treatment of se- Instruction Sheet vere pruritus primarily of his arms and legs of 5 years’ Eczema is a chronic condition of the skin that can cause itchiness and duration. He reported that the itching was so severe that redness. Patients with eczema have sensitive skin, more sensitive than it was interfering with his sleep. Unsuccessful treat- normal skin. Sensitive skin is more easily irritated (which causes the ments in the past included applications of petroleum jelly, itchiness) by dryness and irritants in the environment (such as wool in aloe, various moisturizers, halobetasol propionate oint- clothing or chemicals in lotions). Eczema can be controlled with good ment, fluocinolone acetonide ointment, and betametha- skin care and environmental measures (avoiding things that irritate your skin). sone dipropionate augmented. A physical examination Soaking and Smearing revealed dryness of the patient’s arms and legs, with ex- This is an aggressive treatment that is both messy (find an old pair of coriations present. He was diagnosed as having severe xe- pajamas) and time intensive. This regimen may use a medication you rosis with pruritus and began to undergo the soak and have used before without success. But this medicine is being used in a different way as part of an intensive treatment regimen that must be smear regimen with 0.1% triamcinolone acetonide oint- followed exactly to work. This treatment can lead to marked ment applied to wet skin after a 20-minute plain water improvement in even a couple of days. The number of nights of soak. The patient was educated regarding alteration of soaking and smearing depends on the severity of the disease and how bathing habits and moisturizing after his daily showers. long it takes to get under control. Usually patients do the soaking and At follow-up 5 weeks later, the patient’s condition was smearing at night for 4 nights to 2 weeks. The soaking and smearing treatments are done at night because the ointment on your skin will clear. He reported relief of his symptoms beginning with get on your pajamas instead of your clothes (that you wear during the the first night of treatment. After 2 weeks, he was sim- daytime) and the ointment will be on your skin for several hours while ply smearing 0.1% triamcinolone acetonide ointment be- you sleep. After the skin is under control, the soaking is stopped but fore bedtime. He was sleeping well, and his skin was well the nighttime smears with an ointment or moisturizer should continue. Soak in a bath (not a shower) in plain water for 20 minutes (use a hydrated. During the follow-up visit, the patient was timer) at night, THEN smear immediately, without drying the skin, switched to the soak and smear therapy with only pe- with the ointment containing ___________________________ troleum jelly, with the plan to eventually use moistur- (steroid) for _________ days. For hand dryness and cracking, soak izer only after his showers and before bedtime as main- your hands continuously in a pan of water for 20 minutes at night and tenance therapy. follow with the smearing as above. After the skin is under control, the soaks at night can be stopped. But continue to smear the ointment each night. Throughout the treatment period you can apply METHODS ______________________ cream to the worst areas in the morning. The soaking will allow water to go into the skin and hydrate it, then smearing on the ointment will (1) trap the water in the skin (because Patients were identified from a university-based referral prac- water cannot move through oil) and moisturize the skin and (2) allow tice focusing on difficult-to-treat and difficult-to-diagnose der- the anti-inflammatory ingredient in the ointment to get deep into matologic diseases. Initial screening was done of medical rec- the skin. ords of patients who were diagnosed as having atopic dermatitis, Maintenance Treatment: Prevent Drying/Irritation xerosis, or chronic hand dermatitis, and who underwent treat- Repeated wetting (ie, baths, showers, swimming) without ment with the soak and smear protocol (n=34). Patients were moisturization will actually dry out the skin more. So when showering or washing your hands, it is necessary to apply a moisturizer such as verbally educated regarding the treatment protocol and then __________________ on your slightly moist skin to prevent drying. given a written instruction sheet that summarized and rein- These less thick moisturizers may be used during the daytime, with forced the oral recommendations (Table). Exclusion criteria petroleum jelly always available for more intense moisturization were then applied, which included the following: (1) no fol- at night. low-up after the initial visit (n=5), (2) medical record not avail- Soap able for review (n=1), and (3) soak and smear treatment non- Using soap in the shower can further dry out the skin by removing the compliance (n=0). As a result, the final study population oils the skin naturally produces. There are three types of glands found included 28 patients ranging in age from 24 to 84 years. Out- in the skin. The sebaceous gland produces an oily substance, called come measures were determined by the state of disease at follow- sebum, which is the body’s natural moisturizer. The sebaceous glands are found over most of the body with the highest amount on the face up, which was recorded as either complete clearance, mean- and upper trunk and the fewest on the arms and legs. These latter ing no evidence of disease, or as a percentage of improvement, places are usually the sites that become dry the earliest.