On the utility of soak and smear

Abstract

To the Editor: We read with interest the trial that compared topical corticosteroid application with wet versus dry skin in children with atopic dermatitis. 1 We congratulate the authors for formally studying the soak and smear method of topical steroid care. 2 However, despite the findings of Kohn et al, 1 we will continue to use the soak and smear method for multiple reasons, outlined below.Our objections to the utility of this study are as follows:1. The children with atopic dermatitis in this study were mildly affected. Eczema Area and Severity Index scores run from 0 to 72. The patients in their trial had initial scores in the range of 15 to 16. Our patients were severely affected with a variety of eczematous disease states, and were all adults. 2. The patients' use of or response to prior therapy was not well described. Our patients had not only failed topical care but many were on a variety of oral medications and, in spite of this, remained severely affected. 3. The control population, treated with topical therapy only, had an over 80% response rate. This is not unexpected in a relatively mildly affected group. With such an excellent response to conventional topical care, it is then difficult to demonstrate a difference caused by the soak and smear regimen and it does not seem that the inconvenience of soaking and smearing was necessary. 4. Participants in the control arm were instructed to refrain from applying topical corticosteroid to wet skin. But what did they really do? Compliance was documented for the treatments, but detail about the avoidance of skin wetting for the control group is missing. There is a possibility that patients and their parents had been educated in the past to apply steroids to wet or moist skin and continued this practice rather than strictly applying steroids on dry skin. Thus, the response rate in the control group would be misclassified as relating to dry application, rather than the actual use of wet or moist application.Since our publication in 2005, 2 Assarian et al 3 published a relevant study of 68 adults and 35 children who failed standard therapy using topical steroids and moisturizers. The adults had a variety of eczematous conditions, and showed an 87% response rate to soak and smear, whereas the children, who all had widespread atopic dermatitis, showed a 94% response rate to soak and smear. Both groups were noted to respond within 3 to 5 days, mimicking our experience in our patients with prior refractory dermatoses.In sum, although the 2 large case series cited 2,3 are retrospective, this comparison study does not support the abandonment of the soak and smear method, especially for patients with refractory dermatoses. We strongly advocate for the use of aggressive topical care before resorting to systemic immunosuppressives. The soak and smear method of controlling previously unresponsive eczematous eruptions in our population of referral patients continues to lead many patients to relief with a readily available, safe, and low-cost method. REFERENCES1. Kohn LL, ...