Exercising with Atopic Dermatitis (Eczema): Things To Know
Atopic dermatitis (AD) is a skin condition that affects 2-20% of children worldwide,1 and is associated with inflammation, eczematous skin lesions, and pruritis (itching).2 The intense itch that can be associated with eczema can result in significant morbidity for children and their families.1 Sweating may exacerbate itch, and may influence patients to avoid physical activity--an important lifestyle habit that can prevent disease and improve overall health.3
Atopic Dermatitis and Obstacles to Exercise
Strom and Silverberg conducted a meta-analysis of 2 cross-sectional studies and found that within a sample of 133,107 children aged 6-17 years, children with atopic disease, including eczema, have a higher risk of sedentary behaviours.4 More specifically, children with eczema had decreased odds of vigorous physical activity on ≥ 3 days and higher odds of spending ≥ 5 hours daily watching television or playing video games.
In addition, the severity of disease was also found to modulate the risk of sedentary behaviours. For example, relative to mild disease, severe eczema was associated with significantly lower odds of vigorous physical activity, and increased odds of engaging in ≥ 5 hours of television and video games per day. Also relative to mild eczema, moderate and severe cases were associated with decreased participation in sports in the past 12 months prior to the study.4
The pruritic aspect of AD can impact the sleep of affected individuals,4 and in turn, act as an obstacle to exercise. In the aforementioned Strom and Silverberg study, children with eczema who had only 0-3 nights of adequate sleep per week had lesser odds of sports participation. Furthermore, insufficient sleep was associated with increased odds of ≥ 5 hours daily of television or video games. When eczema and insufficient sleep are combined, the odds of engaging in ≥ 5 daily hours of television or video games are increased.4
Overall, while causative conclusions cannot be made, this suggests that children with AD accompanied by sleep disturbance may be at greater risk for sedentary behaviours. With this in mind, AD patients and their families must be educated about sleep hygiene to potentially alleviate an obstacle to physical activity.
The underlying pathophysiology of sweat and itch in AD
Physical activity can result in a physiologically normal increase in sweat production. However, for the AD patient, sweat production aggravates the itch associated with eczema, and may, consequently, result in the avoidance of exercise.2
Sweat dysfunction in eczematous skin results in physiologic changes that contribute to pathologic outcomes, and are outlined in Table 1.5 These abnormalities should be further explored when working towards clinical interventions that mitigate the itch associated with sweat and exercise.
Decreased sweating ability
Patients with AD have decreased sweating ability relative to healthy subjects.5 This abnormality is thought to be related to:
- Inflammatory mediators (such as histamine) that may inhibit sweat6
- Sweat retention due to occlusion of sweat pores by horny plugs7
- Anxiety levels (found to negatively correlate with sweating response to acetylcholine stimulation)8
This impaired ability to sweat is associated with increased heat retention, xerosis, and an increased susceptibility to itch.5
Sweat leakage into the dermis
Tight junctions in sweat glands are composed of claudin-3 proteins and are important for water barrier function.9 Relative to healthy subjects, patients with AD have been found to have reduced claudin-3 expression.9 This finding has been associated with sweat leakage into the dermis and sensations of a tingling pain or itch.9
Increased sweat glucose concentration
One study has found that the sweat of AD patients during acute flares contain an increase in sweat glucose concentration, relative to healthy patients or those with chronic inflammation.10 This increase in glucose is thought to potentially disturb the epidermal barrier, alter the skin microbiome, and contribute to sensations of itch.5
Table 1. Abnormalities in sweat and AD5
Potential Causes and Contributing Factors
Decreased sweating ability
· Inflammatory mediators
· Sweat pore occlusion
· Anxiety levels
· Heat retention
Sweat leakage into dermis
· Decreased claudin-3 expression
· Tingling pain or itch
Increased sweat glucose concentration
· The causes and contributing factors of increased glucose concentration are not yet understood but have been correlated with disease severity
· Disruption to skin barrier
· Disruption to microbiome
Importance of exercise
While the sweat associated with exercise can induce itch in AD patients, encouraging regular physical activity remains important, as it plays a role in cardiovascular health, overall AD management, and sleep quality.
Exercise is known to help reduce body weight, prevent cardiovascular conditions, and improve overall health.2 This aligns with studies that suggest that there is an association between childhood atopic disease and increased cardiovascular risk factors (obesity and hypertension).4
Improvement and Management of Atopic Dermatitis with Exercise
Sports and Atopic Dermatitis
A questionnaire-based study performed by Salzer et al. investigated the impact of regular physical exercise in the form of sports on patients with eczema.11 Thirty eczema patients who engaged in regular sports activities had an increased mood and psychosocial wellbeing compared to 30 eczema patients who did not perform similar sports activities regularly.
The authors also investigated the impact of this intervention on thermoregulation, as heat and warmth may stimulate the sensation of itch.12 Results demonstrated that after 3 weeks, the treatment group had normal temperature reactions to warmth exposure.11 Overall, the authors of this study conclude that regular sport participation could be a complementary therapy for AD patients, with an exception during the acute stages of AD.
Low-intensity Resistance Exercise and Atopic Dermatitis
A study involving a mice AD model assessed eczema symptoms and associated pathophysiology on the ears of mice after low-intensity tower climbing resistance exercise.2
After 4 weeks, the AD group that engaged in low-intensity tower exercise had:2
- Significantly reduced ear thickness
- Significantly reduced epidermal and dermal thickness
- Reduced infiltrating immune cells (mast cells)
- Significant suppression of inflammatory markers and Th-2 related cytokines (IL-4, IL-13, IL-31)
- Reduced size and weight of draining lymph nodes
Another study observed increased Ig and cytokine expression in AD mice who participated in high-intensity swimming exercise.13 However, the authors conclude that it is specifically the low-intensity exercise that may reduce AD symptoms and aid in the treatment.2 More research will be needed to understand the effect of low- vs. high-intensity exercise on AD.
Studies suggest an association between eczema and an increased prevalence of sleep disturbance and poor sleep quality.4 Although there is no available human study to specifically suggest that exercise in AD patients improves sleep, research suggests that exercise can generally increase sleep time and improve sleep quality.14
Minimizing Eczema Triggers to Support Physical Activity
To better support eczema patients with physical activity, it is important to identify eczema triggers so that they can be better avoided or minimized. A 2009 study in the British Journal of Dermatology used a survey to assess exposures (temperature, relative humidity, sun exposure, sweating, clothing, cleansing/washing products, outdoor pollen level, dusty environment, swimming, etc.) that trigger flares in eczema in 60 subjects aged 0-15 years old with eczema.1
Direct contact with nylon clothing (particularly on trunk and limbs), wool clothing on truncal areas, exposure to dust, exposure to unfamiliar pets, sweating, and shampoo use all exacerbated disease severity (as measured by how bothersome the eczema sensations felt on a given day).
“Scratch scores” were also examined relative to various exposures and were graded on a scale of 0-10, where 0 indicated no scratching and 10 indicated scratching all the time. The results suggest higher association between these scores and swimming, exposure to wool clothing, sweating, shampoo, and high grass pollen levels.1 Other findings show that patients felt that they had to “step up” treatment after they went swimming and that combining exposures was associated with a greater increase in eczema severity.
Recommendations for Exercise in AD Patients
Exposure to triggers
Based on the exposures outlined above and the associated flares, we may recommend avoiding these exposures before, during, and (in the case of shampoo), after exercise.1 Furthermore, since both swimming and shampoo are associated with flares, it may be worth using a swim cap during swimming, to avoid having to shampoo and thus, avoid combining these triggers together.1 In addition, it may be important to avoid having shampoo run over the body by rinsing well to potentially avoid a flare.
Skin barrier function
Next, it may be helpful to apply an emollient on the skin prior to exercise to minimize exposure to allergens (from dust, pets, pollen), especially given the increased barrier permeability associated with AD.15 Sweat should be dabbed, not rubbed or wiped, to preserve the limited epidermal barrier function
Though further research is needed, low-intensity exercise may offer more benefit for AD symptoms, and may be less likely to induce inflammation compared to high-intensity.2,13
Given that children with AD accompanied by sleep disturbance seem to be at greater risk for sedentary behaviours,4 improving sleep efficiency and quality may alleviate some of the obstacles to engaging in exercise.
Assess for asthma
Studies suggest that asthma and exercise-induced wheezing are common in children with AD.16,17 Thus, being assessed for asthma prior to engaging in a new exercise activity or routine is recommended.
- Children with atopic disease, including eczema, have a higher risk of sedentary behaviours.
- There are unique findings in sweat production and composition in AD patients (decreased sweating ability, sweat leakage into dermis, and increased glucose concentration).
- Sweating can exacerbate the itch associated with AD.
- Minimizing the itch and overcoming obstacles to exercise is important as physical activity may offer AD patients benefit to cardiovascular health, overall AD management, and sleep quality.
- Langan SM, Silcocks P, Williams HC. What causes flares of eczema in children? Br J Dermatol. 2009;161(3):640-646. doi:10.1111/j.1365-2133.2009.09320.x
- Kim J. Low-intensity tower climbing resistance exercise reduces experimentally induced atopic dermatitis in mice. J Exerc Rehabil. 2019;15(4):518-525. doi:10.12965/jer.1938276.138
- Kim A, Silverberg JI. A systematic review of vigorous physical activity in eczema. Br J Dermatol. 2016;174(3):660-662. doi:10.1111/bjd.14179
- Strom MA, Silverberg JI. Associations of Physical Activity and Sedentary Behavior with Atopic Disease in United States Children. J Pediatr. 2016;174:247-253.e3. doi:10.1016/j.jpeds.2016.03.063
- Murota H, Yamaga K, Ono E, Murayama N, Yokozeki H, Katayama I. Why does sweat lead to the development of itch in atopic dermatitis? Exp Dermatol. 2019;28(12):1416-1421. doi:10.1111/exd.13981
- Takahashi A, Tani S, Murota H, Katayama I. Histamine Modulates Sweating and Affects Clinical Manifestations of Atopic Dermatitis. In: Yokozeki H, Murota H, Katayama I, eds. Current Problems in Dermatology. Vol 51. S. Karger AG; 2016:50-56. doi:10.1159/000446758
- Sulzberger MB, Herrmann F, Zak FG. Studies of Sweating. J Invest Dermatol. 1947;9(5):221-242. doi:10.1038/jid.1947.92
- Kijima A, Murota H, Matsui S, et al. Abnormal Axon Reflex-Mediated Sweating Correlates with High State of Anxiety in Atopic Dermatitis. Allergol Int. 2012;61(3):469-473. doi:10.2332/allergolint.12-OA-0429
- Murota H, Yamaga K, Ono E, Katayama I. Sweat in the pathogenesis of atopic dermatitis. Allergol Int. 2018;67(4):455-459. doi:10.1016/j.alit.2018.06.003
- Ono E, Murota H, Mori Y, et al. Sweat glucose and GLUT2 expression in atopic dermatitis: Implication for clinical manifestation and treatment. Brandner JM, ed. PLOS ONE. 2018;13(4):e0195960. doi:10.1371/journal.pone.0195960
- Salzer B, Schuch S, Rupprecht M, Hornstein OP. [Group sports as adjuvant therapy for patients with atopic eczema]. Hautarzt Z Dermatol Venerol Verwandte Geb. 1994;45(11):751-755. doi:10.1007/s001050050165
- Murota H, Katayama I. Evolving understanding on the aetiology of thermally provoked itch. Eur J Pain Lond Engl. 2016;20(1):47-50. doi:10.1002/ejp.777
- Kim S-H, Kim E-K, Choi E-J. High-Intensity Swimming Exercise Increases Dust Mite Extract and 1-Chloro-2,4-Dinitrobenzene-Derived Atopic Dermatitis in BALB/c Mice. Inflammation. 2014;37(4):1179-1185. doi:10.1007/s10753-014-9843-z
- Driver HS, Taylor SR. Exercise and sleep. Sleep Med Rev. 2000;4(4):387-402. doi:10.1053/smrv.2000.0110
- Tsakok T, Woolf R, Smith CH, Weidinger S, Flohr C. Atopic dermatitis: the skin barrier and beyond. Br J Dermatol. 2019;180(3):464-474. doi:10.1111/bjd.16934
- Honjo S, Murakami Y, Odajima H, et al. An independent relation of atopic dermatitis to exercise-induced wheezing in asthmatic children. Allergol Int Off J Jpn Soc Allergol. 2019;68(1):26-32. doi:10.1016/j.alit.2018.04.013
- Caffarelli C, Bacchini PL, Gruppi L, Bernasconi S. Exercise-induced bronchoconstriction in children with atopic eczema. Pediatr Allergy Immunol. 2005;16(8):655-661. doi:10.1111/j.1399-3038.2005.00327.x