Atopic dermatitis (AD) is a chronic inflammatory skin disease in which type 2 immune activation, epidermal barrier dysfunction, microbial dysbiosis, and neurosensory pathways interact to sustain disease activity and symptom burden. Despite major advances with biologics and Janus kinase inhibitors, residual xerosis, pruritus, sleep disturbance, and barrier fragility may persist in otherwise controlled patients. This narrative review evaluates balneotherapy as adjunctive supportive care in AD, focusing on skin barrier function, microbiome-related effects, pruritus, and clinical integration. A narrative literature review was conducted using PubMed/MEDLINE, Ovid, and Scopus from database inception to 31 December 2025. Search terms addressed AD, type 2 inflammation, skin barrier dysfunction, transepidermal water loss, pruritus, microbiome dysbiosis, thermal spring water, spa therapy, seawater therapy, Dead Sea climatotherapy, hydrotherapy, and balneophototherapy. Clinical, mechanistic, translational, and methodological studies were considered. Available evidence suggests that water-based interventions may improve selected patient-centred outcomes, particularly xerosis-related discomfort, pruritus, sleep impairment, quality of life, and global severity scores. Thermal spring water programmes, Dead Sea climatotherapy, seawater-based approaches, and balneophototherapy differ substantially in exposure characteristics, co-interventions, and outcome reporting. Objective endpoints such as transepidermal water loss, skin hydration, tape stripping biomarkers, and microbiome profiling may help clarify biological plausibility, although current evidence is limited by heterogeneity, short follow-up, and difficulty isolating water-specific effects. Balneotherapy should be positioned as an adjunctive, supportive intervention rather than an alternative to evidence-based anti-inflammatory therapy in AD, particularly for selected patients with persistent barrier- and symptom-dominant residual burden.
Balneotherapy as Adjunctive Care in Atopic Dermatitis: Effects on Skin Barrier, Microbiome, and Pruritus
Zerbinati, Nicola;Carugno, Andrea;
2026-01-01
Abstract
Atopic dermatitis (AD) is a chronic inflammatory skin disease in which type 2 immune activation, epidermal barrier dysfunction, microbial dysbiosis, and neurosensory pathways interact to sustain disease activity and symptom burden. Despite major advances with biologics and Janus kinase inhibitors, residual xerosis, pruritus, sleep disturbance, and barrier fragility may persist in otherwise controlled patients. This narrative review evaluates balneotherapy as adjunctive supportive care in AD, focusing on skin barrier function, microbiome-related effects, pruritus, and clinical integration. A narrative literature review was conducted using PubMed/MEDLINE, Ovid, and Scopus from database inception to 31 December 2025. Search terms addressed AD, type 2 inflammation, skin barrier dysfunction, transepidermal water loss, pruritus, microbiome dysbiosis, thermal spring water, spa therapy, seawater therapy, Dead Sea climatotherapy, hydrotherapy, and balneophototherapy. Clinical, mechanistic, translational, and methodological studies were considered. Available evidence suggests that water-based interventions may improve selected patient-centred outcomes, particularly xerosis-related discomfort, pruritus, sleep impairment, quality of life, and global severity scores. Thermal spring water programmes, Dead Sea climatotherapy, seawater-based approaches, and balneophototherapy differ substantially in exposure characteristics, co-interventions, and outcome reporting. Objective endpoints such as transepidermal water loss, skin hydration, tape stripping biomarkers, and microbiome profiling may help clarify biological plausibility, although current evidence is limited by heterogeneity, short follow-up, and difficulty isolating water-specific effects. Balneotherapy should be positioned as an adjunctive, supportive intervention rather than an alternative to evidence-based anti-inflammatory therapy in AD, particularly for selected patients with persistent barrier- and symptom-dominant residual burden.
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