Volume 73, No.6: 2021 Siriraj Medical Journal
Rattanavalai Nitiyarom, M.D., Nampen Siriwat, M.D., Wanee Wisuthsarewong, M.D.
Division of Dermatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, ailand.
Transepidermal Water Loss after Water Immersion
Objective: To observe changes in transepidermal water loss (TEWL) at dierent times aer water immersion.
Materials and Methods: TEWL values were measured before water immersion and at 3, 5, 10, 15, 20, and 30 minutes
aer immersion of the skin in water for 5 minutes.
Results: Forty-one healthy volunteers were enrolled with an average age of 30.4±5.5 years. Twenty-ve subjects
were female and sixteen were male. e TEWL value before water immersion (TEWL
) was 13.16±7.27 g/m
and TEWL values at 3, 5, 10, 15, 20 and 30 minutes aer immersion were 23.21±7.67, 16.12±3.42, 14.76±6.36,
14.45±6.67, 13.53±4.67 and 12.96±5.18 g/m
/h, respectively. Aer immersion, TEWL values at 3 and 5 minutes
statistically increased compared to TEWL
(p<0.001). TEWL values between 10 to 30 minutes gradually dropped
with no statistically signicant dierence compared to the previous period and TEWL
. Although total water
loss from the skin occurred within 30 minutes, 56.9% of it occurred within 10 minutes aer immersion. ere was
no signicant dierence between TEWL
in males and females but the TEWL values at 3, 5 and 15 minutes
aer immersion in males was higher than in females (p<0.05).
Conclusion: TEWL statistically increased aer water immersion for only 5 minutes. e cumulative percentage
of TEWL was high within 10 minutes. Gender did not aect TEWL values before immersion; however, males
experienced more water loss from the skin than females aer immersion. erefore, moisturizer should be applied
immediately before TEWL occurs.
Keywords: Immersion; TEWL; transepidermal water loss (Siriraj Med J 2021; 73: 386-390)
Corresponding author: Wanee Wisuthsarewong
E-mail: wanee.wisuth@gmail.com
Received 5 February 2021 Revised 19 March 2021 Accepted 22 March 2021
ORCID ID: http://orcid.org/0000-0002-2139-5246
e skin has multiple defensive and regulatory
functions. However, its most important function is to act
as barrier against external stresses and the percutaneous
penetration of chemicals, allergens, and organisms. is
barrier function is almost entirely present in the epidermis
and in particular the stratum corneum (SC). e skin
also maintains water and electrolyte homeostasis and
e functional state of the skin can be investigated
by assessing non-invasive biophysical parameters which
are influenced by several factors.
For example, in
vivo evaluation by measurement for TEWL has proven
to be a reliable indicator of the function of the skin
A defective skin barrier leads to increased
TEWL along with dry skin.
erefore, TEWL values
are directly related to the clinical severity of lesions in
various skin diseases with altered barrier function such
as atopic dermatitis, ichthyosis, contact dermatitis, and
To manage dry skin, bathing and application
of moisturizer is necessary. How the skin changes at
dierent time periods aer bathing can provide useful
information for skin care recommendations.
e purpose of this study was to characterize the
function of skin barrier as evaluated by TEWL values
at dierent time points aer immersion.
Nitiyarom et al.
Volume 73, No.6: 2021 Siriraj Medical Journal
Original Article
A prospective study was conducted at the Department
of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol
University. e study protocol was approved by the
Siriraj Ethical Review Board (Si 702/2015) and the written
informed consent was obtained from all participants.
Healthy participants with no pre-existing dermatoses
or any systemic disorders that could alter the biophysical
parameters were enrolled. e participants were asked
not to apply any skin product for at least 12 hours prior
to testing and to avoid washing the area to be tested on
evaluation day. Before any measurements were made,
participants were asked to rest for 15 minutes in a room
with controlled environmental conditions to help them
acclimatize. All measurements were made in highly
comparable temperatures and humidity-controlled
conditions in accordance with the guidelines for standardized
skin parameter measurements in the European Group
on Ecacy Measurement and Evaluation of Cosmetics
and Other Products (EEMCO) guidelines and by the
Standardization Group of the European Society of Contact
e TEWL value was measured using a
TM 300 (Courage and Khazaka electronic,
Köln, Germany) and expressed in g/m
/h. Participants
were asked to immerse the test area in water rather than
bathe. e volar region of the forearm, which is oen
selected as the test site in dermatological research, was
selected as the test area. Aer baseline TEWL readings
were recorded, the volunteer’s forearms were immersed in
the water bathtub for ve minutes followed by pat drying
with towels and then measuring TEWL again at 3, 5, 10,
15, 20, and 30 minutes later. To avoid inaccuracies, each
measurement was repeated three times at the nearby areas
and the mean value was used for analysis. e patients
were monitored for side eects aer the measurements
were completed.
e data was analyzed using SPSS Statistical soware,
version 20 (IBM, Chicago, IL, USA). A normal distribution
of the data was examined by Kolmogrov-Smirnov test.
e demographic data was presented through descriptive
statistics with an average ± standard deviation (SD) for
normally distributed values and median and range for
non-normally distributed data. For normally distributed
data, an independent t-test was used to compare the
age between genders (Mann-Whitney U test for non-
normal distribution). To compare TEWL values at
each time point and between genders, an analysis of
variance (ANOVA) with Bonferroni post-hoc test was
used (Friedman’s test with Bonferroni post-hoc test for
non-normal distribution). A p-value of less than 0.05
was regarded as being statistically signicant.
is study contained forty-one healthy volunteers
(61% female and 39% male) with an average age of
30.4±5.5 years. ere was no statistical dierence in
age between both genders (p=0.190). e average room
temperature was 23.20±0.89°C, and the relative humidity
was 47.00±7.38%.
e TEWL value before water immersion (TEWL
was 13.16±7.27 g/m
/h. Aer immersion, the TEWL
value statistically increased at 3 minutes, and 5 minutes,
(p<0.001) before rapidly decreasing during 10 to 30
minutes aer immersion when it showed no statistical
dierence compared to the baseline (Table 1).
Cumulative TEWL aer immersion, which reects
total water loss from the skin, was 23.2, 39.3, 54.1, 68.5,
82.1, 95.0 g/m
/h at 3 minutes, 5 minutes, 10 minutes,
15 minutes, 20 minutes, and 30 minutes, respectively
(Fig 1). Regarding the percentage of cumulative TEWL at
dierent time points, 24.4%, 41.4% and 56.9% of TEWL
occurred within 3 minutes, 5 minutes, and 10 minutes
aer immersion, respectively.
e baseline TEWL value in males was the same
as in females (p=0.121). e TEWL values in both male
and female volunteers increased aer immersion in
water (p<0.001), however, it became equal to before
immersion at 10 minutes (p>0.05). e TEWL values
in males were statistically higher than in females at 3
minutes, 5 minutes, and 15 minutes aer immersion
(Table 2). No side eects were reported from the testing.
Non-invasive biophysical skin parameters such as
TEWL are widely accepted as a reliable tool for assessment
of the skin barrier function. Dry skin is a common condition
in many skin diseases. Regular bathing and application
of moisturizer to hydrate the skin and prevent water
loss is necessary. is study demonstrated a signicant
increase in TEWL post water immersion compared to
the baseline, however, the value returned to the baseline
levels aer 10 minutes. e cumulative TEWL value
within 10 minutes of testing was 56.9% of all water
loss in 30 minutes. e baseline TEWL values showed
no statistical dierence between male and female, but
TEWL values in males was higher than females until at
least 15 minutes aer immersion.
Our data conrmed results from previous studies which
showed that TEWL increased aer water application.
Although an increase in TEWL values usually relate
to impairment of the skin barrier,
the increased in
TEWL aer immersion was not only due to an impaired
skin barrier function. It is assumed that the skin absorbs
Volume 73, No.6: 2021 Siriraj Medical Journal
Nitiyarom et al.
Fig 1. Cumulative TEWL at every time point aer
TABLE 1. Comparison of TEWL values at dierent time points.
TEWL p-value p-value
Time (mean±SD) g/m
/h compare to baseline compare to previous
Before immersion (baseline) 13.16±7.27 - -
3 min after immersion 23.21±7.67 <0.001* <0.001*
5 min after immersion 16.12±3.42 <0.001* <0.001*
10 min after immersion 14.76±6.36 1.000 0.166
15 min after immersion 14.45±6.67 1.000 0.656
20 min after immersion 13.53±4.67 1.000 1.000
30 min after immersion 12.96±5.18 1.000 1.000
*p-value <0.05 = statistical signicance
TABLE 2. Comparison of TEWL values between genders at dierent time points.
TEWL p-value
Time (mean±SD) g/m
/h compare between genders
Male Female
Before immersion (baseline) 14.77±9.09 12.05±5.55 0.121
3 min after immersion 25.93±10.34 21.34±4.32 0.012*
5 min after immersion 16.84±3.34 15.61±1.79 0.048*
10 min after immersion 16.14±8.25 13.80±4.50 0.130
15 min after immersion 16.78±9.14 12.84±3.53 0.013*
20 min after immersion 14.32±4.84 12.98±4.53 0.237
30 min after immersion 12.94±2.52 12.97±5.18 0.979
*p-value <0.05 = statistical signicance
Volume 73, No.6: 2021 Siriraj Medical Journal
Original Article
water instantaneously aer being immersed; however, the
water-holding capacity of the SC is maintained only for
a short period of time aer which the remaining excess
water evaporates from the skin leading to a gradual
return to baseline levels.
According to results obtained, immersion increased
TEWL values and its accumulation correlates to an
absolute total amount of water loss from the skin was
high (56.9%) within 10 minutes aer immersion.
the TEWL continues, dry skin will get worse. Apply
occlusive moisturizer as soon as possible aer bathing
to maintain SC water content should be recommended
as part of the skin care regimen.
Patients with dry
skin will benet from occlusive moisturizer application
when skin hydration is still retained.
Although a precise denition of normal TEWL value
does not exist,
variations in TEWL values have been
A wide ranges of TEWL values
are inuenced by several endogenous, exogenous, and
environmental factors.
ere is insucient evidence
to conclude that gender aects TEWL.
While some
studies did not observe much of a dierence in TEWL
values between genders,
others noticed higher TEWL
values in males.
e baseline TEWL value in our
study was not dierent between genders but the TEWL
value aer immersion was signicantly higher in males
who experienced more water loss from the skin than
females, possibly due to dierent hormonal eects, skin
conditions, barrier functions, and outdoor working
habits and activities.
is study has limitations because the duration
of water exposure was only ve minutes, which may
be too short to reveal profound eects of skin barrier
function structurally and functionally. Furthermore, this
study measured only TEWL values, other biophysical
parameters such as skin capacitance and pH might add
more information about dynamic changes in the skin
aer water immersion. Hence, future studies with longer
immersion duration, more frequent measurements, and
a range of biophysical skin parameters should provide
more helpful information.
In conclusion, this study evaluated the eects of
the routine practice of water exposure through water
immersion of the skin. Since the TEWL value increased
signicantly for a short period, it is reasonable to encourage
the application of moisturizer immediately aer bathing
to prevent water loss from SC
is study was supported by a grant for the Research
Development and Medical Education, Faculty of Medicine
Siriraj Hospital, Mahidol University. Bangkok, ailand
(grant no. R015931013).
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