Association between domestic water hardness, chlorine, and atopic dermatitis risk in early life: A population-based cross-sectional study

J Allergy Clin Immunol. 2016 Aug;138(2):509-16. doi: 10.1016/j.jaci.2016.03.031. Epub 2016 Apr 28.


Background: Domestic water hardness and chlorine have been suggested as important risk factors for atopic dermatitis (AD).

Objective: We sought to examine the link between domestic water calcium carbonate (CaCO3) and chlorine concentrations, skin barrier dysfunction (increased transepidermal water loss), and AD in infancy.

Methods: We recruited 1303 three-month-old infants from the general population and gathered data on domestic water CaCO3 (in milligrams per liter) and chlorine (Cl2; in milligrams per liter) concentrations from local water suppliers. At enrollment, infants were examined for AD and screened for filaggrin (FLG) skin barrier gene mutation status. Transepidermal water loss was measured on unaffected forearm skin.

Results: CaCO3 and chlorine levels were strongly correlated. A hybrid variable of greater than and less than median levels of CaCO3 and total chlorine was constructed: a baseline group of low CaCO3/low total chlorine (CaL/ClL), high CaCO3/low total chlorine (CaH/ClL), low CaCO3/high total chlorine (CaL/ClH) and high CaCO3/high total chlorine (CaH/ClH). Visible AD was more common in all 3 groups versus the baseline group: adjusted odds ratio (AOR) of 1.87 (95% CI, 1.25-2.80; P = .002) for the CaH/ClL group, AOR of 1.46 (95% CI, 0.97-2.21; P = .07) for the CaL/ClH, and AOR of 1.61 (95% CI, 1.09-2.38; P = .02) for the CaH/ClH group. The effect estimates were greater in children carrying FLG mutations, but formal interaction testing between water quality groups and filaggrin status was not statistically significant.

Conclusions: High domestic water CaCO3 levels are associated with an increased risk of AD in infancy. The influence of increased total chlorine levels remains uncertain. An intervention trial is required to see whether installation of a domestic device to decrease CaCO3 levels around the time of birth can reduce this risk.

Keywords: Filaggrin; atopic dermatitis; eczema; transepidermal water loss; water hardness.

MeSH terms

  • Adult
  • Age of Onset
  • Calcium Carbonate / adverse effects
  • Calcium Carbonate / chemistry
  • Chlorine / adverse effects*
  • Chlorine / chemistry
  • Comorbidity
  • Cross-Sectional Studies
  • Dermatitis, Atopic / epidemiology*
  • Dermatitis, Atopic / etiology*
  • Female
  • Filaggrin Proteins
  • Genetic Predisposition to Disease
  • Humans
  • Infant
  • Infant, Newborn
  • Intermediate Filament Proteins / genetics
  • Male
  • Maternal Exposure
  • Middle Aged
  • Mutation
  • Odds Ratio
  • Population Surveillance
  • Pregnancy
  • Prenatal Exposure Delayed Effects
  • Prevalence
  • Risk Factors
  • United Kingdom / epidemiology
  • Water / adverse effects*
  • Water / chemistry
  • Young Adult


  • FLG protein, human
  • Filaggrin Proteins
  • Intermediate Filament Proteins
  • Water
  • Chlorine
  • Calcium Carbonate