Water-immersion wrinkling is due to vasoconstriction

Upper-limb dysfunction in cancer survivors with chemotherapy-induced peripheral neurotoxicity

INTRODUCTION

Upper-limb symptoms are often reported in the context of chemotherapy-induced peripheral neurotoxicity (CIPN), but objective quantification of functional deficits is often lacking. We examined and compared a range of neurophysiological and functional assessments of the upper-limb in the assessment of CIPN severity.

METHODS

Cross-sectional assessment of neurotoxic chemotherapy-treated patients was undertaken using patient-reported and clinically-graded CIPN measures. Upper-limb functional assessments comprised of assessing fine motor skills, sensory perception, and neurophysiological measures of the median nerve. Group comparisons between participants who reported absence or presence of upper-limb functional deficits were investigated.

RESULTS

60 participants who were 11.5 (IQR = 4.0-26.0) months post-neurotoxic chemotherapy treatment reported CIPN. 65% (n = 39) reported upper-limb CIPN symptoms. Reduction in fine motor skills, sensory perception and median nerve SNAP amplitudes were associated with higher CIPN severity. Participants who self-reported presence of upper-limb functional deficits had worse CIPN severity across all measures, compared to participants who reported no upper-limb functional deficits.

CONCLUSIONS

Participants who reported upper-limb symptoms and functional deficits had worse CIPN severity and quality-of-life. There is a high burden of upper-limb dysfunction long after neurotoxic chemotherapy treatment cessation. Focus on research into supportive care and rehabilitation options to improve upper-limb function is warranted to improve patient quality-of-life.

[Skin Wrinkling on Hands and Feet: Theory and Practice]

The wrinkling of the skin on hands and feet when submersed in water is a well-known phenomenon. However, the explanation for this is not quite trivial. The peripheral nervous system seems to have an influence. In case of nerve injuries, it is often observed that skin wrinkling does not occur. In this report, three cases are presented in which wrinkling of the hand was absent after a nerve injury. In addition, we provide an overview of the studies on this topic.

Aquagenic wrinkling of the palms: review of the literature

Aquagenic wrinkling of the palms (AWP) is a rare dermatological disease characterized by development of rapid and excessive wrinkling and oedema of the palms and transient whitish or yellowish papules without erythema on the palmar surfaces after immersion in water. This phenomenon can be accompanied by pain and/or pruritus. The most common treatment of AWP involves aluminium-based topicals. This article discusses the associations, pathological mechanisms and treatment options of AWP.

Local-flexible coupling optical-resolution photoacoustic microscopy with enhanced sensitivity

An acoustic coupling scheme largely determines the performance of optical-resolution photoacoustic microscopy (OR-PAM), including practicability, sensitivity, and stability. In this study, we propose OR-PAM based on a local-flexible acoustic coupling scheme, which includes a well-designed combiner connecting a set of circulating systems. The combiner integrates an objective lens and an ultrasonic transducer, controls the water level, restricts the flow rate, and drains bubbles. The circulating system provides sustained and steady flowing water. The flowing water constrained in the combiner and the circulating system forms a flexible and stable local contact between the sample and the transducer. Phantom experiments demonstrate that the proposed method can maintain high optical resolution but improve the detection sensitivity by approximately 1.9 times in comparison to dry coupling. In vivo imaging experiments of the mouse eyeground are conducted to examine the practicability of the proposed system in biomedicine. Moreover, in vivo experiments show that OR-PAM based on local-flexible coupling can reveal more details of eyeground microvasculatures, benefiting from its enhanced sensitivity. These merits promise that OR-PAM based on local-flexible coupling may have broad applications in biomedical fields.

The optimal duration for the wrinkle test in a clinical setting

To determine the time needed or the development of a positive result on the wrinkle test among patients with complete laceration of a digital nerve in a clinical setting. We prospectively recruited 20 patients who had undergone surgery for digital nerve laceration. The wrinkle test was conducted at a follow-up session up to 2 months after surgery, and the time to a positive wrinkling result was recorded. The wrinkle test was compared between the patient's injured versus uninjured contralateral finger. The average time required for a positive result on the wrinkle test was 24.5 min (± 11), with 25% patients requiring 40 min to obtain a positive result. When evaluating a patient with digital nerve injury in a "non-laboratory" environment, the wrinkle test may require up to 40 min to obtain a positive result. Our study suggests that if tests are completed following the generally accepted time limit reported in the literature (30 min), up to 25% of tests may produce false negative results.

Efficiency of 90-Min Extended EMLA-Induced Stimulated Skin-Wrinkling Test in the Diagnosis of Carpal Tunnel Syndrome

Background:

Previous researchers have used a 30-min eutectic mixture of local anesthetic (EMLA) test, which assesses the sympathetically mediated vasomotor function, in diagnosing carpal tunnel syndrome (CTS). However, its specificity was low, limiting its clinical diagnostic utility. In this study, we assessed the efficiency of 90-min extended EMLA-induced stimulated skin-wrinkling (SSW) test in CTS diagnosis.

Methods:

A cross-sectional study was designed among patients clinically diagnosed with CTS. Hands of healthy volunteers and the asymptomatic hands of selected patients served as control. The Boston symptom severity scale (SSS) and the neuropathic pain severity inventory (NPSI) were used to assess symptom severity, and nerve conduction study (NCS) was used to assess electrophysiological severity. EMLA-induced SSW was visually graded after 90 min of application and correlated with symptom and NCS severities.

Results:

Forty-two symptomatic hands and 30 asymptomatic hands were enrolled as cases and controls, respectively. The diagnostic efficiency of the extended EMLA test was found to be 83.4% for digit 2 and 87.3% for the lateral 4 digits (mean), whereas the diagnostic efficiency of standard NCS was 88.1%. Boston SSS and NPSI were better correlated with EMLA positivity than NCS positivity. A linear regression analysis showed negative correlation of wrinkling grade with NCS grade.

Conclusion:

With its improved diagnostic efficiency, the 90-min extended EMLA test can feasibly be used as an alternative to NCS, especially in general practice settings. Its potential clinical utility should be explored in a large population of CTS patients showing varying clinical and electrophysiological severities.

Water-immersion finger-wrinkling improves grip efficiency in handling wet objects

For most people, immersing their hands in water leads to wrinkling of the skin of the fingertips. This phenomenon is very striking, yet we know little about why it occurs. It has been proposed that the wrinkles act to distribute water away from the contact surfaces of the fingertip, meaning that wet objects can be grasped more readily. This study examined the coordination between the grip force used to hold an object and the load force exerted on it, when participants used dry or wrinkly fingers, or fingers that were wet but not wrinkly. The results showed that wrinkly fingers reduce the grip force needed to grip a wet object, bringing that force in line with what is needed for handling a dry object. The results suggest that enhancing grip force efficiency in watery environments is a possible adaptive reason for the development of wrinkly fingers.

Can novel non-invasive autonomic tests help discriminate between pure autonomic failure and multiple system atrophy?

BACKGROUND

Pure autonomic failure (PAF) and multiple system atrophy (MSA) are rare disorders causing severe autonomic failure. Their initially similar clinical presentation may lead to years of diagnostic difficulties. Improving the differentiation would have an important impact on patients and families in view of better prediction of disease progression.

OBJECTIVE

To investigate whether several new non-invasive autonomic tests are beneficial in discriminating between PAF and MSA.

METHODS

Patients and controls underwent two tests examining the autonomic innervation of the skin (Sudoscan and water-induced skin wrinkling) and one test measuring retinal nerve fiber layer thickness in the eye.

RESULTS

The skin vasomotor tests yielded differences between the disease and control groups, but did not discriminate between PAF and MSA. No differences in retinal nerve fiber layer thickness were found between the groups.

CONCLUSION

The tests applied in this study may help to confirm autonomic failure but did not support the differential diagnosis between PAF and MSA.

Fluid Containing Structures in the tips of the fingers and toes delineated by Ultrasound Imaging before and after Induced Skin Wrinkling

This Ultrasound study identified spaces within the pulp of distal phalanx of the fingers and toes that halve in area after Water Induced Skin Wrinkling. These spaces appeared as fluid filled sacculi between connective tissue compartments accountable for distending digital pulp under normal circumstances and skin wrinkling after water immersion. Whilst studying conditions related to sympathetic nerve function with WISW ultrasound imaging is a valuable adjunct to the visual assessment.

Multimodal epidermal devices for hydration monitoring

Precise, quantitative in vivo monitoring of hydration levels in the near surface regions of the skin can be useful in preventing skin-based pathologies, and regulating external appearance. Here we introduce multimodal sensors with important capabilities in this context, rendered in soft, ultrathin, 'skin-like' formats with numerous advantages over alternative technologies, including the ability to establish intimate, conformal contact without applied pressure, and to provide spatiotemporally resolved data on both electrical and thermal transport properties from sensitive regions of the skin. Systematic in vitro studies and computational models establish the underlying measurement principles and associated approaches for determination of temperature, thermal conductivity, thermal diffusivity, volumetric heat capacity, and electrical impedance using simple analysis algorithms. Clinical studies on 20 patients subjected to a variety of external stimuli validate the device operation and allow quantitative comparisons of measurement capabilities to those of existing state-of-the-art tools.

Mechanics Reveals the Biological Trigger in Wrinkly Fingers

Fingertips wrinkle due to long exposure to water. The biological reason for this morphological change is unclear and still not fully understood. There are two main hypotheses for the underlying mechanism of fingertip wrinkling: the 'shrink' model (in which the wrinkling is driven by the contraction of the lower layers of skin, associated with the shrinking of the underlying vasculature), and the 'swell' model (in which the wrinkling is driven by the swelling of the upper layers of the skin, associated with osmosis). In reality, contraction of the lower layers of the skin and swelling of the upper layers will happen simultaneously. However, the relative importance of these two mechanisms to drive fingertip wrinkling also remains unclear. Simulating the swelling in the upper layers of skin alone, which is associated with neurological disorders, we found that wrinkles appeared above an increase of volume of [Formula: see text] Therefore, the upper layers can not exceed this swelling level in order to not contradict in vivo observations in patients with such neurological disorders. Simulating the contraction of the lower layers of the skin alone, we found that the volume have to decrease a [Formula: see text] to observe wrinkles. Furthermore, we found that the combined effect of both mechanisms leads to pronounced wrinkles even at low levels of swelling and contraction when individually they do not. This latter results indicates that the collaborative effect of both hypothesis are needed to induce wrinkles in the fingertips. Our results demonstrate how models from continuum mechanics can be successfully applied to testing hypotheses for the mechanisms that underly fingertip wrinkling, and how these effects can be quantified.

Stimulated skin wrinkling as an indicator of limb sympathetic function

Skin wrinkling upon water immersion has been used as an indicator of limb nerve function for more than 80years. Until recently, routine use of the test has been hampered by a poor understanding of the physiology and lack of standardization. The process underlying stimulated skin wrinkling has been recently identified as dependent on digital vasoconstriction mediated via sympathetic nerve fibers. Vasoconstriction is postulated to drive wrinkling through loss of digit volume, which induces a negative pressure in the digit pulp and exerts a downward pull on the overlying skin and ultimately results in wrinkles. Improved test standardization has been achieved through substituting water with EMLA for inducing skin wrinkling. This has made testing much easier and has helped implement stimulated skin wrinkling as a practical routine clinical bedside test. A literature search identified 10 studies of sufficient quality for evaluating stimulated skin wrinkling as a diagnostic test of sympathetic under or over function. Seven studies provide level 1 or 2 evidence as a diagnostic test of small fiber neuropathy and three provide level 1 or 2 evidence for cystic fibrosis. There is reasonable evidence allowing the test to be employed as a simple and effective marker for small fiber neuropathy and cystic fibrosis.

Water-induced finger wrinkles do not affect touch acuity or dexterity in handling wet objects

Human non-hairy (glabrous) skin of the fingers, palms and soles wrinkles after prolonged exposure to water. Wrinkling is a sympathetic nervous system-dependent process but little is known about the physiology and potential functions of water-induced skin wrinkling. Here we investigated the idea that wrinkling might improve handling of wet objects by measuring the performance of a large cohort of human subjects (n = 40) in a manual dexterity task. We also tested the idea that skin wrinkling has an impact on tactile acuity or vibrotactile sensation using two independent sensory tasks. We found that skin wrinkling did not improve dexterity in handling wet objects nor did it affect any aspect of touch sensitivity measured. Thus water-induced wrinkling appears to have no significant impact on tactile driven performance or dexterity in handling wet or dry objects.

Laboratory evaluation of pediatric autonomic disorders

The autonomic nervous system controls a variety of fundamental physiological processes in the human body including regulation of breathing, heart rate, blood pressure, temperature, and gastrointestinal motility. Although, methods of testing autonomic function have been developed and normative data have been collected in adults, development of child-friendly testing and the field of pediatric autonomic medicine is just beginning. These noninvasive testing methods serve to identify changes in autonomic functioning and to clarify whether dysfunction is isolated or crosses into multiple systems. Methods for testing cardiovagal, adrenergic, sudomotor, pupillary, enteric, and bladder function need to be refined and made more child friendly at the same time that age and gender appropriate normative values are developed for children.

Water-induced finger wrinkles improve handling of wet objects

Upon continued submersion in water, the glabrous skin on human hands and feet forms wrinkles. The formation of these wrinkles is known to be an active process, controlled by the autonomic nervous system. Such an active control suggests that these wrinkles may have an important function, but this function has not been clear. In this study, we show that submerged objects are handled more quickly with wrinkled fingers than with unwrinkled fingers, whereas wrinkles make no difference to manipulating dry objects. These findings support the hypothesis that water-induced finger wrinkles improve handling submerged objects and suggest that they may be an adaptation for handling objects in wet conditions.

Are wet-induced wrinkled fingers primate rain treads?

Wet fingers and toes eventually wrinkle, and this is commonly attributed by lay opinion to local osmotic reactions. However, nearly a century ago surgeons observed that no wrinkling occurs if a nerve to the finger has been cut. Here we provide evidence that, rather than being an accidental side effect of wetness, wet-induced wrinkles have been selected to enhance grip in wet conditions. We show that their morphology has the signature properties of drainage networks, enabling efficient removal of water from the gripped surface.

Evaluation of the finger wrinkling test: a pilot study

Purpose

Tilt table testing mainly evaluates the systemic cardiovascular part of the autonomic nervous system, while it is assumed that the finger wrinkling test assesses the peripheral part of the autonomic nervous system. In this study we explored whether the finger wrinkling test could be a useful test for autonomic dysfunction and whether the clinical evaluation of wrinkling can be improved by digital analysis of photographs.

Methods

As much as 20 healthy subjects and 15 patients underwent tilt table testing and finger wrinkling testing. During the finger wrinkling test the right hand was immersed in water at 40°C. The degree of wrinkling was assessed with a 5-point clinical scale at baseline, 5, 15 and 30 min of immersion. Photographs were taken at the same intervals. Several features were evaluated using digital analysis: length and gradient of automatically detected wrinkle and mean, maximum, minimum, variance and derivative of grey value of pixels.

Results

Clinical scoring of wrinkling allowed differentiation between healthy subjects and patients with a normal and an abnormal response to tilt table testing. Relevant features obtained with digital analysis were mean grey value and the gradient of automatically detected wrinkle. McNemar’s test showed no difference in test results between the tilt table test and the finger wrinkling test with a kappa of 0.68.

Conclusion

The finger wrinkling test can be used as a screening test before tilt table testing. Visual evaluation of wrinkling is still superior to digital analysis of photographs.

EMLA and Water Immersion Cause Similar Vasodilatation in Replanted Fingers

BACKGROUND

Skin wrinkling on water immersion is a reliable and simple test of sympathetic innervation. The eutectic mixture of local anesthetic (EMLA) cream has been shown to induce near identical clinical wrinkling scores and reduction in digit blood flow as that following water immersion in people with normal sympathetic innervation. This study was designed to investigate the vasomotor response to EMLA in replanted fingers that had poor sympathetic innervation.

METHODS

Laser Doppler imaging (PeriScan PIM II; Perimed AB, Stockholm, Sweden) was used to detect perfusion changes in the pulps of fourteen replanted fingers before and after 0.5 g of 5% EMLA cream application and water immersion in a 40 degrees C normal saline for 30 min, respectively. Comparisons were made with the contralateral corresponding normal fingers.

RESULTS

After water immersion and EMLA application, all of the normal fingers showed a considerable and similar decrease in blood perfusion that demonstrated in the absolute perfusion units (pU) (baseline: 1.57 +/- 0.33 pU, after water-immersion, 1.19 +/- 0.22 pU, P < 0.001; decrease: 23.6 +/- 7.7%, after EMLA application: 1.20 +/- 0.18 pU, P < 0.001; decrease: 22.4 +/- 8.9%). In contrast, all of the replanted fingers showed a statistically significant vasodilatatory response (baseline: 1.20 +/- 0.29 pU, after water-immersion: 1.36 +/- 0.28 pU, P < 0.001; increase: 15.2 +/- 9.1%, after EMLA application: 1.38 +/- 0.27 pU, P < 0.001; increase: 16.8 +/- 9.1%).

CONCLUSIONS

EMLA and water immersion both cause vasodilatation and no skin wrinkling in replanted fingers. These results imply that intact sympathetic nerve function is required to induce the vasoconstrictive effect of EMLA.

Acquired palmoplantar keratoderma

Palmoplantar keratodermas (PPKs) are a diverse entity of disorders that are characterized by abnormal thickening of the skin on the palms and soles. Traditionally they have been classified as either hereditary or acquired and are distinguished from each other on the basis of mode of inheritance, presence of transgrediens (defined as contiguous extension of hyperkeratosis beyond the palmar and/or plantar skin), co-morbidities with other symptoms, and extent of epidermal involvement, namely diffuse, focal, and punctate. As the terms hyperkeratosis and keratoderma have been used interchangeably throughout the literature, we define acquired keratoderma as a non-hereditary, non-frictional hyperkeratosis of the palms and/or soles that involves >/=50% of the surface of involved acral areas and that may or may not be associated with clinical and histologic inflammation. Given the numerous possible underlying causes for acquired PPKs, evaluation of patients presenting with acquired PPK can be a perplexing task. To facilitate such evaluations, this review categorizes the acquired PPKs as: keratoderma climactericum, drug related, malnutrition associated, chemically induced, systemic disease related, malignancy associated, dermatoses related, infectious, and idiopathic. In order to avoid the possibility of overlooking an underlying etiology and to eliminate excessive testing, we present an algorithm for assessing patients presenting with acquired PPK. The first step should include a comprehensive history and a physical examination, including a complete skin examination. If findings are consistent with a hereditary keratoderma, then a genetics consultation should be considered. Any findings suggestive of underlying conditions should be aggressively evaluated and treated. If no pertinent findings are identified after a history and a physical examination, laboratory and radiology studies should be undertaken in a systematic, logical fashion. In terms of treatment, the most successful results occur when the underlying etiology is diagnosed and treated. If no such etiology is evident, then conservative treatment options include topical keratolytics (urea, salicylic acid, lactic acid), repeated physical debridement, topical retinoids, topical psoralen plus UVA, and topical corticosteroids. Etretinate and acitretin have also shown some success as alternative treatments in recalcitrant cases.

A new wrinkle: skin manifestations of aging may relate to autonomic dysfunction

Various mechanisms have been argued for skin wrinkling, one of the hallmarks of aging. We hypothesize that chronic sympathetic bias is a previously unrecognized mechanism for wrinkling. In the acute setting of water immersion, reversible skin wrinkling is a well-known reflex mediated by the autonomic nervous system. We postulate that skin wrinkling results as a local maladaptive manifestation of a global chronic sympathetic bias that emerges during aging. The persistence of such changes may induce additional compensatory remodeling to cause permanent alteration of the skin. Sympatholytic agents may prove beneficial for arresting or ameliorating the development of wrinkles. Conditions that amplify sympathetic bias such as stress, smoking, amphetamine abuse, HIV, heart failure, and transplantation may accelerate wrinkling. Other common diseases of the skin may also arise as particular manifestations of aberrant autonomic activity through induction of vascular and immune dysfunctions. The temporal and spatial distribution of these dermatologic conditions may reflect variation of autonomic balance, which also regulates T helper immune balance. For all of these dermatologic conditions, local and systemic administration of drugs and medical devices that pharmacologically or electrically modulate autonomic nervous system activity may yield benefits as well.

Paradoxical response to water immersion in replanted fingers

When the fingers are immersed in water digital blood flow is reduced and the skin wrinkles, suggesting that vasoconstriction plays a role. However, is wrinkling due to sympathetic activation or some intrinsic property of the skin? To define the role of autonomic innervation in skin wrinkling we measured changes in blood perfusion (Laser Doppler Perfusion Imager) in 20 successfully replanted fingers (mean time after complete amputation 17.5 +/- 5.2 months). We compared responses in replanted fingers with those in corresponding contralateral normal fingers before and immediately after immersion in saline (0.5 mol/l NaCl at 40 degrees C). In the normal fingers, immersion caused a decrease in blood flow by 27.6 +/- 11.5% and skin wrinkling. However, in the replanted fingers blood flow increased by 22.8 +/- 19.6% and the skin did not wrinkle. The paradoxical cutaneous vasodilatation and absence of wrinkling in the denervated fingers suggests that sympathetic innervation is important in water-immersion skin wrinkling.

Transient aquagenic palmar hyperwrinkling: the first instance reported in a young boy

Transient reactive papulotranslucent acrokeratoderma is a rare palmoplantar keratoderma seen predominantly in adolescent and young adult women. Clinically it is characterized by translucent white papules generally involving the palmar surfaces after exposure to water. The typical "hands-in-the-bucket" sign, which is not clearly visible until the hand is submerged in water, is indispensable for the diagnosis. Histologic examination shows a mild orthokeratotic hyperkeratosis and dilated eccrine ducts. We propose the term "transient aquagenic palmar hyperwrinkling" to describe this condition. Until now, a total of 12 patients have been reported in the literature, all female, with an age of onset from 9 to 33 years. We present the first reported instance of this condition in a young boy.

Water immersion and EMLA cause similar digit skin wrinkling and vasoconstriction

Water immersion skin wrinkling tests limb sympathetic vasoconstrictor function. We have recently shown that water immersion wrinkling is accompanied by digit vasoconstriction and postulated that vasoconstriction is the main underlying mechanism. To test this further, we applied vasoconstrictive cream (EMLA) to the distal digit and compared the degree of skin wrinkling and digit blood flow reduction with those after water immersion. In 25 healthy volunteers (6 male, 19 female; mean age, 35 yr) subjected to EMLA and water immersion, both clinical wrinkling scores and reduction in digit blood flow (mean of 2.01 and 2.29 cm/s, respectively) were nearly identical. Control using aqueous cream resulted in minimal skin wrinkling and nonsignificant reduction in digit artery flow (P = 0.170). These data further support that water immersion skin wrinkling is mediated by vasoconstriction. The EMLA cream patch test may develop into a useful screening test for hand sympathetic vasoconstrictor function.