Documentation of impaired epidermal barrier in mild and moderate diaper dermatitis in vivo using noninvasive methods

Global perspective on the incidence, severity, and management of diaper dermatitis in neonates, infants, and young children

OBJECTIVE

We aimed to determine the incidence and severity of diaper dermatitis (DD) among neonates, infants and young children and identify the most effective treatment strategies with a global perspective.

MATERIALS AND METHODS

We conducted a narrative review of literatures searches from PubMed, EMBASE, and SCOPUS, found 1996 citations, selected primary source papers on infants and children ≤36 months and critically reviewed reports on incidence, severity, and treatment.

RESULTS

The analysis produced information on DD incidence and diaper skin care habits from 7500 subjects in 12 countries including extremely premature infants. Three studies suggested that dark-skinned infants had lower incidence and/or severity versus light-skinned subjects. Treatments were generally effective but varied somewhat in rate and/or extent of DD reduction. Variations in DD assessment methods, study design, and starting severity were limitations for comprehensive treatment comparison.

CONCLUSIONS

DD incidence is relatively high, ranging from 36 to 75 % in home and hospital settings, with severe cases from 1 to 24 %. The review suggests that treatments with "drying" processes or ingredients are promising strategies for improved outcomes. It highlights skin care practices that may reduce DD and prompts questions for future research to understand and manage conditions for optimum skin function in the diaper environment.

Incidence of incontinence-associated dermatitis in hospitalised neonates. Adaptation and validation of a severity scale

INTRODUCTION

Up to 60% of hospitalised neonates may develop incontinence-associated dermatitis (IAD). Our aim was to adapt the Clinical Evaluation Scale for Characterization of the Severity of Diaper Dermatitis to the Spanish population and to find out the nationwide frequency of IAD in hospitalized neonates.

METHODS

Cross-cultural adaptation and assessment of content validity of the scale. We carried out a prospective, multicentre observational study of the incidence of nappy rash in postnatal wards and neonatal intensive care units in 6 Spanish hospitals.

RESULTS

We obtained a content validity index of 0.869 for the total scale (95% CI, 0.742-0.939). The sample included 196 neonates. The cumulative incidence of IAD was 32.1% (9.1% mild-moderate, 8% moderate and 1.6% severe). The incidence rate was 2.2 IAD cases per 100 patient days. A stool pH of less than 5.5, a greater number of bowel movements a day, a greater daily urine output and the use of oral drugs were among the factors associated with the development of IAD.

CONCLUSION

The Spanish version of the Clinical Evaluation Scale for Characterization of the Severity of Diaper Dermatitis had an adequate content validity for the assessment of DAI in the hospitalised neonatal population. Mixed feeding, treatment with oral drugs and the use of medical devices in the perianal area were associated with an increased risk of nappy dermatitis in infants.

Bioactive tri-component nanofibers from cellulose acetate/lignin//N-vanillidene-phenylthiazole copper-(II) complex for potential diaper dermatitis control

Current research targets innovative medical textiles of nanofibrous nature and antibacterial activity to prevent diaper dermatitis. The work is based on electrospun nanofibers from cellulose acetate (CA) and lignin (Lig) polymers. A series of new copper complexes were synthesized and loaded to the CA/Lig solution mix then subjected to electrospinning, giving rise to the tricomponent bioactive mats CA/Lig/Cu-complex. The surface morphology of electrospun nanofiber mats was smooth and homogenous as the concentration of lignin increased in the mixture. The incorporation of lignin improved the electrospinnability of the cellulose acetate; however, it increased the fiber diameter. The water contact angle, absorption underload were significantly improved as lignin content increased. The incorporation of Cu-complex in electrospun CA and CA/Lig fiber mats occurred without any substantial change in the surface morphology, indicating well encapsulation of the complex. The electrospun mats were active against Pseudomonas aeruginosa, Acinetobacter baumannii, Staphylococcus epidermidis, and Streptococcus faecalis. The cytotoxicity, protein leakage, and biological results, together with the above studies, would advocate copper complex loaded CA/Lig nanofibers as a potential candidate for hygienic applications.

Skin Barrier Function in Infants: Update and Outlook

A good understanding of infant skin should provide a rationale for optimum management of the health of this integument. In this review, we discuss the skin barrier function of infants, particularly with reference to the use of diapers and baby wipes. The skin barrier of newborns continues to develop with age. Two years after birth, the barrier properties of infant skin closely resemble those of adult skin. However, several risk factors may contribute to impaired skin barrier and altered skin permeability in infants. Problems may arise from the use of diapers and baby wipes. The skin covered by a diaper is effectively an occluded environment, and thus is vulnerable to over-hydration. To date there has been no published information regarding dermal absorption of ingredients contained in baby wipes. Similarly, dermal absorption of topical ingredients in infants with underlying skin conditions has not been widely explored. Clearly, there are serious ethical concerns related to conducting skin permeation studies on infant skin. However, the increasing availability of non-invasive methods for in vivo studies is encouraging and offers new directions for studying this important patient group.

Dynamic trends in skin barrier function from birth to age 6 months and infantile atopic dermatitis: A Chinese prospective cohort study

BACKGROUND

Skin barrier functions develop after birth and may be related to skin disorders in infants. We aimed to assess associations between dynamic trends of four skin barrier functional parameters in early life with infant atopic dermatitis (AD).

METHODS

Based on the prospective cohort MKNFOAD (NCT02889081), we examined transepidermal water loss (TEWL), stratum corneum hydration (SCH), skin pH, and sebum content at five anatomical sites (cheek, forehead, forearm, abdomen, and lower leg) in 418 term infants at birth, 42 days, and 6 months. Trend differences by sex and association with AD at age 1 year were tested using variance analyses. Associations of the parameters with AD risk were tested using discrete time survival analysis, adjusting extensive covariates including parental history of allergy, infant's sex, birth weight (kg), and delivery mode. Odds ratios (ORs) and 95% confidence interval (CIs) were reported.

RESULTS

Overall TEWL and SCH appeared trends of increase while skin surface pH and sebum content showed trends of decrease within the first six postnatal months. Sex differences were significant for sebum content only (p < 0.001). After adjustment for parental and children covariates, cheek TEWL at birth (OR = 1.26, 95% CI 1.00-1.57, p = 0.045) and 42 days (OR = 1.52, 95% CI 1.17-1.97, p = 0.002) were significantly associated with increased AD risk. Associations were not observed between SCH, skin pH, and sebum content at birth or 42 days with AD.

CONCLUSIONS

Skin barrier functions of Chinese term infants varied nonlinearly after birth. Higher postnatal TEWL levels in early life indicate higher risk of early-onset AD.

Imaging reveals distinct textures at three infant skin sites and reflects skin barrier status

BACKGROUND

Infant diaper dermatitis (DD) is a prevalent condition due to multiple, interactive factors including increased skin hydration, irritant exposure, and increased skin pH. We examined diaper dermatitis vs within diaper and non-diaper controls over time and characterized the association of skin color and texture relative to skin barrier integrity, hydration, and pH.

MATERIALS AND METHODS

The prospective study included 46 infants with DD at well-child visits. Skin integrity was evaluated over 15 days, including visual skin condition, rate of stratum corneum transepidermal water accumulation, hydration, pH, and skin color and texture from high-resolution digital skin surface images. Effects by site and time were evaluated with general linear models.

RESULTS

Six distinct texture patterns were observed. All three sites differed significantly for texture class frequency. Normal dermatoglyphics were more frequent for non-diaper vs both within diaper and rash sites. Dermatoglyphics with marked furrows or lines (class 3) were common within diaper vs rash but not for non-diaper vs within diaper. Streaks were highest for DD and lowest for non-diaper. Flat regions were more frequent DD. Barrier integrity, that is, moisture accumulation rate, was lower for normal dermatoglyphics than streaks or flat texture. DD severity decreased over 15 days. Barrier properties of within diaper and non-diaper areas were not well-differentiated.

CONCLUSION

The incidence of streak texture in the within diaper high magnification images was high despite being visually normal. This finding suggests that it is an "early indicator" of skin damage and may be clinically useful for early detection and treatment.

Use of an emollient-containing diaper and pH-buffered wipe regimen restores skin pH and reduces residual enzymatic activity

BACKGROUND/OBJECTIVES

Diaper dermatitis is one of the most frequent skin conditions affecting infants and is associated with elevated skin pH, exposure to urine and feces, and increased fecal protease and lipase activity, resulting in stratum corneum barrier damage and increased risk of infection. The study aim was to determine the impact of two diaper and wipe regimens on newborn infant skin pH and residual enzyme activity after stool cleaning.

METHODS

Two diaper and wipe regimens were compared in a randomized, single-blinded crossover study. Regimen A paired an emollient-containing diaper with an acidic, pH-buffered wipe. Regimen B was a non-emollient diaper and wipe with limited buffering capacity. A 3-day washout period preceded each 3-day regimen use period. Skin pH at the perianal/buttocks interface (PBI), genital region, and undiapered chest control were measured at baseline and day 3. Skin swabs were collected for residual enzyme activity after a stool cleaning event.

RESULTS

Diapered skin pH at the PBI was similar to undiapered skin after 3 days of use for Regimen A, while PBI pH for Regimen B was elevated versus control. PBI pH was lower for Regimen A versus Regimen B. After a stool cleaning, PBI skin pH for Regimen A was lower immediately and had lower residual enzyme activity versus Regimen B (P < .05), and the pH-lowering effect was sustained up to 60 minutes.

CONCLUSIONS

These results suggest that the use of an emollient-containing diaper with a pH-buffered wipe creates conditions favorable to optimum diapered skin health.

Short-term skin reactions following use of N95 respirators and medical masks

Background

In the context of the COVID‐19 pandemic, cases of adverse skin reactions related to the wearing of masks have been observed.

Objectives

To analyze the short‐term effects of N95 respirators and medical masks, respectively, on skin physiological properties and to report adverse skin reactions caused by the protective equipment.

Methods

This study used a randomized crossover design with repeated measurements. Twenty healthy Chinese volunteers were recruited. Skin parameters were measured on areas covered by the respective masks and on uncovered skin 2 and 4 hours after donning, and 0.5 and 1 hour after removing the masks, including skin hydration, transepidermal water loss (TEWL), erythema, pH, and sebum secretion. Adverse reactions were clinically assessed, and perceived discomfort and non‐compliance measured.

Results

Skin hydration, TEWL, and pH increased significantly with wearing the protective equipment. Erythema values increased from baseline. Sebum secretion increased both on the covered and uncovered skin with equipment‐wearing. There was no significant difference in physiological values between the two types of equipment. More adverse reactions were reported following a N95 mask use than the use of a medical mask, with a higher score of discomfort and non‐compliance.

Conclusions

This study demonstrates that skin biophysical characters change as a result of wearing a mask or respirator. N95 respirators were associated with more skin reactions than medical masks.

Diaper dermatitis prevalence and severity: Global perspective on the impact of caregiver behavior

OBJECTIVES

To compare prevalence and severity of diaper dermatitis (DD) in infants and toddlers (babies) across three countries (China, USA, and Germany), including diapered skin measures and caregiver practices.

METHODS

A cross-sectional study of 1791 babies (~600 from each country) was recruited at each clinical site. Based on regional toilet-training habits, exclusively diaper-wearing infants were recruited between ages 2-8 months in China and 2-18 months in the USA and Germany. DD was measured, as well as skin pH, transepidermal water loss (TEWL), and relative humidity (RH) in the diapered region. Caregiver habits were collected via a questionnaire and included information on hygienic practices.

RESULTS

Diaper dermatitis was highest in the perianal area, followed by the intertriginous, genital, and buttock regions. In general, DD was significantly lower in babies in China, highest in Germany, and intermediate in the USA. This rank ordering of DD by geography was also observed in baby age 2-8 months. The lower DD observed in China was associated with lower skin pH and TEWL on diapered skin and decreased RH in the diaper. Chinese caregivers had the highest rate of prophylactic topical product usage, the most robust cleaning of the diapered area, lack of cleansing after urine-only diaper changes, and Chinese infants spent the least time in an overnight diaper.

CONCLUSIONS

These data suggest caregiver behaviors including prophylactic use of topical products, thorough cleaning after stooling and reduced time in an overnight diaper are associated with less DD, lower superficial skin pH, and enhanced skin barrier.

Stepwise approach of development of dermo-cosmetic products in healthy and atopic dermatitis paediatric population: safety evaluation, clinical development and postmarket surveillance

Background/objectives

Paediatric skin, considered sensitive, and infant skin, more susceptible to percutaneous toxicity, require specially formulated cosmetic products. As recently shown, early use of emollients in infants “at risk” of developing atopic dermatitis has shown controversial results in reducing the incidence of atopic dermatitis. Development of dermo‐cosmetic products for this specific population should especially ensure tolerance and safety. In absence of good clinical practice guideline, we propose here a stepwise approach for the development of paediatric cosmetic skincare products.

Methods

Our stepwise methodology for cosmetics aimed at paediatrics, starts with in vitro assessment of product's ingredients safety, followed by preclinical and clinical evaluations of the final product, including sequentially: (1) Repeated Open Application Test (ROAT), (2) Human Repeated Insult Patch Test (HRIPT), (3) In‐use dermatological and ophthalmological tolerance studies (sequentially in 3a: healthy adults, 3b: healthy paediatric subjects and finally 3c: paediatric patients). We also describe the integrated cosmetovigilance–toxicological surveillance during the clinical development phase and postmarketing.

Results

As illustrated with one dermo‐cosmetic product intended to be used as a preventative/maintenance treatment for atopic dermatitis in paediatric population, we show that using this stepwise methodology to test a product reduces potential risks of irritation and contact dermatitis in this sensitive population.

Conclusion

Standardized ethical stepwise development approach is needed to ensure the commercialization of safe and well‐tolerated dermo‐cosmetics for paediatrics. The approach described here could potentially serve as guidance for evaluation of new paediatric cosmetic products.

Diagnosis and management of diaper dermatitis in infants with emphasis on skin microbiota in the diaper area

Diaper dermatitis is the most common inflammatory skin eruption within the diaper area in infants and toddlers. Although it rarely causes problems for prolonged periods of time, it causes considerable distress for both infants and parents. Diapered skin is exposed to friction, excessive hydration, varying pH, and is in constant contact with urine and feces, both of which are highly irritant to the skin. The three most common types of diaper dermatitis include chaffing dermatitis, irritant contact dermatitis, and diaper candidiasis. However, a variety of other skin conditions may manifest in the diaper area. Candida albicans and Staphylococcus aureus are most frequently isolated from the affected area and are thought to have a predominant role in diaper dermatitis. The review includes an overview of the epidemiology, etiology, and common skin microbiota in the diaper area. State-of-the-art strategies for diagnosis, management, and prevention of diaper dermatitis are also included. Appropriate skin care can help in the prevention of diaper dermatitis and can aid the reparation of the skin. This review discusses common causes, skin microbiota within the diapered area, differential diagnosis, and finally possible prevention and treatment recommendations. Recent findings have proven that the key to efficient eradication of irritant diaper dermatitis lies in its prevention.

Efficacy of the combined use of a mild foaming cleanser and moisturizer for the care of infant skin

Objective

Despite the application of skin care treatments, many infants have skin problems such as dryness and erythema. We proposed a new combination skin care for infants which consisted of a foaming cleanser with lower surfactant activity and moisturizers that contained pseudo-ceramide.

Subjects and methods

A total of 50 infants (age: 3–24 months) with insignificant levels of dry skin were enrolled in this usage trial. The parents washed the infants with the test cleanser while bathing and then applied the moisturizer (lotion or cream) containing pseudo-ceramide. Prior to and following the 4-week usage period, visual evaluation of the skin condition was conducted by a dermatologist, in addition to instrumental analysis.

Results

Erythema and papule, accompanied by dryness, were commonly observed at week 0. However, by week 4, these symptoms significantly improved; the condition of none of the subjects deteriorated. The number of infants with lower cutaneous barrier function and higher skin pH decreased. The parents of the infants recognized improvements in the skin symptoms and were appreciative of the test materials.

Conclusion

The combined usage of the foaming cleanser with lower surfactant activity and a moisturizer containing pseudo-ceramide may be effective in maintaining healthy infant skin and ameliorating the skin symptoms.

Skin Health Connected to the Use of Absorbent Hygiene Products: A Review

Over the past 50 years, absorbent hygiene products such as baby diapers and incontinence products have become essential features of modern day life. Through innovation and enhanced technology, their design, composition and performance have been dramatically upgraded from their early forms, and they have transformed the lives of millions of people, improving their quality of life. Skin health related to the use of absorbent hygiene products has accordingly also greatly improved. Still, the wearing of absorbent hygiene products will affect the skin, and for some users the changes in microclimate, mechanical interactions and the exposure to urine and faeces may result in irritant contact dermatitis, i.e. diaper dermatitis (DD) or incontinence-associated dermatitis (IAD). Babies with developing skin and the elderly with deteriorating skin functions who are the most frequent users of absorbent hygiene products are more vulnerable to the causal factors. Although irritant reactions are the most common, allergic contact dermatitis should be considered if a DD/IAD fails to improve by recommended actions. There is also a connection between IAD and pressure ulcer development of which it is important to be aware. A holistic approach of using high-quality absorbent hygiene products in combination with appropriate skin care will help maintaining good skin health.

Comparison of the Effect of Skin Preparation Pads on Transepidermal Water Loss in Ex Vivo Human Skin

Introduction

Pre-treatment of the skin to remove scales and crusts prior to photodynamic therapy (PDT) is essential to enhance the uptake of topically applied methyl aminolevulinate (MAL) and to improve treatment efficacy. This study compared the effect of two different skin preparation pads on skin integrity in ex vivo human skin.

Methods

Ex vivo human skin samples from three donors were pre-treated in triplicates with PREPSTER™ (PR) skin preparation pad (6, 8, and 10 passages) or Ambu Unilect™ (A-UN) skin preparation pad (6, 8, and 10 passages). In addition, skin samples were pre-treated with tape strippings (10 adhesive tape strips) as a reference method for comparison. Transepidermal water loss (TEWL) was measured on intact skin and following skin barrier impairment using skin preparation pads and tape stripping. Histological analysis was performed to verify the impairment of the stratum corneum (SC) barrier function in samples from intact skin (control), 10 tape strippings (reference method), 10 passages of PR, and 10 passages of A-UN.

Results

TEWL increased with the increasing number of passages of skin preparation pads, with 2.4- and 3.3-fold increases following 10 passages of A-UN and PR, respectively, versus a 2.2-fold increase with 10 tape strippings (reference). Histological analysis showed only partial removal of the SC, with no damage observed on the epidermis, regardless of the procedure used.

Conclusion

Pre-treatment of skin using PR and A-UN skin preparation pads markedly increases TEWL, indicating slight impairment of the SC barrier function. Comparison of both skin preparation pads showed that PR pad consistently induced significantly higher TEWL than A-UN pad (p < 0.05), regardless of the number of passages. Both skin preparation pads are thought to increase the uptake of MAL and can therefore be used for the preparation of skin prior to PDT.

Funding

Nestlé Skin Health – Galderma R&D.

Superficial Mycoses Associated with Diaper Dermatitis

Diapers create particular conditions of moisture and friction, and with urine and feces come increased pH and irritating enzymes (lipases and proteases). Fungi can take advantage of all these factors. Candida yeasts, especially C. albicans, are responsible for the most frequent secondary infections and are isolated in more than 80 % of cases. Correct diagnosis is important for ensuring the correct prescription of topical antimycotics. Nystatin, imidazoles and ciclopirox are effective. It is important to realize there are resistant strains. Dermatophytes can infect the diaper area, with the most common agent being Epidermophyton floccosum. The clinical characteristics of dermatophytosis are different from those of candidiasis, and it can be diagnosed and treated simply. Malassezia yeasts can aggravate conditions affecting the diaper area, such as seborrheic dermatitis, atopic dermatitis, and inverse psoriasis. Additional treatment is recommended in this case, because they usually involve complement activation and increased specific IgE levels. Erythrasma is a pseudomycosis that is indistinguishable from candidiasis and may also occur in large skin folds. It is treated with topical antibacterial products and some antimycotics.

Water-Holding and Transport Properties of Skin Stratum Corneum of Infants and Toddlers Are Different from Those of Adults: Studies in Three Geographical Regions and Four Ethnic Groups

BACKGROUND/OBJECTIVE

Epidermal structure, function, and composition are different in white infants and adults. We investigated whether ethnicity and location contribute to differences in functional and clinical measurements of skin barrier function during the first years of life and in adults.

METHODS

Children (n = 397, ages 3-49 mos) and women (n = 117, mean age 31 yrs) were enrolled at independent centers in Beijing, China (ethnic Chinese), Skillman, New Jersey (white, African American), and Mumbai, India (ethnic South Asian). Water barrier properties of the stratum corneum were assessed using high-frequency conductance and transepidermal water loss (TEWL) on the dorsal forearm and upper inner arm. Digital imaging was used to evaluate facial erythema and scaling.

RESULTS

Despite differences in local climate, TEWL was similar in adults. In children, conductance and TEWL decreased monotonically from age 3 months to 4 years. In children from Beijing, TEWL values were higher in both arm locations than in children in Mumbai and Skillman. No significant differences were observed in TEWL or conductance between the white and African American groups.

CONCLUSION

In general, TEWL and conductance were greater on the upper inner arm than the dorsal forearm. Erythema and scaling were observed most often in subjects from Beijing and most infrequently in subjects from Mumbai. Stratum corneum water barrier properties were different in children and adults. Although there may be differences in these properties between ethnic groups in childhood, TEWL values were similar in adults across the three geographic locations and four ethnicities.

Mathematical analysis of dermal absorption rate of heavy metals

Presently 90 - 95% of children in the US wear disposable diapers before completing their toilet training at average age of 30 months. The diaper absorbs urine and liquid component from feces contaminated with excreted toxicants. In this initial study, we posit that the long contact between the diaper and the skin leads to increased dermal reabsorption of excreted body toxicants, mainly heavy metals, which are statistically associated with autism and neurodevelopmental disorder. We developed a mathematical model to analyse the increase of the level of toxicants due to dermal reabsorption after excretion. This simple kinetic model gives us the average reabsorbtion factor in the range of 1.6 to 5. The limitation of this work is that only mathematical model has been considered and it has not been verified experimentally.

Newborn infant skin: physiology, development, and care

Infant skin is critical to the newborn child's transition from the womb environment to the journey to self-sufficiency. This review provides an integrative perspective on the skin development in full term and premature infants. There is a particular focus on the role of vernix caseosa and on the implications of skin development for epidermal penetration of exogenous compounds. Healthy full-term newborn skin is well-developed and functional at birth, with a thick epidermis and well-formed stratum corneum (SC) layers. Transepidermal water loss is very low at birth, equal to, or lower than adults, indicating a highly effective skin barrier. Vernix facilitates SC development in full-term infants through a variety of mechanisms including physical protection from amniotic fluid and enzymes, antimicrobial effects, skin surface pH lowering, provision of lipids, and hydration. Premature infants, particularly those of very low birth weight, have a poor skin barrier with few cornified layers and deficient dermal proteins. They are at increased risk for skin damage, increased permeability to exogenous agents and infection. The SC barrier develops rapidly after birth but complete maturation requires weeks to months. The best methods for caring for infant skin, particularly in the diaper region, are described and related to these developmental changes.

Effect of diaper cream and wet wipes on skin barrier properties in infants: a prospective randomized controlled trial

The effect of different diaper care procedures on skin barrier function in infants has been minimally investigated and may be assessed using objective methods. In a single-center, prospective trial, 89 healthy 9-month-old infants (±8 wks) were randomly assigned to three diaper care regimens: group I used water-moistened washcloths at diaper changes (n = 30), group II additionally applied diaper cream twice daily (n = 28), and group III used wet wipes and diaper cream twice daily (n = 31). Transepidermal water loss (TEWL), skin hydration (SCH), skin pH, interleukin 1α (IL-1α) levels, and microbiologic colonization were measured in diapered skin (upper outer quadrant of the buttocks), nondiapered skin (upper leg), and if diaper dermatitis (DD) occurred, using the most affected skin area at day 1 and weeks 4 and 8. Skin condition was assessed utilizing a neonatal skin condition score and diaper rash grade. On diapered skin, SCH decreased in groups II and III, whereas TEWL values were reduced in group II only. Skin pH increased in groups II and III. In general, SCH, skin pH, and IL-1α levels were higher in healthy diapered skin than in nondiapered skin. The incidence and course of DD was comparable in all groups. Areas with DD had greater TEWL and skin pH than unaffected skin areas. Infants who received diaper cream had lower SCH and TEWL and higher pH levels in the diapered area than on nondiapered skin. No correlation with the occurrence of DD was found.

Relationship between skin barrier function in early neonates and diaper dermatitis during the first month of life: a prospective observational study

Diaper dermatitis, a common skin problem in newborn infants, is characterized by poor functioning of the skin barrier. This study aimed to elucidate the relationship between skin barrier function in 4-day-old infants and the occurrence of diaper dermatitis during the first month of life. We recruited healthy Japanese infants born at 35 weeks of gestation or more. We measured indicators of skin barrier function, namely skin pH and transepidermal water loss, in 4-day-old infants on four places on the body. Individual characteristics were recorded from the infants' medical charts. The presence of diaper dermatitis was judged using the diaper rash and erythema scoring scale, which was based on daily recording of the infants' skin condition by their parents. The parents also filled out a questionnaire 1 month after birth regarding stool frequency and certain external factors. The association between diaper dermatitis and skin barrier function was assessed using multiple logistic regression analysis. The analysis included 88 infants. The incidence of diaper dermatitis was 25.0%. After adjusting for stool frequency for 1 month we noted that high pH on the inner arm skin in 4-day-old infants increased the risk of diaper dermatitis during the first month of life (adjusted odds ratio 3.35 [95% confidence interval = 1.12, 10.04]). Early neonatal skin pH may predict the risk of diaper dermatitis during the first month of life. Our results may be useful in devising strategies to prevent diaper dermatitis.

Prevention of diaper dermatitis in infants--a literature review

Diaper dermatitis (DD) is one of the most common skin conditions in neonates and infants, with a peak between the ages of 9 and 12 months. Appropriate skin care practices that support skin barrier function and protect the buttocks skin from urine and feces are supposed to be effective in the prevention of DD. Despite many recommendations for parents and caregivers on proper diaper skin care, there is no up-to-date synthesis of the available evidence to develop recommendations for DD prevention practice. Therefore we performed a systematic literature review on the efficacy of nonmedical skin care practices on the diapered area of healthy, full-term infants ages 0 to 24 months. We identified 13 studies covering skin care practices such as cleansing, bathing, and application of topical products. DD prevalence and incidence and physiologic skin parameters were used as efficacy parameters. The results of this review indicate that cleansing of the diaper area using baby wipes or water and a washcloth have comparable effects on diapered skin. Bathing with a liquid baby cleanser twice weekly seems comparable with water alone. The application of ointments containing zinc oxide or petrolatum with or without vitamin A seems to have comparable effects on DD severity. There seems to be no information on whether single skin care practices such as cleansing, bathing, and application of topical preparations can prevent DD. High-quality randomized clinical trials are needed to show the effectiveness of skin care practices for controlling and preventing DD.

Diagnosis and management of diaper dermatitis

This article presents an overview of diaper dermatitis for the pediatric community. The pathogenesis, differential diagnosis, and management of this common condition in infancy are reviewed. This information will assist in making the appropriate diagnosis and managing this irritant contact dermatitis of the diaper area. With conservative management, most cases of irritant diaper dermatitis are self-limited. When the condition persists, one must consider other diagnoses.

Diaper dermatitis: etiology, manifestations, prevention, and management

Pediatricians and parents report diaper dermatitis (DD) to be one of the most common skin diseases that affects almost every child at some point during the early months and years of life. Diapered skin is exposed to friction and excessive hydration, has a higher pH than nondiapered skin, and is repeatedly soiled with feces that contains enzymes with high irritation potential for the skin. The combination of these factors frequently results in skin damage, leading to visible erythematous lesions that can be irritating and painful to the child. Behavioral changes such as increased crying and agitation and changes in eating and sleeping patterns indicate emotional distress. Appropriate skin care can help to prevent the occurrence of DD and to speed up the healing of affected skin. This includes frequent diaper changes and aeration, gentle cleansing, and the use of a barrier cream. Mild to moderate cases usually resolve after a few days of following this routine, but the use of harsh cleaning products can exacerbate DD.

Risk factor-dependent dynamics of atopic dermatitis: modelling multi-scale regulation of epithelium homeostasis

Epithelial tissue provides the body with its first layer of protection against harmful environmental stimuli by enacting the regulatory interplay between a physical barrier preventing the influx of external stimuli and an inflammatory response to the infiltrating stimuli. Importantly, this interdependent regulation occurs on different time scales: the tissue-level barrier permeability is regulated over the course of hours, whereas the cellular-level enzymatic reactions leading to inflammation take place within minutes. This multi-scale regulation is key to the epithelium's function and its dysfunction leads to various diseases. This paper presents a mathematical model of regulatory mechanisms in the epidermal epithelium that includes processes on two different time scales at the cellular and tissue levels. We use this model to investigate the essential regulatory interactions between epidermal barrier integrity and skin inflammation and how their dysfunction leads to atopic dermatitis (AD). Our model exhibits a structure of dual (positive and negative) control at both cellular and tissue levels. We also determined how the variation induced by well-known risk factors for AD can break the balance of the dual control. Our model analysis based on time-scale separation suggests that each risk factor leads to qualitatively different dynamic behaviours of different severity for AD, and that the coincidence of multiple risk factors dramatically increases the fragility of the epithelium's function. The proposed mathematical framework should also be applicable to other inflammatory diseases that have similar time-scale separation and control architectures.

The infant skin barrier: can we preserve, protect, and enhance the barrier?

Infant skin is different from adult in structure, function, and composition. Despite these differences, the skin barrier is competent at birth in healthy, full-term neonates. The primary focus of this paper is on the developing skin barrier in healthy, full-term neonates and infants. Additionally, a brief discussion of the properties of the skin barrier in premature neonates and infants with abnormal skin conditions (i.e., atopic dermatitis and eczema) is included. As infant skin continues to mature through the first years of life, it is important that skin care products (e.g., cleansers and emollients) are formulated appropriately. Ideally, products that are used on infants should not interfere with skin surface pH or perturb the skin barrier. For cleansers, this can be achieved by choosing the right type of surfactant, by blending surfactants, or by blending hydrophobically-modified polymers (HMPs) with surfactants to increase product mildness. Similarly, choosing the right type of oil for emollients is important. Unlike some vegetable oils, mineral oil is more stable and is not subject to oxidation and hydrolysis. Although emollients can improve the skin barrier, more studies are needed to determine the potential long-term benefits of using emollients on healthy, full-term neonates and infants.

Diaper dermatitis: a review and update

PURPOSE OF REVIEW

Diaper dermatitis is the most common cutaneous diagnosis in infants. In this review, common causes of diaper dermatitis and similarly presenting conditions will be covered, as well as updates on treatments of common diaper dermatitides.

RECENT FINDINGS

There have been recent advancements in the treatment of diaper dermatitis. In addition, there are many newly recognized causes of diaper dermatitis that clinicians should be aware of.

SUMMARY

Irritant dermatitis is the most common cause of diaper dermatitis. However, there are multiple other common causes of diaper dermatitis and it is thus imperative that the clinician be aware of cutaneous mimickers of irritant diaper dermatitis as well as their treatments.

An RCT on the effects of topical CGP on surgical wound appearance and residual scarring in bilateral total-knee arthroplasty patients

OBJECTIVE

To test the hypothesis that topically applied calcium glycerophosphate (CGP) would improve the appearance of the wound following bilateral knee replacement.

METHOD

Healthy patients, aged 45-75 years, scheduled for bilateral total-knee replacement surgery were recruited into the study. One knee was randomly assigned to the treatment group, while the contralateral knee was designated the control (standard care). Subjects were instructed to apply a preparation of 10% CGP in an aqueous lotion to the treated knee once daily for 42 days, starting at the third postoperative day. Functional sealing and cosmetic appearance of the incision were evaluated by two surgeons by direct examination of the patient and then by two experienced assessors from photographs. The investigators qualitatively scored the intensity and extent of erythema along the incision and over the entire knee, the appearance of visible oedema along the incision and over the knee, and the overall clinical impression of wound healing. All four assessors were blinded to the subjects' allocation and the latter two assessors to the initial investigators' assessments. Subjects were also followed up for an additional 46 weeks, giving a total study duration of 12 months.

RESULTS

Twenty patients completed the study. Statistical analysis showed that both the area and intensity of erythema along the incision were significantly reduced in the treated vs untreated knee over the entire study period. The analysis further showed that treatment significantly reduced oedema, both along the incision and across the entire knee. The differences were most marked at the seventh postoperative day and diminished with time. No adverse effects were observed for any patient, in either treated or untreated knees.

CONCLUSION

These data demonstrate that postoperative application of 10% CGP could improve the appearance of the wound following total knee arthroplasty.