Indicators of skin barrier integrity among newborns massaged with mustard oil in rural Nepal

OBJECTIVE

The objective of this study was to determine the skin barrier changes during postnatal month 1 among infants receiving routine mustard oil massage in the humid conditions of rural Nepal.

STUDY DESIGN

This was an observational study among 500 live-born neonates receiving mustard oil massage. Skin integrity such as erythema, rash, dryness, skin pH, stratum corneum protein concentration and transepidermal water loss was measured on days 1, 3, 7, 14 and 28.

RESULTS

Erythema and rash increased (worsened) during weeks 1 and 2, then decreased over weeks 3 and 4. Skin pH (6.1±0.5 to 5.0±0.6) and stratum corneum protein (16.6±7.9 to 13.5±5.9 μg cm^-2) decreased. Transepidermal water loss increased from 33.2±23.5 to 43.0±24.5 g m^-2 h^-1 at day 28. Skin pH and stratum corneum protein were higher for early versus late premature infants.

CONCLUSION

Premature and full-term skin condition was generally poor especially during the first 2 weeks, improving thereafter. Maturational changes were evident.

A handheld SPIO-based sentinel lymph node mapping device using differential magnetometry

Sentinel lymph node biopsy has become a staple tool in the diagnosis of breast cancer. By replacing the morbidity-plagued axillary node clearance with removing only those nodes most likely to contain metastases, it has greatly improved the quality of life of many breast cancer patients. However, due to the use of ionizing radiation emitted by the technetium-based tracer material, the current sentinel lymph node biopsy has serious drawbacks. Most urgently, the reliance on radioisotopes limits the application of this procedure to small parts of the developed world, and it imposes restrictions on patient planning and hospital logistics. Magnetic alternatives have been tested in recent years, but all have their own drawbacks, mostly related to interference from metallic instruments and electromagnetic noise coming from the human body. In this paper, we demonstrate an alternative approach that utilizes the unique nonlinear magnetic properties of superparamagnetic iron oxide nanoparticles to eliminate the drawbacks of both the traditional gamma-radiation centered approach and the novel magnetic techniques pioneered by others. Contrary to many other nonlinear magnetic approaches however, field amplitudes are limited to 5 mT, which enables handheld operation without additional cooling. We show that excellent mass sensitivity can be obtained without the need for external re-balancing of the probe to negate any influences from the human body. Additionally, we show how this approach can be used to suppress artefacts resulting from the presence of metallic instruments, which are a significant dealbreaker when using conventional magnetometry-based approaches.

Pressure ulcers in the hospitalized neonate: rates and risk factors

Pressure ulcers (PU) are serious, reportable events causing pain, infection and prolonged hospitalization, particularly among critically ill patients. The literature on PUs in neonates is limited. The objective was to determine the etiology, severity and influence of gestational age on PUs among hospitalized infants. A two-year prospective study was conducted among 741 neonatal intensive care patients over 31,643 patient-days. Risk factors were determined by comparing the characteristics of infants who developed PUs with those who did not. There were 1.5 PUs per 1000 patient days with 1.0 PU per 1000 days in premature infants and 2.7 per 1000 days in term infants. The number of PUs associated with devices was nearly 80% overall and over 90% in premature infants. Infants with PUs had longer hospitalizations and weighed more than those who did not. Infants with device-related PUs were younger, of lower gestational age and developed the PU earlier than patients with PUs due to conventional pressure. The time to PU development was longer in prematurely born versus term infants. Hospitalized neonates are susceptible to device-related injury and the rate of stage II injury is high. Strategies for early detection and mitigation of device-related injury are essential to prevent PUs.

Spontaneous preoperative microembolic signals detected with transcranial Doppler are associated with vulnerable carotid plaque characteristics

AIM

Carotid plaque composition is associated with ipsilateral cerebrovascular events. Among patients with carotid artery stenosis, presence of microembolic signals (MES) detected with transcranial Doppler (TCD) is associated with increased stroke risk. We aimed to investigate whether MES detected with TCD in the outpatient clinic among patients scheduled for carotid endarterectomy, was associated with underlying carotid plaque composition.

METHODS

TCD was used to detect MES among 38 symptomatic patients scheduled for carotid endarterectomy. Measurements were performed for 30 minutes. Carotid plaques harvested during CEA were subjected to histopathological examination. Plaques from patients without spontaneous MES were compared with plaques from patients with ≥1 MES.

RESULTS

Median time between TCD and surgery was 4 days. At least 1 MES was detected in 10/38 (26%) patients. Five of ten (50%) patients with spontaneous MES had lipid-rich plaques, compared with 5/28 (17.2%) plaques from patients without MES (P=0.048). Luminal thrombus was observed in 6/10 (60.0%) of plaques from patients with MES compared with 7/28 (25.0%) of plaques from patients without MES (P=0.045).

CONCLUSION

Spontaneous MES were detected in 26% of symptomatic patients scheduled for CEA and were associated with unstable carotid plaque characteristics. TCD might be a useful tool to help identify patients with vulnerable plaques.

The Ontogeny of Skin

Significance: During gestation, fetal skin progresses from a single layer derived from ectoderm to a complex, multi-layer tissue with the stratum corneum (SC) as the outermost layer. Innate immunity is a conferred complex process involving a balance of pro- and anti-inflammatory cytokines, structural proteins, and specific antigen-presenting cells. The SC is a part of the innate immune system as an impermeable physical barrier containing anti-microbial lipids and host defense proteins. Postnatally, the epidermis continually replenishes itself, provides a protective barrier, and repairs injuries. Recent Advances: Vernix caseosa protects the fetus during gestation and facilitates development of the SC in the aqueous uterine environment. The anti-infective, hydrating, acidification, and wound-healing properties post birth provide insights for the development of strategies that facilitate SC maturation and repair in the premature infant. Critical Issues: Reduction of infant mortality is a global health priority. Premature infants have an incompetent skin barrier putting them at risk for irritant exposure, skin compromise and life-threatening infections. Effective interventions to accelerate skin barrier maturation are compelling. Future Directions: Investigations to determine the ontogeny of barrier maturation, that is, SC structure, composition, cohesiveness, permeability, susceptibility to injury, and microflora, as a function of gestational age are essential. Clinicians need to know when the premature skin barrier becomes fully competent and comparable to healthy newborn skin. This will guide the development of innovative strategies for optimizing skin barrier development.

A quality-improvement collaborative project to reduce pressure ulcers in PICUs

BACKGROUND AND OBJECTIVE

Pediatric patients are at risk for developing pressure ulcers (PUs) and associated pain, infection risk, and prolonged hospitalization. Stage III and IV ulcers are serious, reportable events. The objective of this study was to develop and implement a quality-improvement (QI) intervention to reduce PUs by 50% in our ICUs.

METHODS

We established a QI collaborative leadership team, measured PU rates during an initial period of rapid-cycle tests of change, developed a QI bundle, and evaluated the PU rates after the QI implementation. The prospective study encompassed 1425 patients over 54 351 patient-days in the PICU and NICU.

RESULTS

The PU rate in the PICU was 14.3/1000 patient-days during the QI development and 3.7/1000 patient-days after QI implementation (P < .05), achieving the aim of 50% reduction. The PICU rates of stages I, II, and III conventional and device-related PUs decreased after the QI intervention. The PU rate in the NICU did not change significantly over time but remained at a mean of 0.9/1000 patient-days. In the postimplementation period, 3 points were outside the control limits, primarily due to an increase in PUs associated with pulse oximeters and cannulas.

CONCLUSIONS

The collaborative QI model was effective at reducing PUs in the PICU. Pediatric patients, particularly neonates, are at risk for device-related ulcers. Heightened awareness, early detection, and identification of strategies to mitigate device-related injury are necessary to further reduce PU rates.

Regional variation in the free amino acids in the stratum corneum

Regional differences in water-binding free amino acids (FAAs) in the stratum corneum (SC) may be expected, since differences in skin biophysical properties are well known. The objective was to determine whether differences in skin hydration as a function of body site may arise from differences in the chemical makeup of the skin, specifically the FAAs. Levels were quantified from serial SC samples collected from the forearm, calf, back, torso, and jaw in two studies using HPLC methods. FAA levels were higher from the calf versus the forearm and lower from the jaw compared to torso and back skin. Body site variations in skin hydration could not be attributed to differences in FAA levels.

Natural moisturizing factors (NMF) in the stratum corneum (SC). II. Regeneration of NMF over time after soaking

The detrimental effects of prolonged water exposure on skin are well known. Information on the effects of short-term exposure, e.g., during bathing, showering, and hand washing, on NMF levels is limited. In an attempt to isolate the effects of soaking on the NMF, a time course for skin sample collection was devised in which adhesive tapes were applied 0.5 and four hours after soaking of the treated arm. Significant decreases in NMF levels, quantified by HPLC analysis of serial tape strips, were observed 0.5 hours after soaking, with a replacement of NMF occurring by the four-hour mark. This replacement corresponds to a parallel rebound in skin pH also observed at these times. Stratum corneum hydration values, measured instrumentally as the rate of moisture accumulation (MAT), however, were depressed 0.5 hours post-soaking and remained low four hours later. In addition, significant increases in skin pH were observed during the immediate post-soak period. These findings suggest that short-term exposure to water alone produces significant changes in the stratum corneum.

Natural moisturizing factors (NMF) in the stratum corneum (SC). I. Effects of lipid extraction and soaking

Natural moisturizing factor (NMF) is essential for appropriate stratum corneum hydration, barrier homeostasis, desquamation, and plasticity. It is formed from filaggrin proteolysis to small, hygroscopic molecules including amino acids. We hypothesized that common lipid extraction and soaking in water would alter the level of NMF in the upper SC and its biophysical properties. A novel method of measuring and quantifying the amino acid components of NMF is presented. Adhesive tapes were used to collect samples of the stratum corneum (SC) and were extracted with 6mM perchloric acid for analysis by reverse-phase HPLC. HPLC results were standardized to the amount of protein removed by the tapes. An increase in NMF was found with increased SC depth. Also, the combination of extraction and soaking was found to increase NMF loss relative to control or to extraction or soaking alone. Our results indicate that common skin care practices significantly influence the water binding materials in the upper SC. The findings have implications for the evaluation and formulation of skin care products.

Effect of topical treatments on irritant hand dermatitis in health care workers

BACKGROUND

Irritant contact dermatitis (ICD) from repetitive hand hygiene is the primary reason for compliance failure among health care workers (HCWs). Chronic ICD has implications for infection control because higher bacterial counts are associated with increased skin compromise. Guidelines recommend lotions/creams to lessen irritation. We evaluated the effects of 5 to 10 daily applications of a test cream (A, glove and chlorhexidine gluconate compatible) and current lotions/creams (B) compared with a control of normal skin care.

METHODS

Outcomes were visual skin erythema and dryness, excess erythema (quantitative image analysis), and hydration among 80 HCWs in an intensive care unit.

RESULTS

Knuckle dryness was lower for both treatments than the no treatment control (P < .02) after 2 weeks. Skin treated with A had lower knuckle erythema (P=.03) than B and control. HCWs using A had lower excess erythema (right) than B and control (P < .04). Excess erythema was lower for A and B versus control (P=.003).

CONCLUSION

Reduction in erythema suggests that frequent use of cream A may mitigate the damaging effects of repetitive hand hygiene and allow the skin to recover. Intensive treatment of HCW ICD may be required to counteract the skin compromise and minimize the negative impact on infection control.

Use of digital photography and image analysis techniques to quantify erythema in health care workers

BACKGROUND/AIMS

Nosocomial infections affect up to 26% of ICU patients. Compliance with the required hand hygiene procedures remains low, rarely exceeding 50%, with skin irritation as one of the main reasons for lack of conformity. The aim was to quantify the epidermal barrier effects, particularly erythema, from repetitive exposure to hand hygiene procedures among health care workers (HCWs) using an objective, reliable clinical method that could evaluate the entire hand surface.

METHODS

The hand skin of HCWs was evaluated before the initial scrub and at the end of multiple 2-3 days work cycles during spring (n=54) and winter (n=60) trials. The skin condition was measured with live visual skin evaluation (LSG), digital image analysis (DIA) of high-resolution digital images, and visual perception evaluation (VPS) of image pairs.

RESULTS

The HCWs had significantly higher values of erythema than the non-HCW control group with all methods. Knuckle erythema increased over the cycle in both seasons. It decreased during recovery in spring and continued to increase during recovery in winter. For the DIA area of excess redness, the quantitative measure of erythema, the decrease over the cycle in spring was significantly different than the increase over the cycle in winter. Minimal changes in area of excess redness occurred during recovery in both seasons. With the VPS, both judges found a decrease in erythema during recovery in spring and an increase during recovery in winter, indicating significant differences for spring vs. winter (P<0.05). No differences in VPS erythema were seen for either product set over the work cycle during spring. Correlations were observed for (1) results for the VPS vs. the LSG method and (2) between excess erythema (mu+sigma) from DIA and the VPS erythema scores. Relatively low correlations were found between the DIA and VPS methods, i.e., knuckle mu+sigma and VPS erythema.

CONCLUSIONS

Significant work cycle effects for spring vs. winter were observed with DIA, while significant effects were found during the recovery period with VPS. DIA produced an objective quantitative measure of erythema that was not limited or influenced by other aspects of skin irritation (e.g., dryness, scaling) or texture encountered in the visual methods of LSG and VPS. The DIA method minimizes the difficulty in differentiating erythema severity. Standardization of image capture and processing allows assessment of skin condition across clinical locations. The VPS is a more reliable way to compare skin condition at different times, i.e. beginning vs. the end of a treatment cycle, because images are viewed simultaneously and can be carefully examined for differences.

Skin care in the NICU patient: effects of wipes versus cloth and water on stratum corneum integrity

BACKGROUND

NICU patients are at risk of skin breakdown due to prematurity, irritant exposure, medical status and stress. There is a need to minimize damage, facilitate skin development and reduce infection risk, but the literature on the effects of skin care practices in NICU patients is limited.

OBJECTIVES

To test the hypothesis that baby diaper wipes with emollient cleansers and a soft cloth would minimize skin compromise relative to cloth and water.

METHODS

In 130 NICU infants (gestational age 23-41 weeks, at enrollment 30-51 weeks), measurements of skin condition, i.e., skin erythema, skin rash, transepidermal water loss (TEWL) and surface acidity (pH), within the diaper and at diaper and chest control sites were determined daily for 5-14 days using standardized methods. Treatments were randomly assigned based on gestational age and starting skin irritation score: wipe A, wipe B, and the current cloth and water NICU standard of care.

RESULTS

Perineal erythema and TEWL were significantly lower for wipes A and B than cloth and water beginning at day 5 for erythema (scores of 1.11 +/- 0.05, 1.2 +/- 0.05, and 1.4 +/- 0.06, respectively) and day 7 for TEWL (28.2 +/- 1.6, 28.8 +/- 1.6, and 35.2 +/- 1.6 g/m(2)/h, respectively). Wipe B produced a significantly lower skin pH (day 5, 5.47 +/- 0.03) than wipe A (5.71 +/- 0.03) and cloth and water (5.67 +/- 0.04). The starting skin condition, stool total, age and time on current standard impacted the outcomes.

CONCLUSIONS

Both wipes are appropriate for use on medically stable NICU patients, including both full and preterm infants, and provide more normalized skin condition and barrier function versus the cloth and water standard. Wipe B may facilitate acid mantle development and assist in colonization, infection control and barrier repair. Neonatal skin continues to change for up to 8 weeks postnatally, presumably as it adapts to the dry extra-uterine environment.

Host defense proteins on the surface of neonatal skin: implications for innate immunity

OBJECTIVES

To compare the spectrum, concentration, and activity of host defense proteins (HDPs) on the skin surface of newborns and adults, to assess variation in HDP concentrations in different anatomic regions in newborns, and to examine alteration in HDP concentrations with care practices.

STUDY DESIGN

Proteins recovered from tape discs applied to stratum corneum of 25 term newborns (forehead and posterior trunk) and 20 adults (forehead) were analyzed by Western analysis for 5 HDPs and for muramidase activity. Protein concentrations were compared in samples obtained after delivery, after the first bath, and at 24 hours of age.

RESULTS

Total protein was 2.8-fold higher in adults compared with newborns. Lysozyme and lactoferrin were detected in all samples. In contrast to total protein, lysozyme concentrations and muramidase activity were 5-fold higher in newborns relative to adults and were not altered after bathing. Lysozyme concentrations were significantly higher over the trunk compared with the forehead in newborns.

CONCLUSIONS

The newborn skin surface is replete with prototypical HDPs, lysozyme, and lactoferrin. Bathing does not significantly diminish concentrations. These factors are likely to contribute importantly to the newborn infants' defense against invasive bacterial infections.

DeoxyArbutin: a novel reversible tyrosinase inhibitor with effective in vivo skin lightening potency

Modulation of melanogenesis in the melanocytes can be achieved using chemicals that share structural homologies with the substrate tyrosine and as thus competitively inhibit the catalytic function of tyrosinase. We have developed a new tyrosinase inhibitor, deoxyArbutin (dA), based on this premise. DeoxyArbutin demonstrates effective inhibition of mushroom tyrosinase in vitro with a Ki that is 10-fold lower that hydroquinone (HQ) and 350-fold lower than arbutin. In a hairless, pigmented guinea pig model, dA demonstrated rapid and sustained skin lightening that was completely reversible within 8 weeks after halt in topical application. In contrast, HQ induced a short but unsustained skin lightening effect whereas kojic acid and arbutin exhibit no skin lightening effect. Results from a panel of safety tests supported the overall establishment of dA as an actionable molecule. In a human clinical trial, topical treatment of dA for 12 weeks resulted in a significant or slight reduction in overall skin lightness and improvement of solar lentigines in a population of light skin or dark skin individuals, respectively. These data demonstrate that dA has potential tyrosinase inhibitory activity that can result in skin lightening and may be used to ameliorate hyperpigmentary lesions.

Effect of semipermeable membranes on skin barrier repair following tape stripping

Reports in the literature suggest that the permeability of a wound dressing to water transport is an important variable in the healing of superficial wounds. Factors that influence skin hydration during barrier repair, therefore, are important in the optimization of wound treatments. In this study, the effects of semipermeable films on human skin following a standardized wound (tape stripping) were evaluated using measurements of transepidermal water loss (TEWL), skin hydration, rate of moisture accumulation, and erythema. Wounds treated with semipermeable films underwent more rapid barrier recovery than either unoccluded wounds or wounds under complete occlusion. Barrier films that produced intermediate levels of skin hydration during recovery produced the highest barrier repair rates. The results support the hypothesis; that semipermeable wound dressings augment barrier repair and skin quality by providing an optimized water vapor gradient during the wound healing process. The choice of wound dressing is discussed within the larger context of the design of vapor-permeable fabrics (smart materials) and the new fields of corneotherapy and comfort science.

The ability of electrical measurements to predict skin moisturization. I. Effects of NaCl and glycerin on short-term measurements

Non-invasive methods to evaluate skin hydration by measuring electrical properties are widely used in the cosmetic industry. However, there is still some controversy about factors that affect measurement. For example, concerns have often been expressed about the possible confounding effect of salts, either in the formulation or on the skin. Ionized salts on the skin may increase electrical conductivity and may lead to changes in electrical properties that are not related to increased water content. We have performed a systematic study of the effects of salt, i.e., sodium chloride, and glycerin on the electrical properties of skin as measured by the three most commonly used instruments, the Nova DPM 9003, the Corneometer CM 825, and the Skicon 200. Formulations containing salt from 0-3% and glycerin from 0-10% were tested for their effects at one and two hours after a single application. Salt lowered the readings in the absence of glycerin and increased the reading in the presence of glycerin. For all three instruments, there was a linear correlation between the measurement and the glycerin level in the presence or absence of salt.

The ability of electrical measurements to predict skin moisturization. II. Correlation between one-hour measurements and long-term results

We investigated the ability of short-term (one-hour) electrical measurements with three different commonly used instruments to predict the effects of long-term treatment with glycerin-containing formulations on moderately dry leg skin. We report the moisturizing effects of glycerin on healthy female adult skin in a two-week study as measured by electrical conductance and capacitance, transepidermal water loss (TEWL), and clinical grading of skin dryness. The test formulations contained 1.5% NaCl and levels of glycerin from 0% to 15%. Results obtained with a smaller cohort of ten subjects, one hour after treatment, were predictive of moisturizing efficacy in the two-week period among twenty subjects with dry leg skin. Our results show that single application tests can be predictive of longer-term results with humectant-based moisturizers and that electrical measurements of skin conditions correlate well with skin grades.

A controlled evaluation of dermabrasion versus CO2 laser resurfacing for the treatment of perioral wrinkles

Facial skin treatments with laser resurfacing, dermabrasion, and chemical peels were responsible for a significant portion of the 2.7 million cosmetic procedures performed in 1998. Perioral wrinkles are a common problem for which plastic surgical consultation is obtained. The aim of this study was to compare and quantify the advantages and disadvantages of laser resurfacing versus dermabrasion in the treatment of perioral wrinkles. Twenty female patients provided informed consent and participated in the study. Half of the perioral area was treated with dermabrasion and half was treated with the UltraPulse CO2 laser. The two procedures were compared using high-quality photographs; a biophysical evaluation of skin color, hydration, and mechanical properties; and patient evaluation of outcomes. Photographs were evaluated by 10 board-certified plastic surgeons who were blinded to the treatment methods. The laser treatment had a significantly higher erythema score at 1 month and a small but significantly greater improvement in perioral wrinkles at 6 months. Thirteen subjects selected the laser treatment as producing the best result, despite the greater intraoperative pain for this procedure. Biomechanical measurements suggest that the laser treatment produced a skin state more similar to skin in younger patients, presumably with higher levels and/or greater organization of the collagen and elastin. Patient preference was inferred from the resurfacing method that they would recommend to a friend. Although the laser was selected as the best result in a majority of cases, patient preference was equally distributed between the two treatments. The authors think that by studying and quantifying the biophysical changes that occur as a result of CO2 laser resurfacing, greater improvements in restoring actinic damage (e.g., wrinkles) can be achieved. Patients consider more than the objective skin changes from a resurfacing technique when making a recommendation to a friend.