Investigating the release of inflammatory cytokines in a human model of incontinence-associated dermatitis

Silicone dressing combined with topical oxygen therapy alleviates incontinence-associated dermatitis via NF-κB p65/STAT1 signaling pathway

BACKGROUND

Incontinence-associated dermatitis (IAD) is a tough problem in clinical settings, not only increasing the risk of complications like catheter-related urinary tract infections and pressure ulcers in elderly and critically ill patients, but also prolonging hospital stays, raising hospital costs, and possibly leading to medical disputes. This study is aimed to evaluate the therapeutic effect of silicone dressing combined with topical oxygen therapy on IAD in a rat model.

METHODS

An IAD rat model induced by synthetic urine with trypsin was established. Hematoxylin & eosin staining was carried out to examine skin histology. Using immunofluorescence, the microvessel density in the affected skin tissues was determined. ELISA was performed to measure the concentrations of inflammatory cytokines and angiogenic factors in serum. The mRNA expression of EGF, PDGF, and VEGF was detected via qRT-PCR. Western blotting was employed to determine NF-κB p65/STAT1 pathway-related protein levels.

RESULTS

Compared to single therapy, silicone dressing combined with topical oxygen therapy could significantly reduce the severity of IAD, improve skin histology, inhibit inflammation, and promote angiogenesis in IAD rat models. Additionally, the results showed that relatively speaking, the combined therapy suppressed the NF-κB p65/STAT1 signaling pathway more effectively.

CONCLUSION

These findings indicated that silicone dressing combined with topical oxygen therapy can alleviate IAD through promoting wound healing and inhibiting inflammation via NF-κB p65/STAT1 signaling pathway in a rat model, which provided a theoretical basis for the prevention and treatment of IAD in clinic.

Detecting and monitoring incontinence associated dermatitis: Does impedance spectroscopy have a part to play?

In this review, current understanding of the prevention and treatment of Incontinence Associated Dermatitis (IAD) is discussed. The need for preventative measures which target specific faecal/urinary irritants is highlighted, including the role of urease inhibitors. There is no existing internationally and clinically accepted method to diagnose and categorise the severity of IAD. Diagnosis currently relies on visual inspection; non-invasive techniques to assess skin barrier function could remove subjectiveness, particularly in darker skin tones. Impedance spectroscopy is a non-invasive technique which can be used to monitor skin barrier function, supporting visual assessments. Six studies (2003-2021) which used impedance to assess dermatitis were reviewed; inflamed skin was distinguishable from healthy skin in each case. This suggests that impedance spectroscopy could be useful in diagnosis early-stage IAD, potentially enabling earlier intervention. Finally, the authors present their initial findings on the role of urease in skin breakdown in an in vivo IAD model, using impedance spectroscopy.

The multi-factorial modes of action of urease in the pathogenesis of incontinence associated dermatitis

Background

Incontinence Associated Dermatitis (IAD) is a type of skin inflammation caused by chronic exposure to urine and/or faeces. Current treatment strategies involve creating a barrier between the skin and urine/faeces rather than targeting specific irritants. Urease expressing pathogens catalyse the conversion of urea, present in urine, into ammonia. The accumulation of ammonia causes an elevation in skin pH which is believed to activate faecal enzymes which damage skin, and opportunistic pathogens, which lead to secondary infections.

Objectives

To develop a better, multi-factorial model of IAD pathogenesis, including the effect of urease-expressing bacteria on skin, mechanism of damage of urease and urease-triggered activity of faecal enzymes and secondary pathogens. To study the effect of urease inhibition on preventing IAD skin damage.

Methods

Five separate studies were made using ex vivo porcine skin and in vivo human skin models. Measurements of the change in skin barrier function were made using skin impedance, trans-epidermal water loss (TEWL), stratum corneum moisture and pH. Skin was exposed to artificial urine, inoculated with various microbes, enzymes and chemicals to examine the influence of: 1) urease-positive Proteus mirabilis 2) ammonia, 3) combination of P. mirabilis and a faecal enzyme, trypsin, 4) combination of P. mirabilis and opportunistic pathogens, Candida albicans and Staphylococcus aureus, 5) inhibition of urease using acetohydroxamic acid (AHA) on barrier function.

Results

The urease-mediated production of ammonia had two principal effects: it elevated skin pH and caused inflammation, leading to significant breakdown in skin (stratum corneum) barrier function. Urease was found to further increase the activity of faecal enzymes and opportunistic pathogens, due to elevated skin pH. The urease inhibitor, AHA, was shown to have significantly reduced damage to skin barrier function, measured as its electrical resistance.

Conclusions

Targeted therapeutic strategies should be developed to prevent the manifestation of IAD, rather than creating a generic barrier between skin and urine/faeces. Urease has been identified as a crucial component in the manifestation of IAD, due to its role in the production of ammonia. Urease inhibition provides a promising therapeutic target to halt the progression of IAD.

Testing the effectiveness of a polymeric membrane dressing in modulating the inflammation of intact, non-injured, mechanically irritated skin

We investigated the inflammatory (IL-1 alpha) and thermal (infrared thermography) reactions of healthy sacral skin to sustained, irritating mechanical loading. We further acquired digital photographs of the irritated skin (at the visible light domain) to assess whether infrared imaging is advantageous. For clinical context, the skin status was monitored under a polymeric membrane dressing known to modulate the inflammatory skin response. The IL-1 alpha and infrared thermography measurements were consistent in representing the skin status after 40 min of continuous irritation. Infrared thermography overpowered conventional digital photography as a contactless optical method for image processing inputs, by revealing skin irritation trends that were undetectable through digital photography in the visual light, not even with the aid of advanced image processing. The polymeric membrane dressings were shown to offer prophylactic benefits over simple polyurethane foam in the aspects of inflammation reduction and microclimate management. We also concluded that infrared thermography is a feasible method for monitoring the skin health status and the risk for pressure ulcers, as it avoids the complexity of biological marker studies and empowers visual skin assessments or digital photography of skin, both of which were shown to be insufficient for detecting the inflammatory skin status.

Humidity-Sensing Mattress for Long-Term Bedridden Patients with Incontinence-Associated Dermatitis

Designing new medical devices with advanced humidity sensors is of great significance for patients with incontinence-associated dermatitis (IAD). The primary goal of this study is to test the humidity-sensing mattress system for patients with IAD in clinical settings. The design of the mattress is set at 203 cm, with 10 × 3 sensors, dimensions of 19 × 32 cm, and a weighted bearing of 200 kg. The main sensors consist of a humidity-sensing film, a thin-film electrode (6 × 0.1 mm), and a glass substrate (500 nm). The sensitivity of the test mattress system showed that the resistance-humidity sensor was at a temperature of 35 °C (V0 = 30 V, V0 = 350 mV), with slope at 1.13 V/fF, f = 1 MHz, 20-90% RH, and a response time of 20 s at 2 μm. In addition, the humidity sensor reached 90% RH, with a response time of less than 10 s, a magnitude of 107-104 Ω, 1 mol%, CrO1.5, and FO1.5, respectively. This design is not only a simple, low-cost medical sensing device, but also opens a new pathway for developing humidity-sensing mattresses in the field of flexible sensors, wearable medical diagnostic devices, and health detection.

Altered mRNA Expression of NFKB1 and NFKB2 Genes in Penile Lichen Sclerosus, Penile Cancer and Zoon Balanitis

BACKGROUND

The nuclear factor-κB transcription factors 1 and 2 (NFKB1 and NFKB2) are key components of the NF-κB pathway, which responds to inflammatory signals. Since the NFKB1/2 factors are activated via different inflammatory molecules, we aimed to check their expression levels in penile cancer (PC), penile dermatoses: lichen sclerosus (PLS) and zoon balanitis (ZB).

METHODS

Skin biopsies from altered and healthy looking foreskin were obtained from 59 (49 LS; early PLS: 13, moderate PLS: 32, severe PLS: 4; 6 PC; 4 ZB) and unchanged foreskin from 13 healthy control adult males undergoing circumcision. NFKB1/2 mRNA levels were quantified by qPCR.

RESULTS

The highest levels of NFKB1 and NFKB2 were observed in PC, ca. 22 and 3.5 times higher than in control, respectively. NFKB1 expression was correlated with PLS progression (rs = 0.667) and was ca. 20 times higher in advanced PLS than in controls and early PLS. Occurrence of micro-incontinence was associated with elevated NFKB1 levels in PLS.

CONCLUSION

This is the first study regarding gene profiles of NFKB1/2 in PC and penile dermatoses. New drugs targeting modulation of canonical-activated NF-κB pathway should be studied and introduced to the treatment of PLS and PC apart from other treatments.

Bacterial invasion into the epidermis of rats with sodium lauryl sulphate-irritated skin increases damage and induces incontinence-associated dermatitis

Incontinence-associated dermatitis (IAD) is caused by prolonged exposure to urine/liquid stool. It is a common and often painful skin condition in older incontinent adults because of poor prevention. Patients with urinary infections are at risk of developing IAD, and to guide the development of novel prevention strategies, we aimed to develop an animal model of IAD by urine and bacteria. First, contralateral sites on the dorsal skin of Sprague-Dawley rats were compromised by sodium lauryl sulphate (SLS), simulating frequent cleansing with soap/water. Filter discs were then placed inside ring-shaped chambers on foam dressings, inoculated with or without Pseudomonas aeruginosa, covered with agarose gels immersed in cultured filtrated urine, and secured in place with an occlusive dressing for 3 days. Untreated and SLS-compromised sites served as controls. The IAD was developed at bacteria-inoculated sites, characterised by severe IAD-like redness that persisted for up to 3 days post-exposure and higher disruption of the skin barrier function compared with non-inoculated sites. Pathological changes included epidermal thickening, partial skin loss, inflammatory cell infiltration, accumulation of red blood cells, and invasion of bacteria into the epidermis. This novel, clinically relevant IAD rat model can serve for future prevention developments.

Moisture-Associated Skin Damage: Expanding and Updating Practice Based on the Newest ICD-10-CM Codes

Moisture-associated skin damage (MASD) occurs when skin is repeatedly exposed to various sources of bodily secretions or effluents, often leading to irritant contact dermatitis with inflammation, with or without denudation of affected skin. In 2020, the Wound, Ostomy and Continence Nurses Society took an initiative that led to the addition of multiple International Classification for Diseases codes for irritant contract dermatitis caused by various forms of MASD for use in the United States (ICD-10-CM). In the last issue of the Journal of Wound, Ostomy and Continence Nursing, a clinical practice alert identifying the various new codes was published that summarized each of the new codes and provided highlights of the descriptions of each of the these codes. This is the first in a series of 2 articles providing a more detailed description of the newest irritant contact dermatitis codes linked to MASD. Specifically, this article reviews the clinical manifestations and assessment, pathophysiology, epidemiology, prevention, and management of irritant contact dermatitis due to saliva, respiratory secretions, and fecal or urinary incontinence.

An exploratory study of the effects of the pH of synthetic urine on skin integrity in healthy participants

Background: Incontinence-associated dermatitis (IAD) develops from prolonged exposure of skin to urine and/or stool and represents a common complication in older adults, reducing the quality of life. Increased pH is an important etiologic factor of IAD, however, the relationship between urinary pH and skin barrier disruption remains unclear. Objective: To examine the effects of synthetic urine (s-urine) at various pH on transepidermal water loss (TEWL), stratum corneum hydration (SCH) and skin surface pH. Methods: S-urine solutions (pH 5.0-9.0) were applied to the volar forearms of 15 healthy participants for 2 hrs, with another site serving as the untreated control. Measurements of TEWL, SCH and skin surface pH were obtained at baseline and after each challenge. Skin buffering capacity was also examined in 5 volunteers by recording skin pH at baseline, after 2 hrs exposure and every 5 mins for 40 mins. Results: TEWL and SCH were increased following exposure to s-urine compared to baseline values. Although there was tendency for pH to an increase after exposure, further investigation showed that changes are only temporal as pH value is restored to baseline within 5 mins. There were no significant differences between solutions. Conclusions: This study revealed that urine disrupts healthy skin integrity; however, its effects are not pH dependent. Transient changes were observed on the acid mantle of the skin due to its innate buffering capacity. Future studies need to examine the effects of urine combined with bacteria responsible for pH elevation in patients with urinary incontinence.