Skin Blotting: A Noninvasive Technique for Evaluating Physiological Skin Status

Relationship Between Cytokines and Face Skin Symptoms in Newborns in Two Japanese Cities

AIM

Several skin disorder symptoms may appear in infants, each resulting from a different inflammatory response. In this study, we investigated the relationship between skin cytokine levels and skin symptoms in newborns.

METHODS

This cross-sectional study was conducted in Tokyo and Oita, two Japanese cities. The participants were healthy, 1-month-old infants and their parents. Symptoms including erythema, papules, dryness, and exudate/yellow scaling on infant faces were evaluated as outcomes. Cytokine levels (interleukin [IL]-4, IL-6, IL-8, and IL-17) were measured by skin blotting. A multilevel analysis using a mixed-effects model was conducted to account for regional differences.

RESULTS

A total of 231 infants (119 from Tokyo and 112 from Oita) participated in this study. Erythema, papules, dryness, and exudate/yellow scaling were present in 59 (25.5%), 133 (57.6%), 37 (16.0%), and 16 (6.9%) of the infants, respectively. In terms of the associations between symptoms and cytokines, there was a significant association between papules and IL-8 positivity (adjusted odds ratio [AOR]: 1.94, 95% confidence interval [CI] 1.09-3.47) even after adjustment for differences in barrier function, area, and skin care.

CONCLUSIONS

This study demonstrated that cytokines were linked to skin conditions, even after accounting for regional differences and genetic factors. This suggests that different symptoms point to the involvement of various cytokines in skin conditions in neonates, with mechanisms varying based on the symptoms. These findings could aid in developing specific preventive strategies in the future.

Comparison of the Effects of Bathing and the Dry Technique on the Skin Condition of Early Neonates: A Prospective Observational Study

BACKGROUND

In Japan, neonates have typically been bathed in a bathtub immediately after birth because bathing is a custom for cleansing impurities. However, dry technique has been introduced into many institutions since 2000. There is little scientific evidence on the benefit or harmfulness of either method to neonatal skin, and consequently, opinion remains split on which method is superior.

OBJECTIVE

The purpose of the present study was to determine whether bathing or the dry technique of cleaning is better in maintaining skin health in the early neonatal period.

METHODS

Transepidermal water loss (TEWL) and skin pH, considered an index of skin barrier function, were measured in each group. Tumor necrosis factor (TNF)-alpha and interleukin (IL)-6, which are inflammatory cytokines released by keratinocytes, were measured by skin blotting.

RESULTS

TEWL and skin pH of neonates were lower with the dry technique than with bathing. The expression level of IL-6 and TNF-α in chest skin of neonates was higher with bathing than with the dry technique.

CONCLUSION

These results suggest that the dry technique may maintain skin health better than bathing in the early neonatal period.

Development of a method to identify persistent and blanchable redness by skin blotting in mice

Persistent and blanchable redness (PBR) is not currently included in category I pressure injury (PI), which is defined as non-blanchable redness (NBR). However, PBR progresses to PI in a clinical setting. Therefore, it should be clinically managed as category I PI, and a method to distinctly identify PBR is needed. This study aimed to examine whether PI-related biomarkers can distinguish PRB from transient redness (TR) and NBR using skin blotting. TR, PBR, and NBR models were established by the different conditions of dorsal skin compression. Redness observation and skin blotting were performed, and the skin tissue samples were subjected to histological and molecular biological analyses. The vascular endothelial growth factor (Vegf) b, heat shock protein (Hsp) 90aa1, tumour necrosis factor, interleukin (Il) 1b, and Il6 messenger ribonucleic acid levels were significantly different between the three models. The VEGF-A, VEGF-B, IL-1β, and IL-6 protein levels were different between the three models. Although the results of skin blot examinations were inconsistent with those of the expression analysis of tissue, HSP90α and IL-1β are suggested to be potential markers to distinguish PBR from TR and NBR.

The Science of Skin: Measuring Damage and Assessing Risk

Significance: Healthy skin provides a barrier to contaminants. Breaches in skin integrity are often encountered in the patient health care journey, owing to intrinsic health issues or to various procedures and medical devices used. The time has come to move clinical practice beyond mere awareness of medical adhesive-related skin injury and toward improved care and outcomes. Recent Advances: Methods developed in research settings allow quantitative assessments of skin damage based on the measurement of baseline skin properties. These properties become altered by stress and over time. Assessment methods typically used by the cosmetic industry to compare product performance could offer new possibilities to improve clinical practice by providing better information on the status of patient skin. This review summarizes available skin assessment methods as well as specific patient risks for skin damage. Critical Issues: Patients in health care settings may be at risk for skin damage owing to predisposing medical conditions, health status, medications taken, and procedures or devices used in their treatment. Skin injuries come as an additional burden to these medical circumstances and could be prevented. Technology should be leveraged to improve care, help maintain patient skin health, and better characterize functional wound closure. Future Directions: Skin testing methods developed to evaluate cosmetic products or assess damage caused by occupational exposure can provide detailed, quantitative information on the integrity of skin. Such methods have the potential to guide prevention and treatment efforts to improve the care of patients suffering from skin integrity issues while in the health care system.

Relationship between facial skin problems with a focus on inflammatory cytokines and the presence of Malassezia in 1-month-old infants

Infantile skin problems not only cause temporary pain and discomfort, but also have a long-term impact on health. Hence, the purpose of this cross-sectional study was to clarify the relationship between inflammatory cytokines and Malassezia fungal facial skin problems in infants. Ninety-six 1-month-old infants were examined. Facial skin problems and the presence of inflammatory cytokines in the forehead skin were assessed using the infant facial skin visual assessment tool (IFSAT) and the skin blotting method, respectively. Malassezia, a fungal commensal, was detected using forehead skin swabs, and its percentage in the total fungal population was analyzed. Infants with positive interleukin-8 signals were more likely to have severe facial skin problems (p = 0.006) and forehead papules (p = 0.043). No significant association between IFSAT scores and Malassezia was found, but infants with forehead dryness had a lower percentage of M. arunalokei in the total fungal population (p = 0.006). No significant association was observed between inflammatory cytokines and Malassezia in the study participants. Longitudinal studies on the development of facial skin problems in infants are warranted to investigate the involvement of interleukin-8 and devise preventive strategies in the future.

Sampling the skin surface chemistry for diagnosis and prognosis

Skin and wound blotting are non‐invasive techniques used to sample the skin and wound surface chemistry, whereby a nitrocellulose membrane is applied to an intact or broken cutaneous surface to detect biomarkers. However, there has been no comprehensive review of the evidence for the techniques used and data obtained to date. The primary aim of this study was to review the utilities of surface blotting for the diagnosis and prognosis of physiological, pre‐disease, and pathological states. The secondary aim was to summarise the procedural steps. A systematic literature search was conducted on 9 July 2021 using Medline, Embase, and Google Scholar databases. Investigators used McMaster's Critical Review Form for Quantitative Studies to assess quality, then performed a narrative synthesis reporting according to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. Twenty‐five studies were reviewed. Eighteen studies were of good quality, and seven were of moderate quality. These studies conducted skin and wound blotting on 176 animals and 1546 humans. Studies reported physiological and pathological states for diagnosis and prediction of conditions, including skin tears, wound healing, biofilm detection, and skin barrier function. The four steps for blotting are surface preparation, blot preparation, application and removal of blot, and analysis. This review demonstrates that blotting can determine the skin and wound surface chemistry using a versatile and reproducible technique. However, future research is needed to validate the technique and skin biomarkers identified.

Identification of microRNAs responsive to shear loading in rat skin

Pressure injuries (PIs) are localised skin injuries that result from pressure with or without shear force. Shear force is more destructive than pressure in clinical settings. Therefore, determining the critical external forces is important for selecting the appropriate care to prevent PIs. To quantitatively distinguish pressure and shear loading with high specificity, we focused on microRNAs (miRs). This study aimed to identify the miRs that are distinguishable between pressure with and without shear loading in rat skin. Microarray analysis identified six candidate miRs from the comparisons among the pressure, shear, and unloaded groups. We analysed the expression levels of the candidate miRs in the process of PI development using real‐time reverse transcriptase polymerase chain reaction. In the pressure and shear groups, miR‐92b expressions at 6 hours after loading were 2.3 ± 1.3 and 2.9 ± 1.0, respectively, which were significantly higher than those in the control group (P = .014 and .004, respectively). miR‐877 expression at 6 hours after loading was significantly increased only in the shear group (2.8 ± 0.9) compared with the control group (P = .016). These results indicate that miR‐92b and miR‐877 are promising biomarkers to determine for which external force healthcare professionals should intervene.

The identification of biophysical parameters which reflect skin status following mechanical and chemical insults

BACKGROUND

Skin is constantly exposed to mechanical and chemical insults, in the form of prolonged loading, overhydration or exposure to irritants. An array of non-invasive biophysical tools has been adopted to monitor the changes in skin response. The present study aims to identify a set of robust parameters sensitive to mechanical and chemical challenges to skin integrity.

MATERIALS AND METHODS

Eleven healthy participants were recruited to evaluate the skin response following mechanical loading, tape stripping, overhydration and chemical irritation. Forearm skin responses were recorded at baseline and at three time points following the insult. Measurements included transepidermal water loss, sub-epidermal moisture, erythema and laser Doppler imaging. Thresholds were informed by basal values, and the sensitivity of parameters to detect skin changes was evaluated.

RESULTS

High degree of variability in skin response was observed with selected biophysical parameters, such as sub-epidermal moisture, laser Doppler imaging and erythema, even in the absence of an applied insult. Temporal skin response revealed distinct response profiles during each evoked insult. Indeed, the sensitivity of the biophysical parameters was influenced by the threshold values and time point of measurement. Some statistically significant correlations were determined between the biophysical parameters.

CONCLUSION

The study revealed that thresholds derived from single biophysical parameters were limited in detecting skin changes following insults. A complementary evaluation using combined parameters has the potential to provide a more sensitive assessment. Further research is required to identify robust biophysical parameters, to aid the early detection of skin damage in clinical settings.

Validity of skin blot examination for albumin and nerve growth factor β to detect itching of the skin in Indonesian older adults

AIM

Itching, a common skin disorder, impacts the quality of life of individuals. Itchy skin occurs more with increasing age and the prediction of itchy skin prognosis is necessary to provide good skincare. This study validated biomarkers in skin blotting to identify and measure itching sensation as well as conventional methods to measure skin barrier function.

MATERIALS AND METHODS

From a cross-sectional study conducted in Long-term Care (LTC) facilities in Indonesia itching symptoms were obtained through a questionnaire. Skin conditions were assessed using photographs, stratum corneum (SC) hydration, skin pH, and skin blotting for biomarkers: albumin, interleukin 2 (IL2), nerve growth factor β (NGFβ), and thymic stromal lymphopoietin (TSLP). Association of skin measurements with the presence of skin blotting and trends analysis were conducted.

RESULTS

Altogether, 564 LTC residents (average age, 70 years) participated. The SC hydration, skin pH, albumin, and NGFβ were associated with the presence of itch (p value= <0.001, <0.001, <0.001, and <0.001, respectively). The signal levels of skin blotting biomarkers were higher in itch group than in the non-itch group. Additionally, the higher quantile of SC hydration was significantly associated with a lower intensity level of NGFβ and TSLP (p value = 0.005, 0.003, respectively). The lower quantile of skin pH (better skin condition) was significantly associated with lower albumin, NGFβ, and TSLP (p value = 0.048, 0.035, and <0.001, respectively).

CONCLUSION

The albumin, NGFβ, and TSLP could be a candidate for measurement of itchy skin among older adult with disrupted skin barrier function and local skin inflammation.

Development of recurrent pressure ulcers, risk factors in older patients: a prospective observational study

Objective:

Prevention of recurrent pressure ulcers (PU) is one of the most important challenges in wound care, furthermore, the risk factors for recurrent PUs are still not fully understood. This study aimed to explore the risk factors for recurrent PU development within two weeks, including biophysical skin properties, pro-inflammatory cytokine (tumour necrosis factor [TNF]-α) levels and bacterial species, in older patients.

Method:

This prospective study was conducted in a long-term care facility with patients whose PU had healed within two months. Biophysical skin properties were evaluated by stratum corneum hydration, pH, sebum content and transepidermal water loss. TNF-α level was measured using skin blotting. Skin bacteria were collected using tape stripping and determined by species-specific gene amplification. These parameters, along with Braden scale and interface pressure, were evaluated every two weeks for a total period of eight weeks. A penalised generalised estimating equation analysis was used to determine the risk factors for recurrent PUs.

Results:

In total, 20 patients were included in this study, with 57 observations. Of these, recurrent PU was seen in eight observations. Elevation of pH (p=0.049; odds ratio [OR] per 1 unit=3.91, 95% confidence interval [CI]:1.01–15.15), presence of Acinetobacter spp. (p=0.039; OR versus culture-negative=6.28, 95%CI:1.10–35.86) and higher interface pressure (p=0.008; OR per 1 mmHg=1.06, 95%CI:1.01–1.10) on the healed PU were significantly related to the development of recurrent PU.

Conclusion:

Higher pH, existence of Acinetobacter spp. and higher interface pressure on the site of the healed PU were associated with the development of recurrent PUs in older patients undergoing conservative treatments.

The relationship between skin ultrasound images and muscle damage using skin blotting in wheelchair basketball athletes

STUDY DESIGN

Secondary analysis of a cross-sectional observation study.

OBJECTIVES

To determine the relationship between skin ultrasound images and muscle damage in wheelchair basketball athletes, using skin blotting examinations of the ischial regions.

SETTING

Community, Japan.

METHODS

Fourteen elite wheelchair basketball athletes were recruited. We obtained data regarding participants' characteristics. We undertook ultrasonographic images and quantitative skin blotting of the ischial region before and after training, and after rest.

RESULTS

We identified Category II and III pressure injuries in 2 of the 12 participants. Structural features were classified into four categories based on ultrasonographic features, namely, normal skin structure, unclear superficial and deep fascia, cloudy fat layer, and fat infiltration and low-echoic lesion/anechoic lesions. The muscle-type creatinine kinase (CK-M) level (median [interquartile range: IQR], 2.98 [2.80-3.47]) in the fat infiltration and low-echoic lesion/anechoic lesion group was significantly higher (1.43 [1.41-1.49]) than in a nonfat infiltration and low-echoic lesion/anechoic lesion group after training (p = 0.03). The interleukin-6 (IL-6) level (median [IQR], 23.5 [16.15-58.97]) in the fat infiltration and low-echoic lesion/anechoic lesion group was significantly higher (1.94 [1.74-4.44]) than in the nonfat infiltration and low-echoic lesion/anechoic lesion group after rest (mean difference = -25.4, 95% CI -61.1 to 10.7, p = 0.03).

CONCLUSIONS

The combination of ultrasonographic images and skin blotting using CK-M and IL-6, could detect early deep tissue damage in wheelchair athletes. These techniques could be potentially useful in the treatment and prevention of pressure injuries.

SPONSORSHIP

This study was supported in part by YAMAHA Motor Foundation for Sports.

Models for predicting skin tears: A comparison

A recently published model that predicted the risk of skin tears in older adults was compared with seven additional published models. Four models were excluded because of limitations in research design. Four models were compared for their relative predictive performance and accuracy using sensitivity, specificity, and the area under the curve (AUC), which involved using receiver-operating characteristic analysis. The predictive ability of the skin tear models differed with the AUC ranging between 0.673 and 0.854. Based on the predictive ability, the selection of models could lead to different clinical decisions and health outcomes. The model, which had been adjusted for potential confounders consisted of five variables (male gender, history of skin tears, history of falls, clinical skin manifestations of elastosis, and purpura), was found to be the most parsimonious for predicting skin tears in older adults (AUC 0.854; 81.7% sensitivity; 81.4% specificity). Effective models serve as important clinical tools for identifying older individuals at risk of skin tears and can better direct more timely and targeted prevention strategies that improve health outcomes and reduce health care expenditure.

Clinical purpura and elastosis and their correlation with skin tears in an aged population

The previous research reported the results of a prospect cohort study that used logistic regression analysis to construct a risk prediction model for skin tears in individuals aged over 65 years. The model identified three baseline individual characteristics (male gender, history of STs, and history of falls) and two baseline skin manifestations (purpura and elastosis) that predicted the risk of dorsal forearm skin tears. This paper outlines the relationships between baseline skin manifestations and the risk of skin tears. Univariable logistic regression analysis was conducted of all the baseline data collected from the same-study participants to identify variables that significantly predicted purpura and elastosis at baseline. Amongst the 173 participants, 71 (41%) developed one or more skin tears, and in these participants, 52 (73.2%) displayed purpura, 41 (57.8%) had elastosis, and 30 (42.3%) exhibited both manifestations of the dorsal forearm at baseline. Four individual characteristics (age, history of skin tears, history of falls, and antiplatelet therapy) and three skin properties (pH, subepidermal low echogenicity band of the forearms, and skin thickness) were found to predict the risk of purpura. Conversely, three individual variables (age, gender, and smoking), three clinical skin variables (uneven skin pigmentation, cutis rhomboidalis nuchae, and history of actinic keratosis) and one skin property variable (collagen type IV) predicted the risk of skin elastosis. Progressive changes to the skin's structural and mechanical properties from the underlying effects of chronological ageing, and environmental and lifestyle-related influences increased the risk of purpura and elastotic skin manifestations and concomitantly increased risk of skin tears amongst participants.

A risk model for the prediction of skin tears in aged care residents: A prospective cohort study

The objective of this study was to construct a predictive model to identify aged care residents at risk of future skin tears. Extensive data about individual characteristics, skin characteristics, and skin properties were gathered from 173 participants at baseline and at 6 months. A predictive model, developed using multivariable logistic regression, identified five variables that significantly predicted the risk of skin tear at 6 months. These included: a history of skin tears in the previous 12 months (OR 3.82 [1.64-8.90], P = 0.002), purpura ≤20 mm in size (OR 3.64 [1.42-9.35], P = 0.007), a history of falls in the previous 3 months (OR 3.37 [1.54-7.41], P = 0.002), clinical manifestations of elastosis (OR 3.19 [1.38-7.38], P = 0.007), and male gender (OR 3.08 [1.22-7.77], P = 0.017). The predictive model yielded an area under the receiver operating characteristic curve of 0.854 with an 81.7% sensitivity and an 81.4% specificity. This predictive model could inform a simple but promising bedside tool for identifying older individuals at risk of skin tears.

Reliability of the skin blotting method when used on the elderly

The aim of this study was to compare protein secretion on intact skin of extremities and verify the relationship between the marker proteins on abdominal skin and systemic factors using skin blotting. A cross-sectional study was conducted among elderly patients aged 65 years and older (N = 73) at a long-term medical facility in Japan. Skin blotting was performed on the right and left forearms, right and left lower legs, and abdomen. Pearson's correlations and Bland-Altman plots were utilised for comparing the protein secretion from the skin between the right or left forearms or lower legs. Multiple regression analysis was applied to determine the relationship between intensity levels of 3 proteins on the abdominal skin and the systemic factors. Bland-Altman plots demonstrated that there was no significant difference between right and left secretion levels on the forearms and lower legs among 3 proteins. Multiple regression analysis showed that age and antiplatelet use was positively associated with decreased collagen type IV and increased matrix metalloproteinase 2 levels, respectively. Our findings suggested that collecting samples from either the right or the left skin would be sufficient if skin properties between arms and legs are evaluated using skin blotting.

Probing Skin for Metabolites and Topical Drugs with Hydrogel Micropatches

Sampling the skin surface is a convenient way to obtain biological specimens bearing clinically relevant information. Hydrogel micropatches enable noninvasive collection of skin excretion specimens, which can subsequently be subjected to rapid mass spectrometric analysis providing insights into the skin metabolome.

Skin property can predict the development of skin tears among elderly patients: a prospective cohort study

The aim of this study was to identify skin properties that may be used to predict the development of a skin tear (ST) among elderly patients. A prospective cohort study was conducted among elderly patients aged 65 and older (N = 149) at a long-term medical facility in Japan over an 8-month period. Skin properties at baseline were measured on the forearm using a 20-MHz ultrasound scanner, which measured the thickness of the dermis layer and low-echogenic pixels, and skin blotting method, which evaluated the levels of collagen type IV, matrix metalloproteinase-2 and tumour necrosis factor-alpha. Adjusted hazard ratios (HRs) for the main confounders were obtained using the Cox proportional hazard model. A total of 52 STs were recorded among the 21 patients, resulting in an incidence rate of 1·13/1000 person-days. The predictor of STs was dermis thickness (HR = 0·52; 95% confidence interval = 0·33-0·81; P-value = 0·004). The cut-off point for dermis thickness was 0·80 mm (area under the curve = 0·77; 95% confidence interval = 0·66-0·88; P-value = 0·006). Our results suggest that measuring the dermis thickness at baseline is an easy and accurate way to identify a high-risk patient.

Exploring the prevalence of skin tears and skin properties related to skin tears in elderly patients at a long-term medical facility in Japan

The identification of appropriate skin tear prevention guidelines for the elderly requires clinicians to focus on local risk factors such as structural alterations of the epidermis and dermis related to skin tears. The aim of this cross-sectional study is to explore the prevalence of skin tears and to explore skin properties related to skin tears in elderly Japanese patients at a long-term medical facility. After doing the prevalence study, 18 participants with skin tears and 18 without were recruited and an evaluation of their skin properties using 20-MHz ultrasonography, skin blotting and also Corneometer CM-825, Skin-pH-meterPH905, VapoMeter, Moisture Meter-D and CutometerMPA580 was undertaken. A total of 410 patients were examined, the median age was 87 years and 73·2% were women. The prevalence of skin tears was 3·9%, and 50% of skin tears occurred on the dorsal forearm. The changes in skin properties associated with skin tears included increased low-echogenic pixels (LEP) by 20-MHz ultrasonography, decreased type IV collagen and matrix metalloproteinase-2, and increased tumour necrosis factor-α by skin blotting. In conclusion, this study suggests that increased dermal LEP, including solar elastosis, may represent a risk factor for skin tears; this indicates that skin tear risk factors might not only represent chronological ageing but also photoageing.

Hypo-osmotic shock-induced subclinical inflammation of skin in a rat model of disrupted skin barrier function

Aging disrupts skin barrier function and induces xerosis accompanied by pruritus. In many cases, elderly patients complain of pruritus during skin hygiene care, a condition called aquagenic pruritus of the elderly (APE). To date, the pathophysiology and mechanism of action of APE have not been elucidated. We conducted the present study to test the hypothesis that hypo-osmotic shock of epidermal cells induces skin inflammation and elongation of C-fibers by nerve growth factor β (NGFβ) as a basic mechanism of APE. The dorsal skin of HWY rats, which are a model for disrupted skin barrier function, was treated with distilled water (hypotonic treatment [Hypo] group) or normal saline (isotonic treatment [Iso] group) by applying soaked gauze for 7 days. Untreated rats were used as a control (no-treatment [NT] group). Histochemical and immunohistochemical analyses revealed inflammatory responses in the epidermis and the dermal papillary layer in the Hypo group, while no alterations were observed in the Iso or NT groups. Induction of expression and secretion of NGFβ and elongation of C-fibers into the epidermis were found in the Hypo group. In contrast, secretion of NGFβ was significantly lower and elongation of C-fibers was not observed in the Iso group. These results suggest that hypo-osmotic shock-induced inflammatory reactions promote hypersensitivity to pruritus in skin with disrupted barrier function.