Effect of water on experimentally irritated human skin

Impact of Water Exposure and Temperature Changes on Skin Barrier Function

The frequency of hand hygiene has increased due to the COVID-19 pandemic, but there is little evidence regarding the impact of water exposure and temperature on skin. The aim of this study is to evaluate the effect of water exposure and temperature on skin barrier function in healthy individuals. A prospective observational study was conducted. Temperature, pH, transepidermal water loss (TEWL), erythema and stratum corneum hydration (SCH) were measured objectively before and after hot- and cold-water exposure and TempTest® (Microcaya TempTest, Bilbao, Spain) contact. Fifty healthy volunteers were enrolled. Hot-water exposure increased TEWL (25.75 vs. 58.58 g·h^-1·m^-2), pH (6.33 vs. 6.65) and erythema (249.45 vs. 286.34 AU). Cold-water immersion increased TEWL (25.75 vs. 34.96 g·h^-1·m^-2) and pH (6.33 vs. 6.62). TEWL (7.99 vs. 9.98 g·h^-1·m^-2) and erythema (209.07 vs. 227.79 AU) increased after being in contact with the hot region (44 °C) of the TempTest. No significant differences were found after contact with the cold region (4 °C) of the TempTest. In conclusion, long and continuous water exposure damages skin barrier function, with hot water being even more harmful. It would be advisable to use cold or lukewarm water for handwashing and avoid hot water. Knowing the proper temperature for hand washing might be an important measure to prevent flares in patients with previous inflammatory skin diseases on their hands.

Skin cleansing and emolliating for older people: A quasi-experimental pilot study

AIMS

The aims of this study were to (i) assess the effect of low-cost hygiene and emollient regimens on the skin barrier function (SBF) of people aged >65 year with xerosis (dry skin) on their lower legs; (ii) to assess the utility of portable measures of skin barrier function in terms of stratum corneum hydration (SCH) and transepidermal water loss (TEWL) in community settings; and iii) to provide evidence for a randomised controlled trial on the treatment of adults in a resource-poor country with dry skin on their lower legs which causes and exacerbates the skin disease podoconiosis (non-filarial elephantiasis).

BACKGROUND

Age increases the risk of impaired skin barrier function which can precipitate skin breakdown. Older skin is frequently characterised by troublesome xerosis and pruritus (itching). Hygiene and emollient practices are central to maintaining skin integrity but are currently under-researched.

METHOD

A quasi-experimental pilot study of five combinations of cleansing and emollient interventions was applied to the xerotic lower legs of ten participants with no skin disease for five consecutive days. Stratum corneum hydration and transepidermal water loss were measured at baseline and day six. Products were chosen because of effectiveness, low cost and availability in a poor-resource country.

RESULTS

The greatest difference in transepidermal water loss pre-intervention-postintervention was indicated by the regimen of soapy water, 2% glycerine soak and Vaseline^™ (mean 1.14, SD 1.27). This regimen also indicated the greatest difference in stratum corneum hydration (mean 7.92, SD 3.93). The improvement in stratum corneum hydration was significantly greater than for the control (p = .011), soap (p = .050) or water soak (p = .011).

CONCLUSION

A regimen of washing skin with soapy water, soaking in 2% glycerine for 30 min and applying Vaseline^™ has a beneficial effect on the skin barrier function in older people. The study supports previous findings on the positive effects of glycerine on skin barrier function.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Skin barrier function in older people can be improved using a regimen of washing, soaking in 2% glycerine and applying Vaseline^™ .

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.

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.

Is skin exposure to water mainly occupational or nonoccupational? A population-based study

BACKGROUND

Skin exposure to water is considered to contribute to hand eczema. Knowledge about total water exposure during a day is scanty.

OBJECTIVES

To investigate self-reported water exposure at work as well as throughout the day.

METHODS

Skin exposure to water was assessed from two questionnaire-based health surveys: the nationwide Environmental Health Survey 2007 (EHS), which enquired about water exposure throughout the day, and the Stockholm Public Health Survey 2006 (PHS), which probed water exposure at work. Answers from 19,667 individuals (EHS) and 18,318 individuals (PHS) were available for analysis.

RESULTS

In total, 22% of respondents (women 30%, men 12%) reported skin exposure to water more than 20 times during an entire day (EHS) compared with 6% (women 8%, men 4%) at work (PHS). In a univariate analysis, using a merged file comprising data from the EHS and the PHS, water exposure more than 20 times a day was more common in the EHS (prevalence proportion ratio 3·570, 95% confidence interval 3·353-3·802). In multivariate models the variables studied did not fulfil the criteria for being confounders. Water exposure at work declined with increasing age in both women and men (P < 0·0001) as did water exposure during the entire day in men (P < 0·0001). However, women were equally exposed during the entire day across age groups (P = 0·205).

CONCLUSIONS

High water exposure over the entire day was found to be considerably more frequent than exposure at work. Thus, a significant proportion of water exposure seems to occur outside work. This should be considered in prevention of hand eczema and when counselling patients with hand eczema in clinical practice.

Interactions between domestic water hardness, infant swimming and atopy in the development of childhood eczema

AIM

Recent studies suggest that domestic water hardness and swimming in chlorinated pools may increase the prevalence of childhood eczema. The combined influence of these two factors as well as their interaction with atopic status has not been investigated.

METHODS

We conducted a cross-sectional study on 358 children aged 5-6 years (54% of boys) in 30 kindergarten schools. Parents completed a questionnaire about the child's health, chlorinated pool attendance and potential confounders. Data about tap water quality were provided by water companies. Atopy was defined as a sensitization to at least one aeroallergen or as a medication for allergy. The effect of water hardness and infant swimming practice were assessed by multivariate logistic models. In addition, the effects of these risk factors combined with atopy were evaluated using two measures of biological interaction: the attributable proportion of interaction (AP) and the synergy index (S). AP>0 and S>1 indicate biological interaction between the two risk factors.

RESULTS

Water hardness was linearly associated to the prevalence of eczema whereas the relationship of eczema with infant swimming was not linear. We observed a biological interaction between hard water (>150 mg/L CaCO(3)L(-1)) and atopic status that increases the prevalence of eczema with an odds ratio (OR) of 3.30 and a 95% confidence interval (CI) of 1.34-8.15 (AP, 0.41; 95% CI 0.15-0.66 and S, 2.4; 95% CI 0.96-6.01). Infant swimming practice combined with atopy also increased the prevalence of eczema (OR, 2.72; 95% CI 1.29-5.74) although none of the interaction measures was significant. However, when water hardness and infant swimming were combined, there was no further increase of the eczema prevalence due to some form of antagonistic interaction between these two factors (AP, -0.56; 95% CI -1.12 to -0.01 and S, 0.54; 95% CI 0.33-0.87).

CONCLUSIONS

Our study shows that exposure to hard water and infant swimming interact with atopic status to increase the prevalence of childhood eczema. A breaching of the epidermal barrier by detergents or salts in hard water and by chlorine-based oxidants in swimming pool water might explain these interactions.

Amputee skin condition: occlusion, stratum corneum hydration and free amino acid levels

Patients with a prosthetic limb report negative skin effects, including irritation, rash and chafing, which can lead to infection, discomfort and reduced wear time to significantly impact normal activities. The aims were to examine the epidermal integrity (transepidermal water loss, TEWL), stratum corneum (SC) hydration [moisture accumulation rate (MAT)], friction and biomechanical properties in active below the knee amputees and to determine the effects of an inert sock liner on skin condition. The liner reduced hydration, TEWL and friction and increased elasticity versus the amputee's conventional skin care methods. Residual limb TEWL was increased and MAT was reduced versus the contralateral normal skin. In a second study, we hypothesized that complete occlusion would decrease free amino acids (FAA) and quantified them by high performance liquid chromatography in an adult volar forearm model. Occlusion with a water vapor impermeable wet dressing led to increased TEWL, erythema and dryness and reduced MAT versus normal skin, comparable to the results in the amputees. The FAA levels were significantly reduced for the occluded sites. The results suggest that residual limb occlusion in amputees may block the formation of FAA in the upper SC. Therapies based on replacement of water binding FAAs, may alleviate the consequences of long-term occlusion.

Effect of chlorhexidine gluconate on the skin integrity at PICC line sites

OBJECTIVE

To determine the effects of chlorhexidine gluconate (CHG) on skin inflammation and stratum corneum barrier integrity at peripherally inserted central catheter (PICC) sites among patients in the neonatal intensive care setting.

STUDY DESIGN

In a within-subject design, PICC sites with CHG plus semipermeable dressing (PICC) were compared with contralateral dressing sites and untreated controls among 40 neonates (gestational age 32.1+/-4.7) at weekly dressing changes, using quantitative measures of skin erythema, dryness and barrier integrity (transepidermal water loss, TEWL). Data were analyzed using analysis of variance and linear mixed methods.

RESULTS

At week 1, all three sites differed for erythema with the highest value indicating poorer skin condition at the PICC site. Dressing-site erythema was higher than the untreated control. Dryness and TEWL were higher, indicating poorer skin integrity, for the PICC site than either the dressing or the control. After 2 weeks, erythema and dryness scores were higher for the PICC site than the dressing and control skin. By week 3, scores were comparable for PICC and dressing sites and both were higher than the control for erythema and dryness. After 3 weeks, PICC skin TEWL was higher than both dressing and control and they did not differ from each other.

CONCLUSION

The dressings used to secure PICC lines contribute to the observed skin compromise at CHG-treated skin sites and may affect skin barrier development in similar populations of neonates.

Drying stress and damage processes in human stratum corneum

SYNOPSIS

The drying stresses that develop in stratum corneum (SC) are crucial for its mechanical and biophysical function, its cosmetic feel and appearance, and play a central role in processes of dry skin damage. However, quantitative methods to characterize these stresses are lacking and little understanding exists regarding the effects of drying environment, chemical exposures and moisturizing treatments. We describe the application of a substrate curvature technique adapted for biological tissue to accurately characterize SC drying stresses as a function of time following environmental pre-conditioning and chemical treatment in a range of drying environments. SC stresses were observed to increase to stress levels of up to approximately 3 MPa over periods of 8 h depending on pretreatment and drying environment. A unique relationship between the SC stress and water in the drying environment was established. The effect of glycerol on lowering SC stresses and damaging surfactants on elevating SC stresses were quantified. Extensions of the method to continuous monitoring of SC stresses in response to changes in environmental moisture content and temperature are reported. Finally, a biomechanics framework to account for the SC drying stress as a mechanical driving force for dry skin damage is presented.

Recent advances in diaper dermatitis: etiology and treatment

Diaper dermatitis is a highly prevalent condition that causes discomfort and stress for patients and frustration for healthcare staff. Diaper technology has evolved to substantially lessen the severity of diaper dermatitis, but additional improvements are needed. Premature infants and incontinent adults are particularly at risk for developing diaper dermatitis and its potential consequences. Contributing factors include overhydration, irritants, friction, increased skin pH, diet, gestational age, antibiotic use, diarrhea and medical condition. Treatments aim to reduce hydration, provide a semipermeable ‘layer’ to facilitate skin barrier repair, shield the skin from irritants, deactivate specific fecal components and maintain skin surface contact. The published research on the effects of diaper dermatitis treatments is especially sparse. Controlled clinical trials are needed to provide definitive evidence for selection of effective treatments. This article discusses the incidence and etiology of diaper dermatitis in infants and adults. It provides the scientific basis for repair of diaper skin barrier damage and describes recent developments that will be available in the future.

The effect of physical and chemical properties of swimming pool water and its close environment on the development of contact dermatitis in hydrotherapists

BACKGROUND

The association between physical and chemical parameters in swimming pool water and the incidence of contact dermatitis (CD) in hydrotherapists was studied.

METHODS

Chemical and physical parameters characterizing the water and air environment of swimming pools conducting hydrotherapy program were recorded. Differences between the values of these parameters associated with affected and non-affected hydrotherapists employed in 39 pools were tested statistically.

RESULTS

No significant difference was found between the means of each of the physical and chemical parameters associated with the affected and the non-affected group of hydrotherapists. The prevalence ratio of the incidence of CD in pools chlorinated by gaseous chlorine was significantly higher than that in pools disinfected by other forms of chlorine compounds (PR = 1.49, CI = 1.17-1.89, P = 0.017).

CONCLUSIONS

Dosing the water with larger amounts of gaseous chlorine compared to other disinfectants and a subsequent temporary decrease in the pH of the water may produce a more aggressive environment. It is suggested that combined effect of the various factors concomitantly with the irritating effect of prolonged exposure to water may trigger CD in pools treated with other chlorine-based compounds.

Self-reported skin disease in hydrotherapists working in swimming pools

The aim of our study was to investigate the risk and characteristics of self-reported skin diseases among hydrotherapists. We attempted to contact 400 adults who participated in 1 of 2 training courses. 248 were reached and 190 of them (76.6%) completed the questionnaires. The data were collected by means of a telephone interview and a detailed questionnaire sent by mail. Statistical analysis included descriptive statistics, univariate and multifactorial analysis. Of those completing the questionnaire (75.8% females and 24.2% males), 44.4% of the hydrotherapists reported on the development of skin disease for the first time after the beginning of work at the swimming pool. The most common symptoms included pruritus and erythematous patches affecting mainly the extremities and trunk. Both smoking and increased exposure hours to pool water were independently associated with skin disease, suggesting a dose-response relationship. We conclude that contact dermatitis should be recognized as an occupational disease in hydrotherapists.

Scrubbing for cutaneous procedures can be hazardous

Office-based minor cutaneous surgery is a service provided by many medical practitioners. In New South Wales, Australia, it is a legal requirement for practitioners to surgically scrub before donning sterile gloves for all forms of invasive surgery, including minor cutaneous procedures. Frequent scrubbing causes altered skin barrier function, irritant dermatitis and a potential risk of latex sensitization. These adverse effects are associated with significant morbidity and cost. Better tolerated alternatives, including alcohol-based hand rubs, should be considered in preference to traditional surgical scrubs in order to reduce these occupational risks for minor proceduralists. Well-controlled, prospective studies should explore what extent of hand washing is necessary for donning sterile gloves for minor cutaneous surgery.

Water disrupts stratum corneum lipid lamellae: damage is similar to surfactants

Using electron microscopy, we investigated the effect of (i) a dilute surfactant and of water alone on the ultrastructure of stratum corneum lipids in pig skin exposed in vitro at 46 degrees C, and (ii) of water alone on human skin exposed in vivo at ambient temperature. For pig skin, the surfactant sodium dodecyl sulfate disrupts stratum corneum intercellular lamellar bilayers, leading to bilayer delamination and "roll-up" in a water milieu after 1 h, extensive bilayer disruption after 6 h, and nearly complete dissociation of corneocytes after 24 h. Corneodesmosomes show progressive degradation with exposure time. Water alone also disrupts the stratum corneum, but with a slower onset. Alterations in intercellular lamellar bilayers, but not intercellular lamellar bilayer roll-up, are detected after 2 h. Intercellular lamellar bilayer roll-up occurs after 6 h. Extensive dissociation of corneocytes occurs after 24 h of water exposure. Unlike sodium dodecyl sulfate, water exposure results in the formation of amorphous intercellular lipid. Corneodesmosome degradation parallels intercellular lamellar bilayer disruption; calcium appears to offer some protection. Similar disruption of intercellular lamellar bilayers occurs in human skin in vivo at ambient temperature. Our studies show that water can directly disrupt the barrier lipids and are consistent with surfactant-induced intercellular lamellar bilayer disruption being due at least in part to the deleterious action of water. Intercellular lamellar bilayer disruption by water would be expected to enhance permeability and susceptibility to irritants; accordingly, increased attention should be given to the potential dangers of prolonged water contact. For common in vitro procedures, such as skin permeation studies or isolation of stratum corneum sheets, exposure to water should also be minimized.

Effects of repeated skin exposure to low nickel concentrations: a model for allergic contact dermatitis to nickel on the hands

We studied the effects of repeated daily exposure to low nickel concentrations on the hands of patients with hand eczema and nickel allergy. The concentrations used were chosen to represent the range of trace to moderate occupational nickel exposure. The study was double-blinded and placebo controlled. Patients immersed a finger for 10 min daily into a 10-p.p.m. nickel concentration in water for the first week, and during the second week into a 100-p.p.m. nickel concentration. This regimen significantly increased (P = 0.05) local vesicle formation and blood flow (P = 0.03) as compared with a group of patients who immersed a finger into water. The nickel concentrations used also provoked significant inflammatory skin changes on sodium lauryl sulphate (SLS)-treated forearm skin of the patients, whereas inflammatory skin changes were not observed in healthy volunteers without hand eczema and nickel allergy, either on normal or on SLS-treated forearm skin. The present study strongly suggests that the changes observed were specific to nickel exposure. Standardized methods to assess trace to moderate nickel exposure on the hands, and the associated effects in nickel-sensitized subjects, are needed.