Neonatal skin barrier: structure, function, and disorders

Understanding the effects of per- and polyfluoroalkyl substances on early skin development: Role of ciliogenesis inhibition and altered microtubule dynamics

Per- and polyfluoroalkyl substances (PFAS) are a class of highly stable chemicals, widely used in everyday products, and widespread in the environment, even in pregnant women. While epidemiological studies have linked prenatal exposure to PFAS with atopic dermatitis in children, little is known about their toxic effects on skin development, especially during the embryonic stage. In this study, we utilized human embryonic stem cells to generate non-neural ectoderm (NNE) cells and exposed them to six PFAS (perfluorooctanoic acid (PFOA), undecafluorohexanoic acid (PFHxA), heptafluorobutyric acid (PFBA), perfluorooctane sulfonate (PFOS), perfluorohexane sulfonate (PFHxS) and perfluorobutyric acid (PFBS)) during the differentiation process to assess their toxicity to early skin development. Our results showed that PFOS altered the spindle-like morphology of NNE cells to a pebble-like morphology, and disrupted several NNE markers, including KRT16, SMYD1, and WISP1. The six PFAS had a high potential to cause hypohidrotic ectodermal dysplasia (HED) by disrupting the expression levels of HED-relevant genes. Transcriptomic analysis revealed that PFOS treatment produced the highest number (1156) of differentially expressed genes (DEGs) among the six PFAS, including the keratinocyte-related genes KRT6A, KRT17, KRT18, KRT24, KRT40, and KRT81. Additionally, we found that PFOS treatment disturbed several signaling pathways that are involved in regulating skin cell fate decisions and differentiation, including TGF-β, NOTCH, Hedgehog, and Hippo signaling pathways. Interestingly, we discovered that PFOS inhibited, by partially interfering with the expression of cytoskeleton-related genes, the ciliogenesis of NNE cells, which is crucial for the intercellular transduction of the above-mentioned signaling pathways. Overall, our study suggests that PFAS can inhibit ciliogenesis and hamper the transduction of important signaling pathways, leading potential congenital skin diseases. It sheds light on the underlying mechanisms of early embryonic skin developmental toxicity and provides an explanation for the epidemiological data on PFAS. ENVIRONMENTAL IMPLICATION: We employed a model based on human embryonic stem cells to demonstrate that PFOS has the potential to elevate the risk of hypohidrotic ectodermal dysplasia. This is achieved by targeting cilia, inhibiting ciliogenesis, and subsequently disrupting crucial signaling pathways like TGF-β, NOTCH, Hedgehog, and Hippo, during the early phases of embryonic skin development. Our study highlights the dangers and potential impacts of six PFAS pollutants on human skin development. Additionally, we emphasize the importance of closely considering PFHxA, PFBA, PFHxS, and PFBS, as they have shown the capacity to modify gene expression levels, albeit to a lesser degree.

A wireless physiological parameter monitoring system with a treatment feedback function during neonatal phototherapy

Objective. Neonatal jaundice is a common condition in the early stages of newborns, and phototherapy is a fast, safe and effective method that is used to treat it. However, recent studies have shown that phototherapy may elicit side effects in infants, such as hypothermia, hyperthermia and dehydration. To improve the quality of phototherapy and the prognosis of patients, the changes in neonatal physiological parameters during phototherapy should be monitored to give better feedback to pediatricians or the phototherapy system. However, the current standard of clinical care during neonatal phototherapy with hard-wired devices limits this realization.Approach. Here, we developed a prototype of a neonatal wearable device, which can wirelessly potentially monitor the jaundice value, transepidermal water loss, skin wettedness factor and body orientation during phototherapy, and conducted prototype validation experiments. We also set up user-friendly interfaces and an analysis system on custom software, all designed to make the future addition of data interfaces for treatment feedback functions easier.Main results. The preliminaryin vitroexperiment demonstrated the effectiveness of simultaneous monitoring of the required physiological parameters. And further suggestions and specific operations are discussed in terms of optimization of the treatment of neonatal jaundice.Significance. It is believed that the established system has the potential to provide a basis for future phototherapy nursing guidelines and physiological monitoring standards.

Systematic Review of the Effects of Positioning on Nonautonomic Outcomes in Preterm Infants

OBJECTIVE

To identify and synthesize the available evidence on the effect of different positions (prone, supine, and right and left lateral) on nonautonomic outcomes for preterm infants admitted to the NICU.

DATA SOURCES

We searched the CINAHL, MEDLINE, Scopus, and Cochrane databases for reports of primary research studies using a three-step strategy. We also searched for gray literature and reviewed the reference lists of retrieved articles.

STUDY SELECTION

We included reports of quantitative studies published in English from database inception through February 2022 that focused on positioning and nonautonomic outcomes (pain, comfort, skin integrity, behavioral state, and sleep quality and duration) for preterm infants in the NICU. Two authors independently screened titles and abstracts and assessed articles in full text against the inclusion criteria.

DATA EXTRACTION

Two authors independently extracted the data from the full-text articles using a standardized data extraction tool. We synthesized the data narratively because of the different designs and outcome measures among the included studies.

DATA SYNTHESIS

From a total of 550 records initially screened, we included 17 articles in our review. In the included articles, prone positioning improved sleep quality and duration, whereas supine positioning was associated with increased awakenings and activity. Infants demonstrated fewer self-regulatory behaviors in the prone position compared to supine or side-lying and were less stressed in the prone position. We found minimal evidence on the effect of positioning on skin integrity or pain.

CONCLUSION

There is limited good-quality evidence on the effect of positioning on nonautonomic outcomes in preterm infants. To inform clinical practice, high-quality randomized controlled trials focused on the positioning of premature infants are warranted.

Handwashing Results in Incomplete Nicotine Removal from Fingers of Individuals who Smoke: A Randomized Controlled Experiment

OBJECTIVE

Tobacco residue, also known as third-hand smoke (THS), contains toxicants and lingers in dust and on surfaces and clothes. THS also remains on hands of individuals who smoke, with potential transfer to infants during visitation while infants are hospitalized in neonatal intensive care units (NICUs), raising concerns (e.g., hindered respiratory development) for vulnerable infants. Previously unexplored, this study tested handwashing (HW) and sanitization efficacy for finger-nicotine removal in a sample of adults who smoked and were visiting infants in an NICU.

STUDY DESIGN

A cross-sectional sample was recruited to complete an interview, carbon monoxide breath samples, and three nicotine wipes of separate fingers (thumb, index, and middle). Eligible participants (n = 14) reported current smoking (verified with breath samples) and were randomly assigned to 30 seconds of HW (n = 7) or alcohol-based sanitization (n = 7), with the order of finger wipes both counterbalanced and randomly assigned. After randomization, the first finger was wiped for nicotine. Participants then washed or sanitized their hands and finger two was wiped 5 minutes later. An interview assessing tobacco/nicotine use and exposure was then administered, followed by a second breath sample and the final finger wipe (40-60 minutes after washing/sanitizing).

RESULTS

Generalized linear mixed models found that HW was more effective than sanitizer for nicotine removal but failed to completely remove nicotine.

CONCLUSIONS

Without proper protections (e.g., wearing gloves and gowns), NICU visitors who smoke may inadvertently expose infants to THS. Research on cleaning protocols are needed to protect vulnerable medical populations from THS and associated risks.

KEY POINTS

· NICU infants may be exposed to THS via visitors.. · THS is not eliminated by HW or sanitizing.. · THS removal protections for NICU infants are needed..

Application of microneedle patches for drug delivery; doorstep to novel therapies

In the past decade, microneedle-based drug delivery systems showed promising approaches to become suitable and alternative for hypodermic injections and can control agent delivery without side effects compared to conventional approaches. Despite these advantages, the procedure of microfabrication is facing some difficulties. For instance, drug loading method, stability of drugs, and retention time are subjects of debate. Besides, the application of novel refining fabrication methods, types of materials, and instruments are other issues that need further attention. Herein, we tried to summarize recent achievements in controllable drug delivery systems (microneedle patches) in vitro and in vivo settings. In addition, we discussed the influence of delivered drugs on the cellular mechanism and immunization molecular signaling pathways through the intradermal delivery route. Understanding the putative efficiency of microneedle patches in human medicine can help us develop and design sophisticated therapeutic modalities.

Infant heart-rate measurement and oxygen desaturation detection with a digital video camera using imaging photoplethysmography

OBJECTIVE

To assess the feasibility of using an ordinary digital video camera to measure heart rate and detect oxygen desaturations in healthy infants.

STUDY DESIGN

Heart rate and oxygen saturation were measured with a video camera by detecting small color changes in 28 infants' foreheads and compared with standard pulse oximetry measures. Multivariable regression examined the relationship between infant characteristics and heart-rate measurement precision.

RESULTS

The average bias of camera heart-rate measures was -4.2 beats per minute (BPM) and 95% limits of agreement were ±43.8 BPM. Desaturations detected by camera were 75% sensitive (15/20) and had a positive predictive value of 20% (15/74). Lower birth-weight was independently correlated with more precise heart-rate measures (8.05 BPM per kg, [95% CI 0.764-15.3]).

CONCLUSIONS

A digital video camera provides accurate but imprecise measures of infant heart rate and may provide a rough screening tool for oxygen desaturations.

Thirdhand Smoke Contamination and Infant Nicotine Exposure in a Neonatal Intensive Care Unit: An Observational Study

INTRODUCTION

Thirdhand smoke (THS) is ultrafine particulate matter and residue resulting from tobacco combustion, with implications for health-related harm (eg, impaired wound healing), particularly among hospitalized infants. Project aims were to characterize nicotine (THS proxy) transported on neonatal intensive care unit (NICU) visitors and deposited on bedside furniture, as well as infant exposure.

METHODS

Cross-sectional data were collected from participants in a metropolitan NICU. Participants completed a survey and carbon monoxide breath sample, and 41.9% (n = 88) of participants (n = 210) were randomly selected for finger-nicotine wipes during a study phase when all bedside visitors were screened for nicotine use and finger-nicotine levels. During an overlapping study phase, 80 mother-infant dyads consented to bedside furniture-nicotine wipes and an infant urine sample (for cotinine analyses).

RESULTS

Most nonstaff visitors' fingers had nicotine above the limit of quantification (>LOQ; 61.9%). Almost all bedside furniture surfaces (93.8%) and infant cotinine measures (93.6%) had values >LOQ, regardless of household nicotine use. Participants who reported using (or lived with others who used) nicotine had greater furniture-nicotine contamination (Mdn = 0.6 [interquartile range, IQR = 0.2-1.6] µg/m2) and higher infant cotinine (Mdn = 0.09 [IQR = 0.04-0.25] ng/mL) compared to participants who reported no household-member nicotine use (Mdn = 0.5 [IQR = 0.2-0.7] µg/m2; Mdn = 0.04 [IQR = 0.03-0.07] ng/mL, respectively). Bayesian univariate regressions supported hypotheses that increased nicotine use/exposure correlated with greater nicotine contamination (on fingers/furniture) and infant THS exposure.

CONCLUSIONS

Potential furniture-contamination pathways and infant-exposure routes (eg, dermal) during NICU hospitalization were identified, despite hospital prohibitions on tobacco/nicotine use. This work highlights the surreptitious spread of nicotine and potential THS-related health risks to vulnerable infants during critical stages of development.

IMPLICATIONS

THS contamination is underexplored in medical settings. Infants who were cared for in the NICU are vulnerable to health risks from THS exposure. This study demonstrated that 62% of nonstaff NICU visitors transport nicotine on their fingers to the NICU. Over 90% of NICU (bedside) furniture was contaminated with nicotine, regardless of visitors' reported household-member nicotine use or nonuse. Over 90% of infants had detectable levels of urinary cotinine during NICU hospitalizations. Results justify further research to better protect infants from unintended THS exposure while hospitalized.

Neonatal Dermatology: The Normal, the Common, and the Serious

The objective of this review is to help practitioners of neonatal and pediatric medicine become more familiar with diagnosing and managing neonatal skin conditions. This article will discuss normal neonatal skin care and benign and common rashes, as well as some of the serious dermatologic conditions that require specialists for further evaluation and/or treatment.

Opioid transdermal delivery system: a useful method for pain management in children

Transdermal delivery system (TDDS) is a non-invasive and less expensive method for drug delivery. Despite its feasibility, only a restricted group of drugs can be delivered by TDDS, because of the little permeability of skin. Moreover, TDDS is limited to lipophilic drugs with small molecular masses and it is not indicated for peptides, macromolecules and hydrophilic drugs. Among opioids, fentanyl and buprenorphine are suitable for transdermal administration only for chronic pain management (not for acute pain). However, opioid TDDS still remains off-label for chronic pain management in children. In this review, we describe the main features of the adhesive TDDS and the main characteristics of pediatric skin and the differences from the adult one. Moreover, we focus on fentanyl and buprenorphine patches and their non-invasive mechanism of action, and on the main aspects that make them suitable for pain management among the pediatric population.

Skin-interfaced biosensors for advanced wireless physiological monitoring in neonatal and pediatric intensive-care units

Standard of care management in neonatal and pediatric intensive care units (NICUs and PICUs) involve continuous monitoring of vital signs with hard-wired devices that adhere to the skin and, in certain instances, include catheter-loaded pressure sensors that insert into the arteries. These protocols involve risks for complications and impediments to clinical care and skin-to-skin contact between parent and child. Here we present a wireless, non-invasive technology that not only offers measurement equivalency to these management standards but also supports a range of important additional features (without limitations or shortcomings of existing approaches), supported by data from pilot clinical studies in the neonatal intensive care unit (NICU) and pediatric ICU (PICU). The combined capabilities of these platforms extend beyond clinical quality measurements of vital signs (heart rate, respiration rate, temperature and blood oxygenation) to include novel modalities for (1) tracking movements and changes in body orientation, (2) quantifying the physiological benefits of skin-to-skin care (e.g. Kangaroo care) for neonates, (3) capturing acoustic signatures of cardiac activity by directly measuring mechanical vibrations generated through the skin on the chest, (4) recording vocal biomarkers associated with tonality and temporal characteristics of crying impervious to confounding ambient noise, and (5) monitoring a reliable surrogate for systolic blood pressure. The results have potential to significantly enhance the quality of neonatal and pediatric critical care.

Particularities of the management and the treatment in a rare sepsis with Candida tropicalis of a Collodion baby: Case report

RATIONALE

Collodion baby is a rare autosomal recessive disorder. It can be the first expression of some forms of ichthyosis.

PATIENT CONCERNS

The authors present the case of a newborn diagnosed with severe Collodion baby syndrome who required prolonged hospitalization in the intensive care unit because of infectious complications like the fungal sepsis and other bacterial superinfections.

DIAGNOSES

The case has many diagnostic and therapeutic particularities and management difficulties. Skin culture, dermatological and genetic exam were required.

INTERVENTIONS

The treatment required multidisciplinary involvement: neonatologist, pediatrician, geneticist, dermatologist, psychologist, ophthalmologist, audiologist.

OUTCOMES

The evolution during hospitalization was slowly favorable, but later, after a few months, it developed some complications.

LESSONS

In our case, skin injuries, total parenteral nutrition, aggressive and prolonged antibiotic therapy, intravenous devices, high hospitalization duration were risk factors for colonization and sepsis with fungi, especially in the neonatal period, sometimes with severe evolution and prognosis.

Analysis of Dermatologic Consultations in a Neonatal Intensive Care Unit Over a 7-Year Period: Retrospective Review of 60 Cases

BACKGROUND/OBJECTIVES

The need for dermatology consultations for neonatal intensive care unit (NICU) patients is increasing, but no study has systemically examined the skin diseases of patients in NICUs. The aim of this study was to analyze dermatology consultations in the NICU of a tertiary medical center in Korea and determine the effect of the dermatology consultation on the clinical course and management of the patients after the consultation.

METHODS

The medical records of patients undergoing dermatologic consultation during their stay in a NICU between March 2009 and February 2016 were reviewed retrospectively.

RESULTS

Sixty patients were enrolled in this study; the male-to-female ratio was 1:1.1, and mean age at the time of consultation was 3.7 weeks. Mean gestational age was 33.7 weeks, and 35 of the subjects (58.3%) were preterm neonates. Mean birth weight was 2.14 kg (range 550-4,200 g). The most-common disease category was birthmarks and neoplasms (20.0%), followed by eczematous dermatoses (18.3%), skin appendageal disease (16.7%), and infectious disease (13.3%).

CONCLUSION

This study identified the dermatologic problems of neonates in a NICU and can raise dermatologists' awareness of the types of patients they may encounter in a NICU.

Long-Lived Epidermal Cancer-Initiating Cells

Non-melanomatous skin cancers (NMSCs), which include basal and squamous cell carcinoma (BCC and SCC respectively), represent a significant burden on the population, as well as an economic load to the health care system; yet treatments of these preventable cancers remain ineffective. Studies estimate that there has been a 2-fold increase in the incidence of NMSCs between the 1960s and 1980s. The increase in cases of NMSCs, as well as the lack of effective treatments, makes the need for novel therapeutic approaches all the more necessary. To rationally develop more targeted treatments for NMSCs, a better understanding of the cell of origin, in addition to the underlying pathophysiological mechanisms that govern the development of these cancers, is urgently required. Research over the past few years has provided data supporting both a "bottom up" and "top down" mechanism of tumourigenesis. The "bottom up" concept involves a cancer stem cell originating in the basal compartment of the skin, which ordinarily houses the progenitor cells that contribute towards wound healing and normal cell turnover of overlying epidermal skin layers. The "top down" concept involves a more differentiated cell undergoing genetic modifications leading to dedifferentiation, giving rise to cancer initiating cells (CICs). This review explores both concepts, to paint a picture of the skin SCC cell of origin, the underlying biology, and also how this knowledge might be exploited to develop novel therapies.

Comparing 2 Adhesive Methods on Skin Integrity in the High-Risk Neonate

BACKGROUND

Nurses have a primary role in promoting neonatal skin integrity and skin care management of the critically ill neonate. Adhesive products are essential to secure needed medical devices but can be a significant factor contributing to skin breakdown. Current literature does not offer a definitive answer regarding which products most safely and effectively work to secure needed devices in the high-risk neonatal population.

PURPOSE

To determine which adhesive method is best practice to safely and effectively secure lines/tubes in the high-risk neonate population.

FINDINGS/RESULTS

The only main effect that was significant was age group with mean skin scores. Subjects in the younger group (24-28 weeks) had higher skin scores than in the older group (28-34 weeks), validating that younger gestations are at higher risk of breakdown with the use of adhesives.

IMPLICATIONS FOR PRACTICE

The findings did not clearly identify which product was superior to secure tubes and lines, or was the least injurious to skin of the high-risk neonate. Neither a transparent dressing only or transparent dressing over hydrocolloid method clearly demonstrated an advantage in the high-risk, preterm neonate. Anecdotal comments suggested staff preferred the transparent dressing over hydrocolloid method as providing better adhesive while protecting skin integrity. The findings validated that younger gestations are at higher risk of breakdown with the use of adhesives and therefore require close vigilance to maintain skin integrity.

Surgical site infections in a longitudinal cohort of neonatal intensive care unit patients

OBJECTIVE

To estimate the incidence and identify risk factors for surgical site infections (SSIs) among infants in the neonatal intensive care unit (NICU).

STUDY DESIGN

A prospective cohort study of infants undergoing surgical procedures from May 2009 to April 2012 in three NICUs was performed. SSI was identified if documented by an attending neonatologist and treated with intravenous antibiotics. Independent risk factors were identified using logistic regression, adjusting for NICU.

RESULT

A total of 902 infants underwent 1346 procedures and experienced 60 SSIs (incidence: 4.46/100 surgeries). Risk factors for SSIs included younger chronological age (odds ratio (OR) 1.03 per day decrease, 95% confidence interval (CI) 1.01, 1.04), lower gestational age (OR 1.09 per week decrease, CI 1.02, 1.18), male sex (OR 1.17, CI 1.04, 1.34) and use of central venous catheter (OR 4.40, CI 1.19, 9.62). Only 43% had surgical site cultures obtained and Staphylococcus aureus was most commonly isolated.

CONCLUSION

SSIs complicated 4.46% of procedures performed in the NICU. Although few modifiable risk factors for SSIs were identified, future efforts should focus on evaluating the impact of current prevention strategies on the incidence of neonatal SSI.

Evolving concepts of neonatal skin

Skin barrier function is crucial to health. Importantly, the skin operates as an air-liquid, a liquid-liquid, and an immunological barrier. The skin's physical and chemical structures, as well as its microbiome, function to create, maintain, and repair this complex barrier.

Effective use of transdermal drug delivery in children

Transdermal administration offers a non-invasive and convenient method for paediatric drug delivery. The competent skin barrier function in term infants and older children limits both water loss and the percutaneous entry of chemicals including drugs; but the smaller doses required by children eases the attainment of therapeutic concentrations. Transdermal patches used in paediatrics include fentanyl, buprenorphine, clonidine, scopolamine, methylphenidate, oestrogens, nicotine and tulobuterol. Some patches have paediatric labelling supported by clinical trials whereas others are used unlicensed. Innovative drug delivery methods, such as microneedles and sonophoresis are being tested for their safety and efficacy; needleless injectors are primarily used to administer growth hormone; and two iontophoretic devices were approved for paediatrics. In contrast, the immature and rapidly evolving skin barrier function in premature neonates represents a significant formulation challenge. Unfortunately, this population group suffers from an absence of approved transdermal formulations, a shortcoming exacerbated by the significant risk of excessive drug exposure via the incompletely formed skin barrier.

Unobtrusive ECG monitoring in the NICU using a capacitive sensing array

The thin skin of preterm babies is easily damaged by adhesive electrodes, tapes, chest drains and needle-marks. The scars caused could be disfiguring or disabling to 10% of preterm newborns. Capacitive sensors present an attractive option for pervasively monitoring neonatal ECG, and can be embedded in a support system or even a garment worn by the neonate. This could improve comfort and reduce pain aiding better recovery as well as avoiding the scars caused by adhesive electrodes. In this work, we investigate the use of an array of capacitive sensors unobtrusively embedded in a mattress and used in a clinical environment for 15 preterm neonates. We also describe the analysis framework including the fusion of information from all sensors to provide a more accurate ECG signal. We propose a channel selection strategy as well as a method using physiological information to obtain a reliable ECG signal. When sensor coverage is well attained, results for both instantaneous heart rate and ECG signal shape analysis are very encouraging. The study also provides several insights on important factors affecting the results. These include the effect of textile type, number of layers, interferences (e.g. people walking by), motion severity and interventions. Incorporating this knowledge in the design of a capacitive sensing system would be crucial in ensuring that these sensors provide a reliable ECG signal when embedded in a neonatal support system.

Tolerance of skin care regimen in healthy, full-term neonates

Purpose

To assess the tolerance of a baby cleanser and lotion (both lightly fragranced) on healthy, full-term neonates.

Materials and methods

Twenty-six infant–mother pairs were enrolled in a 6-week, nonrandomized, controlled-use study that took place in the routine setting of a pediatric clinic and mothers’ homes. During study weeks 1 to 6, neonates were bathed by their mother with water and a test cleanser (JOHNSON’S® HEAD-TO-TOE® Baby Wash). During study weeks 1 to 3, mothers also applied test lotion (JOHNSON’S® Baby Lotion) to the babies’ skin immediately after bathing and one to three times/day on bathing and non-bathing days. During study weeks 4 to 6, no lotion was applied. At baseline and weeks 3 and 6, the infants’ pediatrician or mother or both performed visual skin assessments.

Results

Twenty-three infant–mother pairs completed the study. The mean age of neonates at enrolment was 17.4 days (range, 13–28 days). Pediatrician observations found no clinical signs of irritation, erythema, or dryness with any significant difference in scores of these parameters compared with baseline throughout the study. Assessment of skin softness, smoothness, dryness, and overall skin condition was very good at baseline and remained so with minimal changes throughout the study. Mothers reported improvements versus baseline (P ≤ 0.05) in overall skin appearance, moisturization, softness, and smoothness on the arms and legs at weeks 3 and 6. A total of four (15.4%) subjects experienced adverse events. For three of the subjects, the investigator suspected that the adverse events were unrelated to either of the test products. In one participant, the cause of the adverse event could not be determined.

Conclusion

The use of a lightly fragranced nonstinging baby cleanser, with or without a lightly fragranced baby lotion, was well tolerated by newborns and resulted in observable skin benefits per the pediatricians’ and mothers’ assessment.

Newborn skin care

Many organ systems undergo significant and rapid changes during the transition from an intrauterine to an extrauterine environment, especially those which serve as interfaces between the infant and the external environment. Historically the skin care methods employed during and after this period of rapid physiologic change have been derived from individual anecdotal experience or cultural tradition, rather than evidence-based or pathomechanistically derived data. While research in this area has historically been limited, it is increasing in scope and volume, and recent work has shed light on the changes experienced by the cutaneous organ during this period of transition. This increased understanding has driven new recommendations in skin care protocols for newborn infants and neonates.

Classification of dermatological disorders in critical care patients: a prospective observational study

PURPOSE

The objective of this study was to identify dermatological disorders detected in the intensive care unit (ICU), to analyze their specific characteristics, and to define a useful classification for intensive care physicians.

MATERIALS AND METHODS

This was a prospective, observational study over a 3-year period (2006-2009) in a mixed ICU. This included all patients presenting with dermatological disorders that were detected at the time of ICU admission or developed along the ICU stay. We recorded the specific characteristics of the disorders and its evolution and treatment, which enabled us to classify the different observed conditions. As general variables, we analyzed demographic factors, the principal diagnosis, ICU procedures, the severity score (Acute Physiology and Chronic Health Evaluation II), length of stay, and mortality.

RESULTS

One hundred thirty-three patients showed at least one dermatological disorder (9.3%) and were classified into (1) preexisting dermatological disorders, (2) life-threatening dermatologic disorders, (3) systemic dermatological disorders, (4) infectious dermatological disorders, (5) reactive dermatological disorders, and (6) others.

CONCLUSIONS

Dermatological disorders are a frequent problem in the ICU, and their recognition is key to set up an appropriate care plan. We propose a classification and description of the different types of dermatological disorders that are most commonly found in ICUs.

Epidermal ADAM17 maintains the skin barrier by regulating EGFR ligand-dependent terminal keratinocyte differentiation

ADAM17 (a disintegrin and metalloproteinase 17) is ubiquitously expressed and cleaves membrane proteins, such as epidermal growth factor receptor (EGFR) ligands, l-selectin, and TNF, from the cell surface, thus regulating responses to tissue injury and inflammation. However, little is currently known about its role in skin homeostasis. We show that mice lacking ADAM17 in keratinocytes (A17(ΔKC)) have a normal epidermal barrier and skin architecture at birth but develop pronounced defects in epidermal barrier integrity soon after birth and develop chronic dermatitis as adults. The dysregulated expression of epidermal differentiation proteins becomes evident 2 d after birth, followed by reduced transglutaminase (TGM) activity, transepidermal water loss, up-regulation of the proinflammatory cytokine IL-36α, and inflammatory immune cell infiltration. Activation of the EGFR was strongly reduced in A17(ΔKC) skin, and topical treatment of A17(ΔKC) mice with recombinant TGF-α significantly improved TGM activity and decreased skin inflammation. Finally, we show that mice lacking the EGFR in keratinocytes (Egfr(ΔKC)) closely resembled A17(ΔKC) mice. Collectively, these results identify a previously unappreciated critical role of the ADAM17-EGFR signaling axis in maintaining the homeostasis of the postnatal epidermal barrier and suggest that this pathway could represent a good target for treatment of epidermal barrier defects.

Children and newborn skin care and prevention

Neonatal skin suffers a progressive adaptation to the extrauterine environment and special care is needed during this period. This skin is very sensitive, thin and fragile. Immaturity of the epidermal barrier reduces the defense against the excessive proliferation of microbes and makes the skin more vulnerable to trauma and percutaneous drug toxicity. Because of the peculiar characteristics of newborn, infant and children's skin, the use of cosmetic products designed for hygiene and protection requires caution. In order to preserve the integrity of neonatal and child's skin, this article reviewed basic preventive care practices in relation to hygiene, bathing, cleansing agents, topical products and their percutaneous toxicity.

Expression of differential genes involved in the maintenance of water balance in human skin by Piptadenia colubrina extract

BACKGROUND

Hydration and integrity of the stratum corneum (SC) is an important determinant of skin appearance, metabolism, mechanical properties, and barrier function. The presence of aquaglyceroporins and envelope proteins are crucial to provide greater corneocyte cohesion to keep water and other moisturizers in the skin.

AIMS

In this study, we evaluated the ability of Piptadenia colubrina, a plant native of South American rain forests, in the expression of genes involved in skin capacitance and SC integrity.

METHODS

The expression of genes for aquaporin-3 (AQP3), loricrin, involucrin (INV), and filaggrin (FLG) was measured by real-time PCR, using an in vitro model of human keratinocytes incubated with concentrations of 2.5, 5, 10, and 20 mg/mL of a hydroglycolic extract of P. colubrina (HEPC). The amount of AQP3 protein was also tested by immunohistochemistry in human skin explants. Clinical trials were conducted to evaluate the effects of a gel-cream containing HEPC on the glycerol index and skin capacitance.

RESULTS

Hydroglycolic extract of P. colubrina increased both the expression and immunoreactivity of AQP3 in cultured keratinocytes and human skin explants. The gene induction to envelope proteins FLG and INV was also observed after cell incubation with HEPC. Skin capacitance was significantly improved in human volunteers under treatment with HEPC-containing cream.

CONCLUSIONS

The extract of P. colubrina promotes cellular hydration and induces gene expression of envelope proteins providing greater corneocyte cohesion to keep water and other moisturizers in the skin and an appropriate epidermal adhesion. The in vitro findings were clinically confirmed and encourage the clinical use of this compound in skin care products.

Effectiveness of No-Sting skin protectant and Aquaphor on water loss and skin integrity in premature infants

OBJECTIVE

The purpose of this study was to evaluate the effects of No-Sting skin protectant and Aquaphor, a water-based emollient, on skin integrity measured by Neonatal Skin Condition Score (NSCS) and transepidermal water loss (TEWL) in premature infants. In addition, with no data regarding the use of No-Sting in the neonatal population and its desirability because it requires less infant manipulation and less nursing time, it was important to evaluate the use of this product.

STUDY DESIGN

In all, 69 premature infants born at <33 weeks gestation were randomly assigned to one of the two treatment groups: (1) No-Sting or (2) Aquaphor for a total of 14 days.

RESULT

Gestational age and total fluid intake were related to NSCS whereas gestational age, incubator humidity levels and total daily fluid intake were significantly related to TEWL. Infants receiving Aquaphor had significantly higher NSCS, but the mean scores in both groups over the 14-day period were in the normal range (<4). There were no differences between Aquaphor and No-Sting in the rate of TEWL over the 14-day period.

CONCLUSION

This study provides the first information regarding the use of No-Sting in the neonatal population. This skin protectant seems as effective as Aquaphor in decreasing TEWL and maintaining skin integrity, and is less resource intensive.

Involucrin–claudin-6 tail deletion mutant (CΔ206) transgenic mice: a model of delayed epidermal permeability barrier formation and repair

Preterm birth is a major global health problem that results in a large number of infant deaths, many of which are attributable to the complications of an immature epidermal permeability barrier (EPB), for which there is currently no effective therapeutic option. The mammalian EPB is formed during development and is essential for survival as it maintains thermoregulation and hydration, and provides a defense against infection. Using transgenic mouse technology, we have demonstrated the importance of claudin (Cldn)-containing tight junctions (TJs) in epidermal differentiation and, in particular, that epidermal suprabasal overexpression of Cldn6 results in an EPB-deficient phenotype that phenocopies the dysfunctional EPB of premature human infants. In this study, we used the same approach to target a Cldn6 tail deletion mutant to the epidermis of mice [involucrin (Inv)-Cldn6-CΔ206 transgenic mice]. The Inv-Cldn6-CΔ206 transgenic mice displayed a developmental delay in EPB formation, as shown by the expression of keratins and Cldns, and by X-Gal penetration assays. Trans-epidermal water loss measurements and immunolocalization studies indicated that the epidermal differentiation program was also perturbed in postnatal Inv-Cldn6-CΔ206 transgenic mice resulting in a delayed maturation. Notably, however, expression/localization of epidermal differentiation and maturation markers, including Cldns, indicated that the transgenic epidermis matured and normalized by postnatal day 10, which is 3 days after the wild-type epidermis. Our results suggest that activation of the extracellular signal-regulated kinase 1/2 (Erk1/2) pathway and Cldn1 phosphorylation are associated with the repair and maturation of the skin barrier processes. These studies provide additional support for the crucial role of Cldns in epidermal differentiation, maturation and the formation of the EPB, and describe a novel animal model for evaluating postnatal epidermal maturation and therapies that may accelerate the process.

Diagnostic pitfalls in newborns and babies with blisters and erosions

Establishing the correct diagnosis in newborns presenting with blisters and erosions is not always a straightforward process. Many different disease entities including acquired (i.e., infectious, immunobullous, traumatic) and inherited disorders have to be taken into consideration. Similarities in clinical appearance, colonization and/or superinfections of preexisting skin lesions, as well as the absence of late changes in the neonate often pose significant diagnostic challenges. In this paper we discuss by giving examples the process of making an accurate diagnosis of blistering skin diseases in the neonatal period on the basis of a diagnostic algorithm. In addition, we provide an overview of the rational use and the limitations of laboratory procedures such as microbial testing, routine light microscopy, immunofluorescence antigen mapping, transmission electron microscopy, and molecular genetic analysis.

Successful treatment of Candida albicans septicemia in a preterm infant with severe congenital ichthyosis (Harlequin baby)

Candida infections are a major cause of fungal septicemia in neonates and are associated with marked morbidity and mortality. Despite the spectrum of antifungal drugs being dramatically extended during the last decade, invasive fungal infections remain a serious challenge for neonatologists. Amphotericin B and its lipid formulations are the drugs of choice for the treatment of systemic candidiasis in neonates. The combination of antifungal drugs with different sites of action, like caspofungin and amphotericin B, may improve antifungal efficacy. Severe congenital ichthyosis often leads to death within the neonatal period. Main causes of death are dehydration, electrolyte disturbances, and respiratory or systemic infections. We report the case of a preterm infant with severe congenital ichthyosis and sepsis caused by Candida albicans. The infection did not improve despite proper liposomal amphotericin B treatment. After addition of caspofungin, the baby recovered. To our best knowledge, a case of a preterm infant suffering from severe congenital ichthyosis and Candida albicans sepsis, who survived, has not been previously described.

Skin care for preterm and term neonates

Neonatal skin experiences a progressive adaptation to the extrauterine environment during which special care is needed. The immaturity of the epidermal barrier in the neonatal period may cause dry skin, vulnerability to trauma, rapid onset of microbial colonization and percutaneous drug toxicity. This article reviews the practical implications for hygiene, bathing practices, skin integrity, emollient use, infection control and exposure to percutaneous toxic agents in preterm and term infants.

Saving the red baby: successful allogeneic cord blood transplantation in Omenn syndrome

Haematopoietic stem cell transplantation is the treatment of choice for severe primary immunodeficiencies, but only has moderate prognosis in Omenn syndrome as it is complicated by highly activated Omenn T-cells resulting in delayed T-cell engraftment and a high rate of graft failure. A 6 1/2 months old patient with a previously unknown compound heterozygous defect within the RAG1 gene (R474C; R975W) underwent 8/10 HLA-matched cord blood transplantation after myeloablative conditioning. Immune reconstitution was impressive with T-, B- and NK-cells reaching the median of age-dependent reference values within twelve, four and two months respectively. With a continuous decrease of activated Omenn T-cells there was a steady increase of naive, probably thymus-derived T-cells. Polyclonal B-cell activation and hypergammaglobulinaemia disappeared with B-cell engraftment. This case emphasizes that, despite their naive status and HLA-barriers, cord blood T-cells were apparently able to achieve T-effector function resulting in the elimination of all activated Omenn T-cells.

Filaggrin and the great epidermal barrier grief

One of the principal functions of human skin is to form an effective mechanical barrier against the external environment. This involves the maturation and death of epidermal keratinocytes as well as the assembly of a complex network of differentially and spatially expressed proteins, glycoproteins and lipids into the keratinocyte cell membrane and surrounding extracellular space. In 2006, the key role of the granular cell layer protein filaggrin (filament-aggregating protein) in maintaining the skin barrier was determined with the identification of loss-of-function mutations in the profilaggrin gene (FLG). These mutations have been shown to be the cause of ichthyosis vulgaris and a major risk factor for the development of atopic dermatitis, asthma associated with atopic dermatitis as well as systemic allergies. Mutations in the FLG gene are extremely common, occurring in approximately 9% of individuals from European populations. The remarkable discovery of these widespread mutations is expected to have a major impact on the classification and management of many patients with ichthyosis and atopic disease. It is also hoped that the genetic discovery of FLG mutations will lead to the future development of more specific, non-immunosuppressive treatments capable of restoring effective skin barrier function and alleviating or preventing disease in susceptible individuals.

The filaggrin story: novel insights into skin-barrier function and disease

Recent reports have uncovered the key role of the protein filaggrin in maintaining an effective skin barrier against the external environment. Loss-of-function mutations in the profilaggrin gene (FLG) are common and are present in up to 10% of the population. These mutations are the cause of the semi-dominant skin-scaling disorder ichthyosis vulgaris and are a major risk factor for the development of atopic dermatitis. The discovery of these mutations also provides new data concerning the genetics of atopic asthma as well as intriguing insight into disease mechanisms of systemic allergies involving antigen exposure in skin with defective barrier function. Collectively, these novel findings have significant implications for the classification and future clinical management of patients with atopic and allergic diseases.

The Grainyhead-like epithelial transactivator Get-1/Grhl3 regulates epidermal terminal differentiation and interacts functionally with LMO4

Defective permeability barrier is an important feature of many skin diseases and causes mortality in premature infants. To investigate the control of barrier formation, we characterized the epidermally expressed Grainyhead-like epithelial transactivator (Get-1)/Grhl3, a conserved mammalian homologue of Grainyhead, which plays important roles in cuticle development in Drosophila. Get-1 interacts with the LIM-only protein LMO4, which is co-expressed in the developing mammalian epidermis. The epidermis of Get-1(-/-) mice showed a severe barrier function defect associated with impaired differentiation of the epidermis, including defects of the stratum corneum, extracellular lipid composition and cell adhesion in the granular layer. The Get-1 mutation affects multiple genes linked to terminal differentiation and barrier function, including most genes of the epidermal differentiation complex. Get-1 therefore directly or indirectly regulates a broad array of epidermal differentiation genes encoding structural proteins, lipid metabolizing enzymes and cell adhesion molecules. Although deletion of the LMO4 gene had no overt consequences for epidermal development, the epidermal terminal differentiation defect in mice deleted for both Get-1 and LMO4 is much more severe than in Get-1(-/-) mice with striking impairment of stratum corneum formation. These findings indicate that the Get-1 and LMO4 genes interact functionally to regulate epidermal terminal differentiation.