The influence of hard water (calcium) and surfactants on irritant contact dermatitis

Effects of ultra-pure soft water on the hands of nurses in a neonatal intensive care unit: A randomized crossover study

BACKGROUND

Healthcare workers (HCWs) wash their hands with tap water (TW) and soap. However, hard TW causes dermatitis.

OBJECTIVES

The present study aimed to compare the effects of ultra-pure soft water (UPSW) with those of TW on the hands of HWCs.

METHODS

The present study was a prospective randomized trial with a crossover design. All the nurses in the neonatal intensive care unit (NICU) at the study centre were divided into Sequence 1 (UPSW to TW) or 2 (TW to UPSW) and washed their hands with TW or UPSW in alternating 4-week periods with a 4-week washout period. Trans-epidermal water loss (TEWL) and stratum corneum hydration (SCH) were evaluated. Skin condition was self-assessed.

RESULTS

Twenty-one and 22 nurses were assigned to Sequence 1 and Sequence 2, respectively. USPW increased SCH to a significantly greater degree than TW (mean: 26.3 μS ± 12.3 SD; 95% confidence interval: 1.12-51.54; p = 0.041) although it did not affect TEWL. UPSW use significantly improved the subjects' skin condition, as reflected in an overall increase in the assessment scores.

CONCLUSIONS

UPSW improved SCH and the condition of hand skin. Prolonged USPW use may increase nurses' comfort during work and hand hygiene compliance.

The association between water hardness and xerosis-Results from the Danish Blood Donor Study

BACKGROUND

The pathophysiology of xerosis depends on extrinsic and intrinsic exposures. Residential hard water may constitute such an exposure.

OBJECTIVES

To estimate the prevalence of xerosis and to compare water hardness exposure in blood donors with and without xerosis.

METHODS

In this retrospective cohort study in 2018-2019, blood donors with self-reported moderately or severely dry skin were compared to blood donors without dry skin. Blood donors with ichthyosis, lichen planus and psoriasis were excluded. Water hardness data was collected from the Geology Survey of Denmark and Greenland.

RESULTS

Overall, 4,748 of 30,721 (15.5%; 95% confidence interval 15.1-15.9%) blood donors had xerosis. After excluding blood donors with ichthyosis, lichen planus and psoriasis, 4,416 blood donors (2,559 females; median age 38.4 years [interquartile range 28.0-49.8]; 700 smokers) remained in this study. Water softer than 12-24 degrees Deutsche härte was associated with decreased probability of xerosis (odds ratio 0.83; 95% confidence interval 0.74-0.94) and water harder than 12-24 degrees Deutsche härte was associated with increased probability of xerosis (odds ratio 1.22; 95% confidence interval 1.03-1.45). The association between water hardness and xerosis remained significant after excluding blood donors with dermatitis.

CONCLUSIONS

Water hardness is associated with xerosis independent of other dermatoses.

Halting the March: Primary Prevention of Atopic Dermatitis and Food Allergies

Atopic dermatitis (AD) is one of the most common inflammatory skin conditions, affecting 15% to 30% of children and 2% to 10% of adults. Population-based studies suggest that having AD is associated with subsequent development of other atopic diseases, in what is known as the "atopic march." We will provide an overview of studies that investigate primary prevention strategies for the first 2 diseases in the march, namely, AD and food allergies (FA). These strategies include emollients, breastfeeding, microbial exposures, probiotics, vitamin D and UV light, water hardness, and immunotherapy. Some studies, including randomized controlled trials on emollients and microbial supplementation, have found encouraging results; however, the evidence remains limited and contradictory. With regard to breastfeeding, microbial and lifestyle exposures, vitamin D and UV light, water hardness, and immunotherapy, the lack of randomized controlled trials makes it difficult to draw definitive conclusions. Current American Academy of Pediatrics guidelines support the idea that breastfeeding for 3 to 4 months can decrease AD incidence in children less than 2 years old. Recommendations regarding a direct relationship between breastfeeding on FA, however, cannot be made because of insufficient data. Regarding microbial supplementation, most guidelines do not recommend probiotics or prebiotics for the purpose of preventing allergic diseases because of limited evidence. Before definitive conclusions can be made regarding these interventions, more well-designed, longitudinal, and randomized controlled trials, particularly in at-risk populations, are required.

The effect of water hardness on atopic eczema, skin barrier function: A systematic review, meta-analysis

BACKGROUND

Hard domestic water has been reported to worsen atopic eczema (AE) and may contribute to its development in early life.

OBJECTIVE

To review the literature on the relationship between the effect of water hardness (high calcium carbonate; CaCO₃ ) on (a) the risk of developing AE, (b) the treatment of existing AE and (c) skin barrier function in human and animal studies.

DESIGN , DATA SOURCES AND ELIGIBILITY CRITERIA

We systematically searched databases (MEDLINE, Embase, Cochrane CENTRAL, GREAT and Web of Science) from inception until 30/6/2020. Human and animal observational and experimental studies were included. The primary outcomes were risk of AE and skin barrier function. Studies were meta-analysed using a random effects model. Evidence certainty was evaluated using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

RESULTS

Sixteen studies were included. Pooled observational data from seven studies on 385,901 participants identified increased odds of AE in children exposed to harder versus softer water (odds ratio 1.28, 95% CI 1.09, 1.50; GRADE certainty: very low). Two mechanistic studies in humans reported higher deposition of the detergent sodium lauryl sulphate in those exposed to harder versus softer water. Two randomized controlled trials comparing water softeners with standard care did not show a significant difference in objective AE severity with softened water (standardized mean difference 0.06 standard deviations higher, 95% CI 0.16 lower to 0.27 higher; GRADE certainty: moderate).

CONCLUSIONS & CLINICAL RELEVANCE

There was a positive association between living in a hard water (range: 76 to > 350 mg/L CaCO₃ ) area and AE in children. There is no evidence that domestic water softeners improve objective disease severity in established AE. There may be a role of water hardness in the initiation of skin inflammation in early life, but there is a need for further longitudinal and interventional studies.

Protective properties of Avène Thermal Spring Water on biomechanical, ultrastructural and clinical parameters of human skin

BACKGROUND

Thermal Spring Water (TSW) has been recognized to have beneficial effects on skin; however, the mechanisms underlying these are not completely elucidated.

AIMS

We compared the effects of Avène TSW with mineral-rich (MR) TSW on the biomechanical properties of the skin using mechanistic ex vivo assays and clinical studies.

METHODS

Ex vivo studies included the effect of both TSWs on the structure of the surface of human skin explants using scanning electron microscopy (SEM); mineral elemental content on the skin surface using SEM coupled to energy dispersing X-ray spectroscopy; and the stress properties of the stratum corneum (SC) when exposed to dehydration. Human clinical studies were conducted to compare the soothing effect of TSWs after a dermatological chemical peeling of face skin and to evaluate the overall sensitive scale of consumers using Avène TSW for 7 days.

RESULTS

Both TSWs preserved surface skin ultrastructure; however, crystals formed from MR-TSW were needle-like and formed small grains, present in clusters heterogeneously spread over the surface. Needle crystals were mainly composed of calcium, while small clusters were mainly composed of sulphur. By contrast, Avène TSW-formed crystals composed of sodium and chlorine only were regular in shape and homogeneously distributed across the skin surface. Peak stress of SC layers was increased by MR-TSW, whereas Avène TSW showed a comparatively reduced effect on dehydration and stress. The difference in the two TSW types was reflected in clinical findings comparing postpeeling redness after TSW application. Avène TSW significantly decreased postpeeling redness, while MR-TSW increased it. The overall sensitive scale of consumers was decreased by 47% using Avène TSW for 7 days.

CONCLUSIONS

Avène TSW decreases postpeeling redness and soothes sensitive skin in human volunteers. Mechanistic studies suggested that differences in biomechanical effects could be linked to differences in calcium content of the TSW.

Prevalence of atopic dermatitis in infants by domestic water hardness and season of birth: Cohort study

BACKGROUND

Atopic dermatitis (AD) appears to be more common in regions with hard domestic water and in children with a fall/winter birth. However, it is unknown whether a synergistic effect exists.

OBJECTIVE

We sought to evaluate the association between domestic water hardness and season of birth, respectively, with onset of AD within the first 18 months of life in a large Danish birth cohort.

METHODS

Of children from the Danish National Birth Cohort, 52,950 were included. History of physician-diagnosed AD and population characteristics were obtained from interviews. Birth data were obtained from the Civil Registration System, and domestic water hardness data were obtained from the Geological Survey of Denmark and Greenland. The relative prevalence (RP) of AD was calculated by using log-linear binomial regression.

RESULTS

The prevalence of AD was 15.0% (7,942/52,950). The RP of AD was 5% (RP_trend, 1.05; 95% CI, 1.03-1.07) higher for each 5° increase in domestic water hardness (range, 6.60-35.90 German degrees of hardness [118-641 mg/L]). Although the RP of AD was higher in children with a fall (RP, 1.24; 95% CI, 1.17-1.31) or winter (RP, 1.18; 95% CI, 1.11-1.25) birth, no significant interaction was observed with domestic water hardness. The population attributable risk of hard domestic water on AD was 2%.

CONCLUSION

We observed that early exposure to hard domestic water and a fall/winter birth was associated with an increase in the relative prevalence of AD within the first 18 months of life. Although the 2 exposures did not interact synergistically, a dose-response relationship was observed between domestic water hardness and AD.

Linoleic acid salt with ultrapure soft water as an antibacterial combination against dermato-pathogenic Staphylococcus spp

AIMS

Skin colonization of Staphylococcus spp. critically affects the severity of dermatitis in humans and animals. We examined different types of fatty acid salts for their antibacterial activity against Staphylococcus spp. when used in ultrapure soft water (UPSW). We also evaluated their therapeutic effect on a spontaneous canine model of dermatitis.

METHODS AND RESULTS

UPSW, in which Ca(++) and Mg(++) were replaced with Na(+) , was generated using a water softener with cation-exchange resin. Staphylococcus aureus (Staph. aureus), Staphylococcus intermedius (Staph. intermedius), and Staphylococcus pseudintermedius (Staph. pseudintermedius) were incubated with various fatty acid salts in distilled water (DW) or UPSW and the number of bacteria was counted. Among the fatty acids, oleic acid salt and linoleic acid (LA) salt reduced the number of these bacteria. Also, UPSW enhanced the antibacterial effect of LA on Staph. spp. In spontaneously developed itchy dermatitis in companion dogs, shampoo treatment with liquid soap containing 10% LA in UPSW improved skin conditions.

CONCLUSIONS

LA salt showed antibacterial activity against Staph. spp. Treatment with soap containing LA with UPSW reduced clinical conditions in dogs with dermatitis.

SIGNIFICANCE AND IMPACT OF THE STUDY

Because colonization of Staph. spp. on the skin exacerbates dermatitis, the use of LA-containing soap in UPSW may reduce unpleasant clinical symptoms of the skin.

Hard water softening effect of a baby cleanser

BACKGROUND

Hard water is associated with atopic dermatitis (eczema). We wanted to determine if a baby cleanser and its individual components altered free ionized calcium (Ca²⁺) in a simulated hard water baby bath. For these studies, an in vitro determination of free Ca²⁺ in a simulated hard water baby bath, and an in vivo exploratory study of free Ca²⁺ absorption into skin from hard water were performed.

METHODS

Free Ca²⁺ was measured with an ion-sensitive electrode in vitro in hard water (100-500 ppm, Ca²⁺) before and after addition of the cleanser and/or its components. In an exploratory study, absorption of Ca²⁺ into skin from hard water was determined in three female participants (aged 21-29 years).

RESULTS

At an in-use dilution of 1%, the test cleanser reduced free Ca²⁺ from ~500 ppm to <200 ppm; a 10% in-use dilution bound virtually all free Ca²⁺. The anionic surfactant component contributed the most to this effect. In the exploratory in vivo study, we measured a reduction of ~15% in free Ca²⁺ from simulated hard water over 10 minutes.

CONCLUSION

Baby cleansers can bind free Ca²⁺ and reduce the effective water hardness of bath water. Reducing the amount of free Ca²⁺ in the water will reduce the availability of the ion for binding to the skin. Altering or reducing free Ca²⁺ concentrations in bath water may be an important parameter in creating the ideal baby bath.

Nipple and Areolar Eczema in the Breastfeeding Woman

Eczema of the nipple and areola can occasionally develop in the breastfeeding patient and is associated with sore, burning, and painful areolae and nipples. Management includes elimination of any precipitating allergens and irritants and the judicious use of appropriate topical corticosteroid preparations. Patients must also be offered effective pain control and support. The proper diagnosis and management of eczema of the nipple and areola in breastfeeding patients will prevent premature and iatrogenic weaning.

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.

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.

Regular use of a hand cream can attenuate skin dryness and roughness caused by frequent hand washing

BACKGROUND

Aim of the study was to determine the effect of the regular use of a hand cream after washing hands on skin hydration and skin roughness.

METHODS

Twenty-five subjects washed hands and forearms with a neutral soap four times per day, for 2 minutes each time, for a total of two weeks. One part of them used a hand cream after each hand wash, the others did not (cross over design after a wash out period of two weeks). Skin roughness and skin hydration were determined on the forearms on days 2, 7, 9 and 14. For skin roughness, twelve silicon imprint per subject and time point were taken from the stratum corneum and assessed with a 3D skin analyzer for depth of the skin relief. For skin hydration, five measurements per subject and time point were taken with a corneometer.

RESULTS

Washing hands lead to a gradual increase of skin roughness from 100 (baseline) to a maximum of 108.5 after 9 days. Use of a hand cream after each hand wash entailed a decrease of skin roughness which the lowest means after 2 (94.5) and 14 days (94.8). Skin hydration was gradually decreased after washing hands from 79 (baseline) to 65.5 after 14 days. The hand wash, followed by use of a hand cream, still decreased skin hydration after 2 days (76.1). Over the next 12 days, however, skin hydration did not change significantly (75.6 after 14 days).

CONCLUSION

Repetitive and frequent hand washing increases skin dryness and roughness. Use of a hand cream immediately after each hand wash can confine both skin dryness and skin roughness. Regular use of skin care preparations should therefore help to prevent both dry and rough skin among healthcare workers in clinical practice.

Functional assessment of a washing emulsion for sensitive skin: mild impairment of stratum corneum hydration, pH, barrier function, lipid content, integrity and cohesion in a controlled washing test

BACKGROUND/PURPOSE

Sensitive skin has been described as a skin type with higher reactivity than normal skin and exaggerated reactions to external irritants. Washing with soaps is harmful for barrier-related parameters. Cutaneous irritation induced by cleansing products under exaggerated test conditions, e.g. patch testing, is not necessarily predictive of the irritation occurring under standardized daily use conditions. The purpose of the study was to assess the effect of an improved washing solution for sensitive skin in a half-site comparison on barrier-related parameters.

METHODS

Thirty healthy volunteers with self-reported sensitive and so-called problematic skin performed standardized washings with a soap-free washing emulsion with mild acidity (pH 5.5) for 3 weeks. Test areas were both forearms and the cheek. Non-invasive biophysical measurements of the following skin parameters, epidermal permeability barrier function measured as transepidermal water loss (TEWL), stratum corneum (SC) hydration, pH value, skin surface lipids, skin temperature and SC integrity/cohesion, were assessed prior to the first washing, on days 7, 14 and 21 after beginning the washing procedure. SC cohesion was quantified using two independent methods on D-Squame tapes: optical spectroscopy measuring the absorbance and a protein assay assessing the total protein (Bradford). Both methods showed a good correlation. SC integrity was quantified by measuring TEWL after sequential stripping with D-Squame tapes.

RESULTS

The use of the washing emulsion led to a mild damage of the epidermal permeability barrier function with no marked difference to water application. Furthermore, a mild but significant dehydration was assessed after 21 days vs. baseline without any differences between the water-treated and the washing emulsion-treated forearm. On the cheek no dehydration was detectable but the lipid content was reduced under the washing emulsion. The pH value increased in all three test areas after 21 days, again without significant differences between water and the washing solution. SC cohesion was quantified using two independent methods on D-Squame tapes: optical spectroscopy measuring the absorbance and a protein assay assessing the total protein (Bradford). Both methods showed a good correlation. The SC cohesion decreased after 21 days on the water-treated as well as on the washing emulsion-treated arm. The decrease over time was significant when used the optical spectroscopy measuring. A standardized questionnaire revealed positive characteristics of the washing emulsion and good acceptance.

CONCLUSION

The investigated standardized washing model with the endpoints epidermal barrier function, SC hydration, surface pH, skin surface lipids, skin temperature and SC integrity/cohesion showed only mild damage comparable to washing with water.

Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs

The etiology of nosocomial infections, the frequency of contaminated hands with the different nosocomial pathogens, and the role of health care workers' hands during outbreaks suggest that a hand hygiene preparation should at least have activity against bacteria, yeasts, and coated viruses. The importance of efficacy in choosing the right hand hygiene product is reflected in the new Centers for Disease Control and Prevention guideline on hand hygiene (J. M. Boyce and D. Pittet, Morb. Mortal. Wkly. Rep. 51:1-45, 2002). The best antimicrobial efficacy can be achieved with ethanol (60 to 85%), isopropanol (60 to 80%), and n-propanol (60 to 80%). The activity is broad and immediate. Ethanol at high concentrations (e.g., 95%) is the most effective treatment against naked viruses, whereas n-propanol seems to be more effective against the resident bacterial flora. The combination of alcohols may have a synergistic effect. The antimicrobial efficacy of chlorhexidine (2 to 4%) and triclosan (1 to 2%) is both lower and slower. Additionally, both agents have a risk of bacterial resistance, which is higher for chlorhexidine than triclosan. Their activity is often supported by the mechanical removal of pathogens during hand washing. Taking the antimicrobial efficacy and the mechanical removal together, they are still less effective than the alcohols. Plain soap and water has the lowest efficacy of all. In the new Centers for Disease Control and Prevention guideline, promotion of alcohol-based hand rubs containing various emollients instead of irritating soaps and detergents is one strategy to reduce skin damage, dryness, and irritation. Irritant contact dermatitis is highest with preparations containing 4% chlorhexidine gluconate, less frequent with nonantimicrobial soaps and preparations containing lower concentrations of chlorhexidine gluconate, and lowest with well-formulated alcohol-based hand rubs containing emollients and other skin conditioners. Too few published data from comparative trials are available to reliably rank triclosan. Personnel should be reminded that it is neither necessary nor recommended to routinely wash hands after each application of an alcohol-based hand rub. Long-lasting improvement of compliance with hand hygiene protocols can be successful if an effective and accessible alcohol-based hand rub with a proven dermal tolerance and an excellent user acceptability is supplied, accompanied by education of health care workers and promotion of the use of the product.

Correlation between pH and irritant effect of cleansers marketed for dry skin

BACKGROUND

Although it is important that dermatologists and the general population know the irritation potential of products marketed for dry skin used for body cleansing, this information is not usually available.

OBJECTIVE

To assess the irritative effect of different soaps and liquid cleansers recommended for sensitive skin. To study the correlation of the irritation effect of each substance with its pH and with the presence or absence of syndet in the product.

METHODS

Seventeen products marketed for dry skin and 12 common soaps used by the general population were studied. Fresh soap emulsions (8%) were applied to the volar side of the right forearm of 30 individuals with sensitive skin for 5 consecutive days using aluminum chambers. The appearance of irritation (erythema, scaling and fissures) was recorded, scored, and expressed in an Irritation index (IrIn). The pH of each solution was measured.

RESULTS

Products with a low IrIn were White Dove (Dove, Lever Pond's, Toronto, Ontario, Canada), Dove Baby, Cetaphil (bar) (Cetaphil, Gulderma Lab., Forth Worth, TX, USA), Dove liquid cleanser for hands, Dove pink, and Aderma (Adenma, Pierre Fabre, Dermo-Cosmetique, Boulagne, France). Most corresponded to syndet products. Among the most used brand-name soap, Camay Classic (Camay, Procter & Gamble de Mexico, México, U.F.) had the lowest IrIn. Dove Baby was the only product with a neutral pH. A significant correlation between pH and the IrIn of cleansers was found (P < 0.006).

CONCLUSIONS

Most products recommended for sensitive skin have a considerable irritation effect, which is related to the pH of the product. Better regulation of advertisement specifications including the pH level and type of cleanser contained is necessary for the majority of soaps and cleansers.

Calcium and potassium inhibit barrier recovery after disruption, independent of the type of insult in hairless mice

Disruption of the cutaneous permeability barrier induces metabolic responses in the epidermis which result in barrier recovery. Barrier disruption by either solvent treatment or tape stripping results in the loss of the epidermal calcium gradient. Previous studies in acetone treated hairless mice have shown that maintaining this calcium gradient inhibits barrier repair, suggesting that alterations in the epidermal calcium concentration may be an important signal for barrier homeostasis. In the present study, we show that in hairless mice disruption of the barrier by treatment with the detergent, SDS, also results in the loss of the calcium gradient, as demonstrated both semi-quantitatively with ultrastructural cytochemical localization and quantitatively using proton induced X-ray emission (PIXE). Additionally, immersion in calcium containing solutions delays barrier repair after either detergent (SDS treatment) or mechanical (tape stripping) disruption of the barrier, as reported previously for acetone treated skin. These results indicate that barrier disruption, regardless of the insult, induces changes in the epidermal calcium gradient which may play an important role in signaling the metabolic changes required for barrier homeostasis.