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Hui A, Chimhini G, Saungweme M, Kaisi D, Munetsi E, Mujuru HA, Darmstadt GL. Postnatal care and acceptability of emollient therapy in very low birthweight infants in Harare, Zimbabwe: a qualitative analysis. BMC Pediatr 2024; 24:187. [PMID: 38493088 PMCID: PMC10943868 DOI: 10.1186/s12887-024-04661-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 02/21/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Preterm birth (birth before 37 completed weeks of pregnancy) is the leading cause of neonatal and child under-five mortality globally, both of which are highest regionally in sub-Saharan Africa. The skin barrier plays a critical role in neonatal health and increasing evidence supports the use of topical emollient therapy to promote postnatal growth and reduce hospital-acquired infections in preterm infants. The World Health Organization (WHO) currently recommends emollient therapy in preterm or low birthweight infants globally but calls for further research on impacts of emollient use, especially in Africa. Little is known about postnatal skincare practices and the tradition of oil massage across sub-Saharan Africa. Further documentation is necessary to understand the context for future emollient intervention trials. METHODS 61 semi-structured interviews with mothers who just delivered preterm or term infants and 4 focus group discussions (32 participants) with physician and nurse providers of newborn care were conducted at Sally Mugabe Central Hospital (SMCH), in Harare, Zimbabwe. SMCH is the principal public-sector tertiary care hospital for newborn infants in the northern part of the country. Mothers and healthcare professionals were questioned about newborn care at the hospital, current neonatal skincare and bathing practices, and the community's receptivity to a future emollient therapy clinical trial. RESULTS Postnatal skincare is centrally important to Zimbabwean communities and petroleum jelly application is nearly universal. The use of cooking oil and other natural oils on infants is also part of traditional customs. The primary needs and desires of mothers who have just given birth to preterm infants are having greater agency in their children's care and financial support in purchasing prescribed medications while at the hospital. Community receptivity to emollient therapy as a cost-effective treatment is high, particularly if mothers are trained to assist with the intervention. CONCLUSION Emollient therapy will likely be well-received by communities in and around Harare because of its accordance with current skincare practices and perceptions; however, cultural norms and the experiences of new mothers who have given birth at a facility highlight challenges and considerations for future clinical trial execution. TRIAL REGISTRATION Clinicaltrials.gov NCT05461404.
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Affiliation(s)
- Alexa Hui
- Human Biology Program, Stanford University, Stanford, CA, USA
| | - Gwendoline Chimhini
- Child and Adolescent Health Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Margaret Saungweme
- Child and Adolescent Health Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Dorah Kaisi
- Child and Adolescent Health Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Elisabeth Munetsi
- Child and Adolescent Health Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Hilda A Mujuru
- Child and Adolescent Health Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe.
| | - Gary L Darmstadt
- Prematurity Research Center, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
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Blanks KJH, Musaba MW, Ren L, Burgoine K, Mukunya D, Clarke A, Williams S, Gebremichael T, Waiswa P, Darmstadt GL. Neonatal emollient therapy and massage practices in Africa: a scoping review. Int Health 2024; 16:152-164. [PMID: 37480339 PMCID: PMC10911534 DOI: 10.1093/inthealth/ihad052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 06/09/2023] [Accepted: 06/23/2023] [Indexed: 07/24/2023] Open
Abstract
There have been few reports from Africa on the use and health effects of emollient therapy for newborn infants. We aimed to describe neonatal skin care practices in Africa, and to illuminate opportunities to introduce evidence-based interventions to improve these practices. We conducted a scoping review of the quantitative and qualitative published peer-reviewed and grey literature in English on emollient use in Africa. Outcomes of interest included neonatal skin care practices, with a focus on the application of oils and other products to infant skin, including in association with bathing and massage. We screened 5257 articles and summarised findings from 23 studies-13 qualitative, nine quantitative and one mixed methods-that met our study criteria. Seven studies reported the use of emollients for perceived benefits, including thermal care, treatment for illness, promotion of growth and development, infection reduction, skin condition improvement, spirituality and lubrication to aid massage. Four studies reported the quantitative health impact of skin care product applications, including improvements in skin condition, neurodevelopment and bone growth, as well as a reduction in nosocomial infections. This review highlights opportunities for skin care intervention and future research on neonatal skin care practices in Africa.
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Affiliation(s)
| | - Milton W Musaba
- Department of Obstetrics and Gynaecology, Busitema University Faculty of Health Sciences, Pallisa, Mbale, PO Box 1460, Uganda
| | - Lily Ren
- Lane Medical Library, Stanford Medicine, Stanford University, 300 Pasteur Drive, L109, Stanford, CA 94305, USA
| | - Kathy Burgoine
- Mbale Clinical Research Institute, Plot 29, 33 Pallisa, Mbale, Uganda
| | - David Mukunya
- Busitema University Faculty of Health Sciences, Pallisa, Mbale, PO Box 1460, Uganda
- Sanyu Africa Research Institute, Mbale, PO Box 2190, Uganda
| | - Andrew Clarke
- Global Programs, Save the Children UK, 1 St John's Lane, London EC1M 4AR, UK
| | - Sarah Williams
- Global Programs, Save the Children UK, 1 St John's Lane, London EC1M 4AR, UK
| | | | - Peter Waiswa
- Makerere University School of Public Health, College of Health Sciences, Plot 1 New Mulago Hospital Complex, Kampala, Uganda
| | - Gary L Darmstadt
- Prematurity Research Center, Department of Pediatrics, Stanford University School of Medicine, 1701 Page Mill Road, Palo Alto, CA 94304, USA
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Darmstadt GL, Al Jaifi NH, Arif S, Bahl R, Blennow M, Cavallera V, Chou D, Chou R, Comrie-Thomson L, Edmond K, Feng Q, Riera PF, Grummer-Strawn L, Gupta S, Hill Z, Idowu AA, Kenner C, Kirabira VN, Klinkott R, De Leon-Mendoza S, Mader S, Manji K, Marriott R, Morgues M, Nangia S, Portela A, Rao S, Shahidullah M, Tran HT, Weeks AD, Worku B, Yunis K. New World Health Organization recommendations for care of preterm or low birth weight infants: health policy. EClinicalMedicine 2023; 63:102155. [PMID: 37753445 PMCID: PMC10518507 DOI: 10.1016/j.eclinm.2023.102155] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 09/28/2023] Open
Abstract
Approximately 11% of infants are born preterm, and complications of prematurity are the most common cause of death in children aged under five years. Almost one million preterm infants die each year across low, high and middle income countries. In 2021, the World Health Organization (WHO) convened a Guideline Development Group (GDG) to examine evidence and formulate recommendations for care of preterm or low birthweight (LBW) infants according to WHO Guideline Review Committee (GRC) criteria. GRADE methods were used to assess the certainty of evidence and the GDG developed judgements using the DECIDE (Developing and Evaluating Communication strategies to support Informed Decisions and practice based on Evidence) framework. Twenty-five recommendations were made; 11 recommendations were new, and 16 were for preventive and promotive care. Kangaroo Mother Care (KMC) was recommended to start immmediately after birth as routine care for all preterm or LBW newborns (except for critically ill infants who are in shock, unable to breath spontaneously after resuscitation, or require ventilatory support) both in the facility and at home. New recommendations were also made for caffeine to treat apnoea and for extubation; family involvement in routine care for preterm or LBW infants; and for post-discharge home-visit follow-up care. New recommendations were also made to consider use of probiotics, emollient therapy, caffeine for prevention of apnoea, continuous positive airway pressure (CPAP) immediately after birth (with or without respiratory distress) in infants less than 32 weeks gestational age; and for family support to enable the care of preterm or LBW infants. The recommendations confirm the pivotal role of preventive and promotive care for preterm and LBW infants, especially the importance of keeping the baby and mother together, and empowering and supporting families to care for their preterm or LBW infant. WHO is now working to help scale up care for small and sick newborns, including organizational shifts in all 'health system building blocks' such as infrastructure, commodities, workforce and monitoring. Funding Nil.
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Elias PM, Man MQ, Darmstadt GL. Optimised emollient mixture for skin barrier repair: Applications to global child health. J Glob Health 2022; 12:03019. [PMID: 35486585 PMCID: PMC9078150 DOI: 10.7189/jogh.12.03019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Peter M Elias
- Department of Dermatology, University of California, Northern California Institute for Research and Education, and Veterans Affairs Health Care Center, San Francisco, California, USA
| | - Mao-Qiang Man
- Department of Dermatology, University of California, Northern California Institute for Research and Education, and Veterans Affairs Health Care Center, San Francisco, California, USA
| | - Gary L Darmstadt
- Prematurity Research Center, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
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Kumar V, Kumar A, Mishra S, Kan P, Ashraf S, Singh S, Blanks KJH, Baiocchi M, Limcaoco M, Ghosh AK, Kumar A, Krishna R, Stevenson DK, Tian L, Darmstadt GL, Darmstadt GL, Elias PM, Ghosh AK, Kan P, Krishna R, Kumar A, Kumar A, Kumar V, Mehrotra H, Mishra S, Patil P, Sahu A, Singh P, Singh S, Singh V, Stevenson DK, Tian L, Yadav R. Effects of emollient therapy with sunflower seed oil on neonatal growth and morbidity in Uttar Pradesh, India: a cluster-randomized, open-label, controlled trial. Am J Clin Nutr 2022; 115:1092-1104. [PMID: 34982820 PMCID: PMC8970981 DOI: 10.1093/ajcn/nqab430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 12/29/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Newborn oil massage is a widespread practice. Vigorous massage with potentially harmful products and forced removal of vernix may disrupt skin barrier integrity. Hospitalized, very-preterm infants treated with sunflower seed oil (SSO) have demonstrated improved growth but community-based data on growth and health outcomes are lacking. OBJECTIVES We aimed to test whether SSO therapy enhances neonatal growth and reduces morbidity at the population level. METHODS We conducted an open-label, controlled trial in rural Uttar Pradesh, India, randomly allocating 276 village clusters equally to comparison (usual care) and intervention comprised of promotion of improved massage practices exclusively with SSO, using intention-to-treat and per-protocol mixed-effects regression analysis. RESULTS We enrolled 13,478 and 13,109 newborn infants in demographically similar intervention and comparison arms, respectively. Adherence to exclusive SSO increased from 22.6% of intervention infants enrolled in the first study quartile to 37.2% in the last quartile. Intervention infants gained significantly more weight, by 0.94 g · kg-1 · d-1 (95% CI: 0.07, 1.82 g · kg-1 · d-1, P = 0.03), than comparison infants by intention-to-treat analysis. Restricted cubic spline regression revealed the largest benefits in weight gain (2-4 g · kg-1 · d-1) occurred in infants weighing <2000 g at birth. Weight gain in intervention infants was higher by 1.31 g · kg-1 · d-1 (95% CI: 0.17, 2.46 g · kg-1 · d-1; P = 0.02) by per-protocol analysis. Morbidities were similar by intention-to-treat analysis but in per-protocol analysis rates of hospitalization and of any illness were reduced by 36% (OR: 0.64; 95% CI: 0.44, 0.94; P = 0.02) and 44% (OR: 0.56; 95% CI: 0.40, 0.77; P < 0.001), respectively, in treated infants. CONCLUSIONS SSO therapy improved neonatal growth, and reduced morbidities when applied exclusively, across the facility-community continuum of care at the population level. Further research is needed to improve demand for recommended therapy inside hospital as well as in community settings, and to confirm these results in other settings.This trial was registered at www.isrctn.com as ISRCTN38965585 and http://ctri.nic.in as CTRI/2014/12/005282.
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Affiliation(s)
| | | | | | - Peiyi Kan
- Prematurity Research Center, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | - Michael Baiocchi
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Mika Limcaoco
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | - David K Stevenson
- Prematurity Research Center, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Lu Tian
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA, USA
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Kumar A, Mishra S, Singh S, Ashraf S, Kan P, Ghosh AK, Kumar A, Krishna R, Stevenson DK, Tian L, Elias PM, Darmstadt GL, Kumar V. Effect of sunflower seed oil emollient therapy on newborn infant survival in Uttar Pradesh, India: A community-based, cluster randomized, open-label controlled trial. PLoS Med 2021; 18:e1003680. [PMID: 34582448 PMCID: PMC8478176 DOI: 10.1371/journal.pmed.1003680] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 06/01/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hospitalized preterm infants with compromised skin barrier function treated topically with sunflower seed oil (SSO) have shown reductions in sepsis and neonatal mortality rate (NMR). Mustard oil and products commonly used in high-mortality settings may possibly harm skin barrier integrity and enhance risk of infection and mortality in newborn infants. We hypothesized that SSO therapy may reduce NMR in such settings. METHODS AND FINDINGS This was a population-based, cluster randomized, controlled trial in 276 clusters in rural Uttar Pradesh, India. All newborn infants identified through population-based surveillance in the study clusters within 7 days of delivery were enrolled from November 2014 to October 2016. Exclusive, 3 times daily, gentle applications of 10 ml of SSO to newborn infants by families throughout the neonatal period were recommended in intervention clusters (n = 138 clusters); infants in comparison clusters (n = 138 clusters) received usual care, such as massage practice typically with mustard oil. Primary analysis was by intention-to-treat with NMR and post-24-hour NMR as the primary outcomes. Secondary analysis included per-protocol analysis and subgroup analyses for NMR. Regression analysis was adjusted for caste, first-visit weight, delivery attendant, gravidity, maternal age, maternal education, sex of the infant, and multiple births. We enrolled 13,478 (52.2% male, mean weight: 2,575.0 grams ± standard deviation [SD] 521.0) and 13,109 (52.0% male, mean weight: 2,607.0 grams ± SD 509.0) newborn infants in the intervention and comparison clusters, respectively. We found no overall difference in NMR in the intervention versus the comparison clusters [adjusted odds ratio (aOR) 0.96, 95% confidence interval (CI) 0.84 to 1.11, p = 0.61]. Acceptance of SSO in the intervention arm was high at 89.3%, but adherence to exclusive applications of SSO was 30.4%. Per-protocol analysis showed a significant 58% (95% CI 42% to 69%, p < 0.01) reduction in mortality among infants in the intervention group who were treated exclusively with SSO as intended versus infants in the comparison group who received exclusive applications of mustard oil. A significant 52% (95% CI 12% to 74%, p = 0.02) reduction in NMR was observed in the subgroup of infants weighing ≤1,500 g (n = 589); there were no statistically significant differences in other prespecified subgroup comparisons by low birth weight (LBW), birthplace, and wealth. No severe adverse events (SAEs) were attributable to the intervention. The study was limited by inability to mask allocation to study workers or participants and by measurement of emollient use based on caregiver responses and not actual observation. CONCLUSIONS In this trial, we observed that promotion of SSO therapy universally for all newborn infants was not effective in reducing NMR. However, this result may not necessarily establish equivalence between SSO and mustard oil massage in light of our secondary findings. Mortality reduction in the subgroup of infants ≤1,500 g was consistent with previous hospital-based efficacy studies, potentially extending the applicability of emollient therapy in very low-birth-weight (VLBW) infants along the facility-community continuum. Further research is recommended to develop and evaluate therapeutic regimens and continuum of care delivery strategies for emollient therapy for newborn infants at highest risk of compromised skin barrier function. TRIAL REGISTRATION ISRCTN Registry ISRCTN38965585 and Clinical Trials Registry-India (CTRI/2014/12/005282) with WHO UTN # U1111-1158-4665.
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Affiliation(s)
- Aarti Kumar
- Community Empowerment Lab, Lucknow, Uttar Pradesh, India
| | - Shambhavi Mishra
- Community Empowerment Lab, Lucknow, Uttar Pradesh, India
- Department of Statistics, Lucknow University, Lucknow, Uttar Pradesh, India
| | | | - Sana Ashraf
- Community Empowerment Lab, Lucknow, Uttar Pradesh, India
| | - Peiyi Kan
- Prematurity Research Center, Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America
| | | | | | - Raghav Krishna
- Community Empowerment Lab, Lucknow, Uttar Pradesh, India
| | - David K. Stevenson
- Prematurity Research Center, Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America
| | - Lu Tian
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California, United States of America
| | - Peter M. Elias
- Department of Dermatology, University of California, San Francisco, California, United States of America
| | - Gary L. Darmstadt
- Prematurity Research Center, Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America
| | - Vishwajeet Kumar
- Community Empowerment Lab, Lucknow, Uttar Pradesh, India
- * E-mail:
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Huang LN, Zhong YP, Liu D, Wang XH, Gong CY, Wen S, Elias PM, Yang B, Man MQ. Adverse cutaneous reactions to skin care products on the face vary with age, but not with sex. Contact Dermatitis 2018; 79:365-369. [PMID: 30206954 PMCID: PMC6234074 DOI: 10.1111/cod.13102] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/20/2018] [Accepted: 07/22/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Adverse skin reactions to skin care products have been increasing in recent years. However, to date, these reactions have not been well characterized. OBJECTIVE To describe the symptoms, clinical signs and frequency of adverse cutaneous reactions to skin care products on the face in males vs females of various ages. PATIENTS AND METHODS All outpatients diagnosed with adverse cutaneous reactions to skin care products on the face examined by dermatologists at the Dermatology Hospital of South Medical University between November 1, 2016 and October 31, 2017, employing a questionnaire and an interview, were eligible. The associations of adverse cutaneous reactions with age and sex were analysed. RESULTS A total of 433 outpatients, accounting for 0.12% of all outpatients, were assessed. Of these, 223 patients, including 204 females and 19 males, aged 4 to 75 years, were eventually diagnosed with adverse reactions to skin care products on the face. Eighty-two per cent of patients experienced pruritus, 80% showed erythema, and 48% showed visible swelling. The incidence rates of both xerosis and oedema correlated positively with age, whereas acne-like lesions were negatively associated with age, but not with sex. CONCLUSIONS Our results indicate that pruritus, xerosis and erythema are common adverse cutaneous reactions to facial skin care products. These reactions vary with age, but not with sex. Vigorous safety testing should precede the marketing of skin care products.
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Affiliation(s)
- Li-ning Huang
- Dermatology Hospital, Southern Medical University, Guangdong, P.R. China
| | - Yi-ping Zhong
- Dermatology Hospital, Southern Medical University, Guangdong, P.R. China
| | - Dan Liu
- Dermatology Hospital, Southern Medical University, Guangdong, P.R. China
| | - Xiao-hua Wang
- Dermatology Hospital, Southern Medical University, Guangdong, P.R. China
| | - Can-yi Gong
- Dermatology Hospital, Southern Medical University, Guangdong, P.R. China
| | - Si Wen
- Dermatology Hospital, Southern Medical University, Guangdong, P.R. China
| | - Peter M. Elias
- Dermatology Services, Veterans Affairs Medical Center and University of California San Francisco, California
| | - Bin Yang
- Dermatology Hospital, Southern Medical University, Guangdong, P.R. China
| | - Mao-Qiang Man
- Dermatology Hospital, Southern Medical University, Guangdong, P.R. China
- Dermatology Services, Veterans Affairs Medical Center and University of California San Francisco, California
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Ye L, Wang Z, Li Z, Lv C, Man MQ. Validation of GPSkin Barrier ® for assessing epidermal permeability barrier function and stratum corneum hydration in humans. Skin Res Technol 2018; 25:25-29. [PMID: 29863296 DOI: 10.1111/srt.12590] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Measurements of transepidermal water loss (TEWL) and stratum corneum (SC) hydration are important for assessing epidermal functions. However, the availability of reliable and user-friendly devices, which can simultaneously measure both TEWL and SC hydration and can allow health providers to remotely access data in time, is limited. MATERIALS AND METHODS GPSkin Barrier® was compared with MPA5 system in the measurements of TEWL and SC hydration on the cheek, the dorsal hand, and the forearm in 200 normal volunteers, including 126 females and 74 males, aged 1-78 years with an average age of 45.24 ± 1.04 years. Correlation of data measured with MPA5 system and GPSkin Barrier® was determined. RESULTS Levels of both TEWL and SC hydration measured with the Barrie GPSkin Barrier® were lower than that with MPA5 system on all 3 body sites except for hydration on the cheek. The levels of both TEWL and SC hydration measured with GpSkin Barrier® were correlated well with that measured with MPA5 system on all 3 body sites CONCLUSIONS: GPSkin Barrier® is a reliable, affordable, and versatile device for assessing epidermal permeability barrier function and SC hydration.
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Affiliation(s)
- L Ye
- Dalian Skin Disease Hospital, Dalian, Liaoning, China
| | - Z Wang
- Department of Dermatology, The 7th People's Hospital of Shenyang City, Shenyang, Liaoning, China
| | - Z Li
- Department of Dermatology, The 2nd Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - C Lv
- Dalian Skin Disease Hospital, Dalian, Liaoning, China
| | - M-Q Man
- Dermatology Services, Veterans Affair Medical Center and University of California, San Francisco, CA, USA
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