Variations in sacral oedema levels over continuous 60-degree head of bed elevation positioning in healthy adults: An observational study

BackgroundSubepidermal moisture (SEM) scanning is a novel technology that measures changes in localised oedema. Accumulation of subepidermal oedema is associated with early tissue damage that may lead to a pressure injury.AimThe primary study objective was to observe the variations in sacral subepidermal oedema levels over a continuous period of 60-degree head of bed elevation positioning.MethodsHealthy adult participants were recruited in this prospective observational study. Participants were positioned at 60-degree head of bed elevation for 120 min and sacral SEM measurements were collected at baseline and in 20 min increments.ResultsA total of 20 participants with a mean age of 39.3 years (SD = 14.7) were recruited. The mean SEM delta value increased 6.3% from 0.46 SEM delta at baseline to 0.49 SEM delta after 120 min, however these differences are not statistically significant (p = .21). There were also no significant findings between SEM delta variations and demographic factors.ConclusionIn a sample of healthy individuals, 120 min of continuous loading with a 60-degree head of bed elevation did not lead to a significant change in sacral subepidermal oedema levels. Further research on the response of healthy adult tissue under external forces associated with different angles of head of bed positioning may further contribute to our understanding pressure injury prevention.     

Effects of Particulate Matter on Healthy Skin: A Comparative Study between High- and Low-Particulate Matter Periods

BackgroundThe influence of airborne particulate matter (PM) on skin has primarily been studied in patients with skin diseases such as atopic dermatitis. Recently, the effect of PM on healthy human skin has gained attention.ObjectiveTo evaluate the relationship between PM concentration and objective skin changes in healthy subjects.MethodsThis prospective study enrolled 25 healthy volunteers without any skin disease. Data regarding daily meteorological parameters and air pollution were collected during a high-PM period and a low-PM period for 14 days. Environmental and lifestyle factors that might influence skin conditions of subjects were also collected during the study period. Biophysical parameters of the skin such as transepidermal water loss (TEWL), hydration, erythema index, and melanin index were measured. Pores, wrinkles, sebum, and skin tone were evaluated using a facial analysis system.ResultsMean TEWL value during the high-PM period was significantly higher than that during the low-PM period (10.16 g/m²/h vs. 5.99 g/m²/h; p=0.0005). Mean erythema index was significantly higher in the high-PM period than that in the low-PM period (4.3 vs. 3.42; p=0.038). For facial analysis system indices, uniformity of skin tone was higher in the low-PM period than that in the high-PM period (p<0.0001). In addition, with increasing PM₁₀ and PM_2.5, TEWL also showed increase when other environmental components were constant (regression coefficient [RC]=0.1529, p<0.0001 for PM₁₀; RC=0.2055, p=0.0153 for PM_2.5).ConclusionIncreased PM concentrations may contribute to disturbed barrier function, increased facial erythema, and uneven skin tone even in healthy human skin.     

The effect of head of bed elevation on sacral and heel subepidermal moisture in healthy adults: A randomised crossover study

BackgroundSubepidermal moisture (SEM) changes may detect early tissue injury and enhance pressure injury risk assessments. However, little is known how modifiable factors, like head of bed elevation (HOBE), affect SEM.AimThis study investigated the influence of HOBE on sacral and heel SEM, using the Provizio ® SEM Scanner.MethodA 2 × 2 randomised crossover study compared the effects of 30-min of 30? versus 60? HOBE on sacral and heel SEM in healthy adults.Results48 participants were randomly allocated to 30? or 60? HOBE and crossed over after a 60-min washout period. The mean age was 40.6 years (SD = 18.3). The study found the sacral and heel SEM values were not statistically different at 30? versus 60? HOBE. No clinically relevant association between SEM and characteristics of age, sex, body mass index and skin type were found. Baseline sacral and heel SEM values recovered after a 60-min washout period. Notably, half of the initial baseline measures suggested pressure injury risk.ConclusionThe HOBE may not influence SEM at the sacrum and heels, in healthy adults after 30 min of loading. Standard operating procedures for measuring SEM for pressure injury risk assessment require a stronger body of evidence in varied populations and timeframes before this technology is widely adopted.Trial registrationAustralian and New Zealand Clinical Trials Registry ACTRN12622001456741.     

A quantitative study of hydration level of the skin surface and erythema on conventional and microclimate management capable mattresses and hospital beds

BackgroundIn addition to pressure itself, microclimate factors are gaining more attention in the understanding of the development of pressure ulcers. While there are already various products to reduce pressure on sore-prone areas to prevent pressure ulcers, there are only a few mattresses/hospital beds that actively influence skin microclimate. In this study, we investigated if microclimate management capable mattresses/hospital beds can influence skin hydration and skin redness/erythema.MethodsWe included 25 healthy subjects in our study. Measurements were made using Courage & Khazaka Multi Probe Adapter MPA with Corneometer CM825 and Mexameter MX18 to determine skin hydration of the stratum corneum and skin redness/erythema before and after the subjects were lying in conventional (Viskolastic® Plus, Wulff Med Tec GmbH, Fedderingen, Germany and Duo™ 2 mattress, Hill-Rom GmbH Essen, Germany) or microclimate management capable mattresses/hospital beds (ClinActiv + MCM™ and PEARLS AFT, Hill-Rom GmbH Essen, Germany).ResultsWhile there was no difference in skin redness/erythema on the different mattresses/hospital beds, skin hydration of the stratum corneum decreased significantly in an air fluidized bed compared to baseline values and values measured on standard mattress/Viskolastic® Plus.ConclusionAir-fluidized therapy reduces skin hydration and therefore could contribute to prevent moisture associated ulcers. Changes in skin hydration as one important factor of skin microclimate can be detected after a short time of incubation and even before an erythema appears.     

Rubeosis faciei diabeticorum is not associated with oxidative stress and skin autofluorescence

BackgroundRubeosis faciei diabeticorum is a persistent facial erythema in patients with diabetes mellitus. The actual pathogenesis has not been studied. However, it is speculated to be a cutaneous diabetic microangiopathy.ObjectiveExamine the correlation between the severity of facial erythema and the possible causes of microvascular diabetic complications, namely oxidative stress, hyperglycemia, and cutaneous accumulation of advanced glycation end-products .MethodsPatients diagnosed with Type 2 diabetes mellitus (n = 32) were enrolled in the study. The facial erythema index was measured using the Mexameter MX18; cutaneous accumulation of advanced glycation end-products was estimated by measuring skin auto fluorescence with the AGE Reader (DiagnOptics Technologies B.V. – Groningen, Netherlands). Glycated haemoglobin, total antioxidant status, and malondialdehyde were measured in blood by TBARS assay. The correlation between the selected variables was assessed by Spearman's rank test; p ≤ 0.05 was considered statistically significant.ResultsThere was a statistically significant correlation between total antioxidant status and the facial erythema index (ρ = 0.398, p = 0.024). Malondialdehyde, skin autofluorescence, glycated haemoglobin, body mass index, duration of diabetes, and age did not demonstrate statistically significant correlation with the facial erythema index.Study limitationsThis is an observational study. Elevation of total antioxidant status could have been caused by several factors that might have also influenced the development of rubeosis faciei, including hyperbilirubinemia and hyperuricemia.ConclusionsThe results contradicted expectations. Total antioxidant status correlated positively with facial erythema index; however, there was no correlation with oxidative stress and skin autofluorescence. Further investigations should be conducted to reveal the cause of total antioxidant status elevation in patients with rubeosis faciei.     

Skin temperature and vascular attributes as early warning signs of pressure injury

ObjectivesThis study aimed to validate the skin temperature on sacral region and vascular attributes as early warning signs of pressure injury.MethodsTotally 415 patients admitted to the adult intensive care unit from August 2018 to April 2019 were prospectively screened. Daily blood pressure and blood glucose affecting vascular attributes and the relative skin temperature of sacral region were measured for 10 consecutive days. Collect the changes of these indicators during the occurrence of pressure injury. The optimal cut-off values of indicators were determined by X-tile analysis. The risk ratios of indicators associated with pressure injury were compared using the Cox proportional hazards regression model.ResultsThere were no obvious interactions among blood pressure, blood glucose and relative skin temperature (P > 0.05). The optimal cutoff value for above indicators was 63.5 mmHg, 9.9 mmol/L and −0.1 °C, respectively. The incidence of pressure injury peaked on the 4th and 5th day after hospitalization when categorizing the patients into low- and high-risk groups according to the cutoff values (P < 0.05). Based on relative skin temperature, patients in the high-risk group were more likely to develop pressure injury (hazard ratio = 6.36, 95% confidence interval = 3.91, 10.36), when compared to the other two indicators of blood pressure and blood glucose.ConclusionStringent skin temperature and vascular attributes measurements were necessary for preventing pressure injury. Nursing measures should be taken according to warning sings to reduce the incidence of pressure injury.     

Quantifying facial skin erythema more precisely by analyzing color channels of The VISIA Red images

Background: The VISIA Red images were developed to document and measure facial skin erythema, but diffuse erythema cannot be fully segmented by the VISIA system due to the automatic thresholding segmentation method. Moreover, topical area analysis is not available in the system. Materials and methods: Erythema severity degrees of 20 simulated Red images were designated 1–20 with 1–20 inflammatory lesions for each, respectively. The RGB channel mean values of each simulated image were acquired by ImageJ and relative intensity of red values calculated. Results: The relative intensity of red values positively correlate to erythema severity with a coefficient of 0.999345 (p < 0.001). We also proposed a method for calibration when pustules were present in the erythema area. The method was proved by mathematical reasoning and verified by certified dermatologists. Conclusion: We demonstrated a simple and more precise method to quantify and compare facial skin erythema by analyzing the RGB channel values of the VISIA Red images. Our method brings convenience for erythema evaluation in dermatological studies.     

Topical polyphenolic antioxidants reduce the adverse effects of intense pulsed light therapy

Background: Intense pulsed light therapy (IPL) has been associated with erythema and increased lipid peroxidation. Polyphenolic antioxidants have been shown to decrease inflammation and reduce oxidative stress in irradiated skin. Objective: To determine whether the topical application of polyphenolic antioxidants to IPL‐treated skin reduced the adverse effects of IPL exposure. Methods: In a split‐face study, 10 volunteers underwent three full‐face IPL treatments (16 J/cm², 10ms, 560nm filter) spaced 3 weeks apart. A polyphenolic antioxidant solution was pneumatically applied to the left side of the face, beginning immediately before the first IPL treatment then weekly for six treatments. The lipid peroxide concentration, skin antioxidant level and skin moisture content were obtained before and after the study. Results: Skin treated with IPL alone contained a significantly higher concentration of lipid peroxides when compared to skin treated with IPL plus polyphenolic antioxidants (p<0.05). Skin treated with IPL alone contained a significantly lower level of polyphenolic antioxidants and had a significantly lower moisture content (p<0.05). Conclusions: In this study, the concurrent pneumatic topical application of polyphenolic antioxidants reduced lipid peroxidation and skin dehydration in IPL‐treated skin. Polyphenolic antioxidants may confer a protective effect on facial skin and enhance the effects of IPL therapy.     

The influence of incontinence pads moisture at the loaded skin interface

AimProlonged mechanical loading on soft tissues adjacent to bony prominences can lead to pressure ulcers. The presence of moisture at the skin interface will lower the tolerance to load. Absorbent pads manage moisture in individuals with incontinence, although their role in maintaining skin health is unknown. The present study investigated the effects of moist incontinence pads on skin physiology after periods of mechanical loading.Material and methodsTwelve healthy participants were recruited to evaluate a single incontinence pad design under three moisture conditions: 0% (dry), 50% and 100% fluid capacity. For each pad condition, pressure (9 kPa) or pressure in combination with shear (3 N) was applied to the sacrum, followed by a period of off-loading. Measures included trans-epidermal water loss (TEWL) and inflammatory biomarkers sampled at the skin interface.ResultsResults revealed no change in TEWL in the loaded dry pad condition. By contrast, when the pads contained moisture, significant increases in TEWL were observed. These increases were reversed during off-loading. Inflammatory biomarkers, specifically IL-1α/total protein ratio, were up-regulated during dry pad loading, which recovered during off-loading. Loaded moist pads caused a significant increase in biomarkers, which remained elevated throughout the test period.ConclusionThe study revealed a marked compromise to stratum corneum integrity when the skin was exposed to moist incontinence pads in combination with mechanical loads. These physiological changes were largely reversed during off-loading. Incontinence pads provided some protection in the dry state, although more research is required to determine optimal clinical guidance for their use.     

Not just quantity: Gluteus maximus muscle characteristics in able-bodied and SCI individuals – Implications for tissue viability

Study aimSome individuals with spinal cord injury (SCI) remain pressure ulcer (PU) free whilst others experience a recurring cycle of tissue breakdown. Detailed analysis of gluteal muscle characteristics may provide insights to local tissue viability variability. The study hypothesis was that SCI individuals have altered muscle composition compared to able-bodied (AB).MaterialsTen AB and ten SCI received a supine pelvic CT scan, with contrast.MethodsCross-sectional area (CSA) and overall muscle volume were derived using image analysis. Gluteal muscle tissue type was classified at the S2/S3 sacral vertebrae midpoint, the superior greater trochanters margin (GT) and the inferior ischial tuberosities margin (IT) using the linear transformation Hounsfield Unit scale.ResultsSCI gluteal CSA was less than for AB throughout the muscle, with the greatest relative atrophy at the IT (48%). Average AB gluteal volume was nearly double SCI. Eight SCI had over 20% infiltrative adipose tissue, three with over 50%. SCI gluteal CSA and intramuscular fat infiltration were significantly negatively correlated (p < 0.05). SCI IT axial slices showed less lean muscle and higher intramuscular fat infiltration than more proximally (p < 0.05).ConclusionSCI gluteal muscle characteristics were indicative of impaired tissue viability. SCI disuse muscle atrophy was anticipated; the analytic approach further indicated that intramuscular atrophy was not uniform. SCI muscle composition showed increased proportions of both low density muscle and adipose tissue. CT scan with contrast is effective for gluteal muscle characterization. This assessment technique may contribute to determination of personalized risk for PU development and other secondary complications.     

Spectrophotometric Measurement of Minimal Erythema Dose Sites after Narrowband Ultraviolet B Phototesting: Clinical Implication of Spetrophotometric Values in Phototherapy

Background

The spectrophotometer is well known to be a useful tool for estimating the objective minimal erythema dose (MED) during planning of phototherapy protocol. However, only a few spectrophotometric values are used to evaluate the erythema and pigmentation of the MED site during phototesting.

Objective

To determinea new meaning of the relationships among spectrophotometric values during phototesting.

Methods

Twenty-five patients with psoriasis and 23 patients with vitiligo were selected before undergoing narrowband ultraviolet B phototherapy. We interpreted the gross findings of erythema and measured the L^*a^*b^* values using a spectrophotometer at each phototest spot. We compared MEDs, basic spectrophotometric values (L^*a^*b^*), and b^*/L^* values separately according to skin type, and determined the correlation of each spectrophotometric value and the correlation between a^* and b^*/L^* values.

Results

Among L^*a^*b^* values, only b^* values showed a statistically significant difference between the type III and IV groups (p=0.003). There was a positive correlation only between MEDs and b^* values (p<0.05). The average b^*/L^*value in the type IV group was significantly higher than the type III group (p<0.05).

Conclusion

The higher b^* values in type IV skin indicates that skin tanning develops more prominently than type III. The correlation between MEDs and b^* values may signify that the skin pigmentation status is deepened with the higher MEDs. The difference in b^*/L^*values between type III and IV skin reflects that the b^*/L^*value is thought to be an index of tanning. The a^* value, known as an index of erythema, does not influence the degree of tanning.     

Dopamine effects on the microcirculation and veins of the skin after local application and their changes by antagonistic drugs

Summary Dopamine causes reflex erythema, central blanching, and piloerection depending on the dose and the type of application wheal reaction. Intracutaneous application shows from 1.5/0.1 ml wheal formation, erythema, piloerection, and blanching combined with increased heat radiation from the skin surface (AGA thermovision).Epicutaneous application from 500 ml (occlusive patch test) following horny layer stripping, causes marked blanching with weak piloerection. Iontophoretic application of dopamine 1/1,000 (60 s, 0.5 mA) causes only blanching and weak surrounding erythema; application of dopamine 1/100 additionally causes piloerection. This application shows no changing of infrared radiation. Iontophoretic application of dopamine 1/100 or 50 /0.1 ml i.c. in a blanched area after locally applied corticosteroids (McKenzie test) shows diminution of infrared radiation proved by AGA thermovision thermography. Antihistaminics, applied externally, decrease reddening, wheal development as well as blanching by dopamine.Guanethedine (1% in eucerin) increases the blanching phenomenon (false transmitter effect of dopamine). Phentolamine 1% in W/O emulsion is without effect on dopamine reaction. Caffeine ointment (4%) reduces erythema and accentuates the degree of blanching. Oral haloperidol has no influence on the dopamine skin reaction, but increases the blanching in areas of antihistamine treatment. Skin veins and varices show marked vasoconstriction within 10 min after iontophoretic (1:100, 3.5 mA, 60s) or i.c. application (50 /0.2 ml).Supported by the Paul-Unna-Stiftung     

Efficacy of a novel intense pulsed light system for the treatment of port wine stains

Abstract

Background and objectives: Port wine stains (PWS) are capillary malformations typically treated with lasers or with intense pulsed light (IPL). This paper summarizes our safety and efficacy findings for a new IPL designed to target the dermal vessels of PWS. Methods: The PWS received three to four treatments with a novel IPL containing a vascular-specific handpiece (LuxG?, dual wavelength band of 500–670 nm and 870–1400 nm; Palomar Medical Technologies, Inc.). Clinical benefit was assessed qualitatively with a quartile-assessment scale and quantitatively with a skinphotometer. Results: Three months post-treatment, over 50% of PWS exhibited statistically significant improvements of 51–75% or higher. The pre-treatment PWS mean erythema value of 189.72±18.40 (95% Confidence Interval [CI]) was reduced to 147.22±16.15 post-treatment, thereby approaching the normal skin erythema value of 117.61 ± 15.90. The mean percent reduction in vascularity at 3 months was statistically significant at ?55.4 (p=0.0000003). Treatments were well-tolerated with minimal to no subject downtime and limited side effects of transient erythema (all subjects) or mild crusting and mild purpura (n=1). Conclusion: These results demonstrate the efficacy and safety of this novel IPL in providing therapeutic benefit to patients suffering from PWS.     

Increased cutaneous oxygen availability by topical application of hydrogen peroxide cream enhances the photodynamic reaction to topical 5-aminolevulinic acid-methyl ester

Topical 5-aminolevulinic acid (ALA) and methyl aminolevulinate (MAL) photodynamic therapy (PDT) of skin lesions is an accepted treatment for skin tumours but success rates need improvement. The effectiveness of PDT is influenced by availability of oxygen. The aim of this study was to demonstrate, in normal skin, whether a decrease in skin oxygen tension reduces the photodynamic reaction (PDR); and whether the addition of topical hydrogen peroxide can reverse the effect. Topical MAL and red light were administered to the inner forearms of 40 healthy volunteers. Skin oxygen availability was lowered during the illumination phase of the PDT, by applying blanching pressure with a plastic slide. Topical hydrogen peroxide was applied under the pressure slide, immediately prior to illumination, to reverse the effect. Erythema was assessed by naked eye and laser Doppler perfusion imaging (LDPI), at baseline and at 1, 5, 24 and 48 h following illumination. Decreasing oxygen availability by pressure altered the PDR with a larger number of subjects (17.5%) not demonstrating any visible erythema at any time point after plastic slide pressure compared to a PDR Control site (7.5%). The addition of topical hydrogen peroxide during pressure application, restored the number of subjects showing no visible erythema compared to that of PDR Control. LDPI data showed that there was a decrease in mean perfusion after plastic slide pressure when comparing the change from baseline to 24 h (P < 0.05) with the PDR Control. The addition of hydrogen peroxide not only restored but also increased the mean perfusion compared to that of PDR Control when comparing the change from baseline to 5 h and the change from baseline to 24 h (P < 0.001). Increasing oxygen availability increased the PDR in normal skin. The possibility that addition of topical hydrogen peroxide to PDT protocols for non-melanoma skin cancer may increase reactivity and, thus, be relevant for outcomes warrants further study.     

Comparative Measurement of Biophysical Parameters in Consideration of Skin Graft Donor Site for Nasal Defects

BackgroundIn planning a skin graft, the texture, color, and size of the recipient and donor site tissues should be considered.ObjectiveWe determined the optimal donor sites for nasal full-thickness skin grafting based on biophysical parameters.MethodsThirty women over the age of 60 were selected for this study. Four recipient sites (nasal root, dorsum, tip, ala) and three donor sites (preauricle, postauricle, forehead) were considered. Biophysical parameters such as transepidermal water loss (TEWL), capacitance, sebum output, erythema/melanin value, and skin replica technique were tested.ResultsThe nasal root was correlated with the forehead in terms of TEWL and sebum output. The nasal dorsum was correlated with the preauricle in terms of TEWL, erythema/melanin value, and skin replica measurements. The nasal tip was correlated with the preauricle in terms of TEWL, sebum output, erythema/melanin value, and skin replica measurements. The ala was correlated with the forehead in terms of TEWL and skin replica measurements.ConclusionThe preauricule is the optimal donor site for resurfacing of the nasal dorsum and tip. The forehead is a good donor site for alar defects. For resurfacing of the nasal root, the forehead and postauricle are good choices.     

Sacral interface pressure can be alleviated by repositioning with a small-angle change using an automated bed in patients with spinal cord injury

Aim of the studyThis study aimed to compare interface pressure and total contact area of the sacral region in different positions, including small-angle changes, in patients with spinal cord injury (SCI). Furthermore, we analyzed the clinical factors influencing pressure to identify the pressure injury (PI) high-risk group.Materials and methodsAn intervention was conducted for patients with paraplegia (n = 30) with SCI. In the first and second trials, interface pressure and total contact area of the sacral region were recorded from large- and small-angled positions using the automatic repositioning bed, which can change the angle of the back, lateral tilt, and knee.ResultsPositions with back raised ≥45° showed significantly higher pressure on the sacrum than most other positions. The pressure and contact area differences were statistically insignificant for combinations of small-angled changes <30°.Additionally, the duration of injury (β = 0.51, p = 0.010) and neurological level of injury (NLI) (β = −0.47, p = 0.020) were significant independent predictors of average pressure. Similarly, the duration of injury (β = 0.64, p = 0.001), the Korean version of the spinal cord independence measure-III (β = −0.52, p = 0.017), and body mass index (BMI; β = −0.34, p = 0.041) were significant independent predictors of peak pressure.ConclusionsFor repositioning, combinations of small-angle changes <30° effectively reduce pressure on the sacral region in patients with SCI. Lower BMI, longer duration of injury, lower functioning score, and NLI ≥ T7 are predictors of high sacral pressures, which increase the risk for PI. Therefore, patients with these predictors require strict management.     

Minocycline and Its Impact on Microbial Dysbiosis in the Skin and Gastrointestinal Tract of Acne Patients

BackgroundAssociations between acne and gastrointestinal comorbidities suggest that microbial dysbiosis and intestinal permeability may promote inflammatory acne, a condition often managed with oral antibiotics.ObjectiveWe performed a case-control study to investigate the skin and gut microbiota in 8 acne patients before and after receiving oral minocycline compared to controls matched by age ±5 years, sex, and race.MethodsDNA was extracted from stool samples and facial skin swabs. Sequencing of the V3V4 region of the bacterial 16S rRNA gene was performed using Illumina MiSeq and analyzed using QIIME/MetaStats 2.0 software.ResultsAcne patients included 7 female and 1 male, ages 20~32. Shannon diversity was not significantly different between the skin (p=0.153) or gut (p<0.999) microbiota of acne patients before and after antibiotics. The gut microbiota in pre-antibiotic acne patients compared to acne-free controls was depleted in probiotics Lactobacillus iners (p=0.001), Lactobacillus zeae (p=0.001), and Bifidobacterium animalis (p=0.026). After antibiotics, the gut microbiota of acne patients was depleted in Lactobacillus salivarius (p=0.001), Bifidobacterium adolescentis (p=0.002), Bifidobacterium pseudolongum (p=0.010), and Bifidobacterium breve (p=0.042), while the skin microbiota was enriched in probiotics Bifidobacterium longum (p=0.028) and Leuconostoc mesenteroides (p=0.029) and depleted in Staphylococcus epidermidis (p=0.009) and Prevotella nigrescens (p=0.028). At the phylum level, significant enrichment of Bacteroidetes in stool of acne patients following antibiotic treatment (p=0.033) led to a decreased Firmicutes to Bacteroidetes ratio.ConclusionMinocycline produces significant derangements in the microbiota of the skin and gut, including many probiotic species, highlighting the potential for more targeted antimicrobial treatments for acne.