Original Paper Skin Pharmacol Physiol 2014;27:234–241 DOI: 10.1159/000354923
Received: April 5, 2013 Accepted after revision: August 8, 2013 Published online: May 8, 2014
Postnatal Maturation of Skin Barrier Function in Premature Infants V. Kanti a A. Bonzel d A. Stroux a, b H. Proquitté c C. Bührer c U. Blume-Peytavi a N. Garcia Bartels a a Department of Dermatology and Allergy, Clinical Research Center for Hair and Skin Science, b Department of Medical Statistics and Clinical Epidemiology, and c Department of Neonatology, Charité-Universitätsmedizin Berlin, Berlin, and d Department of Nephrology, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Germany
Key Words Skin barrier maturation · Preterm infant · Transepidermal water loss · Stratum corneum · pH · Sebum · Skin care · Diaper
Abstract Background: In preterm infants, skin barrier maturation entails regional variability. Objectives: To characterize postnatal skin barrier development in covered, uncovered and diapered regions in healthy premature infants over a longitudinal observation period. Methods: Transepidermal water loss (TEWL), stratum corneum hydration (SCH), pH and sebum were measured at postnatal ages of 1–7 days and 2–7 weeks on the forehead, abdomen, thigh and buttock of preterm infants (gestational age 30–37 weeks; n = 48) under monitored ambient conditions. A standard minimal skin care regimen was practised. Results: TEWL increased significantly on the buttock (p = 0.007), while remaining stable on the forehead, abdomen and thigh. SCH and sebum remained stable in all studied body regions with increasing age. On the buttock, pH increased (p = 0.049), while other body regions exhibited a significant decrease (p ≤ 0.019). TEWL (p < 0.001) and SCH (p ≤ 0.002) revealed significantly higher values on the buttock, compared to other body regions. Conclusions: Stable TEWL, SCH and sebum values may indicate a lack of
© 2014 S. Karger AG, Basel 1660–5527/14/0275–0234$39.50/0 E-Mail [email protected] www.karger.com/spp
skin barrier maturation. Postnatal decrease in skin pH suggests an adaptation process with acid mantle formation. Differences in skin barrier development were observed between anatomical regions. SCH, TEWL and pH values demonstrated a distinct course in the diaper area, indicating an impaired skin barrier function in this region. © 2014 S. Karger AG, Basel
Introduction
In preterm infants, the stratum corneum (SC) layer is thinner and less developed than in term infants and adults, leading to high water loss, percutaneous toxicity and systemic infections, with high morbidity and mortality [1, 2]. Even routine care, such as changing and bathing, can provoke skin irritation, due to compromised skin barrier function [3]. Special skin care regimens and incubator practices are mandatory to optimize and protect postnatal skin barrier function [3–5]. However, no scientifically based guidelines for standard skin care have yet been established for preterm infants, as few data are available about the maturation of skin barrier in this age group. Basic scientific research to gain deeper insight into skin barrier development in preterm infants is therefore important for advances in everyday clinical PD Dr. med. N. Garcia Bartels Department of Dermatology and Allergy Clinical Research Center for Hair and Skin Science, Charité-Universitätsmedizin Berlin Charitéplatz 1, DE–10117 Berlin (Germany) E-Mail natalie.garcia-bartels @ charite.de
issues, such as skin cleansing and use of emollients or oils [4, 6]. Neonatal skin barrier depends on a balance between different functional parameters and shows variability, depending on the body region that is investigated [7– 11]. Previous studies on preterm infants mainly concentrated on the effect of skin care on clinical parameters, like infection rate and morbidity with minor focus on skin functional parameters, such as transepidermal water loss (TEWL), stratum corneum hydration (SCH), surface acidity (pH) and skin surface lipids (sebum) [6, 12]. Limited data are available in preterm infants under adequate neonatal therapy with monitoring and documenting the exact ambient conditions and their correlation to barrier function [13]. In this study, we aimed to characterize postnatal skin barrier development in covered, uncovered and diapered regions in healthy premature infants with gestational age (GA) of 30–37 weeks over a longitudinal observation period and applying a standard minimal skin care to minimize external influence on data [10, 11].
Subjects and Methods Study Site and Population Premature infants were recruited from September 2003 through March 2006 at the Clinic for Neonatology, Charité-Universitätsmedizin Berlin. Inclusion criterion was a GA of 30–37 full weeks and written informed consent provided by guardians [14]. Exclusion criteria were: life-threatening state of health, acute or chronic diseases, body temperature 40 ° C or skin conditions with lesions covering more than 50% of the body surface. The trial was approved by the ethics committee of the Charité-Universitätsmedizin Berlin.
Outcomes Primary outcomes were TEWL, SCH, skin pH and sebum on the forehead, abdomen, thigh and buttock. Secondary outcomes were the effects of the variables GA, room temperature and humidity.
period of 5–10 min. Depending on physical conditions, measurements were performed under radiant warmer or incubator conditions. Room or incubator temperature and humidity were recorded with Room Condition Sensor (Courage & Khazaka). Functional parameters were measured on the forehead, abdomen (lateral to the navel), lateral surface of the upper leg and upper outer quadrant of the buttock. The volar forearm, a commonly used investigational area in children and full-term infants, was not chosen due to practical reasons: in preterm infants, the contact surface of the volar forearm is too small for the measurement device and is not easy to hold still. Standard skin care was practised: newborns were washed twice weekly after birth with tap water and a cotton washcloth. No preventive external therapies were used. Topical products were allowed on areas of skin trauma or diaper dermatitis: zinc paste, optionally with Nystatin; to remove meconium: oil; preventive care in the gluteal area and treatment of fissures on hands and feet: Vaseline. No skin care was performed
Received: April 5, 2013 Accepted after revision: August 8, 2013 Published online: May 8, 2014
Postnatal Maturation of Skin Barrier Function in Premature Infants V. Kanti a A. Bonzel d A. Stroux a, b H. Proquitté c C. Bührer c U. Blume-Peytavi a N. Garcia Bartels a a Department of Dermatology and Allergy, Clinical Research Center for Hair and Skin Science, b Department of Medical Statistics and Clinical Epidemiology, and c Department of Neonatology, Charité-Universitätsmedizin Berlin, Berlin, and d Department of Nephrology, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Germany
Key Words Skin barrier maturation · Preterm infant · Transepidermal water loss · Stratum corneum · pH · Sebum · Skin care · Diaper
Abstract Background: In preterm infants, skin barrier maturation entails regional variability. Objectives: To characterize postnatal skin barrier development in covered, uncovered and diapered regions in healthy premature infants over a longitudinal observation period. Methods: Transepidermal water loss (TEWL), stratum corneum hydration (SCH), pH and sebum were measured at postnatal ages of 1–7 days and 2–7 weeks on the forehead, abdomen, thigh and buttock of preterm infants (gestational age 30–37 weeks; n = 48) under monitored ambient conditions. A standard minimal skin care regimen was practised. Results: TEWL increased significantly on the buttock (p = 0.007), while remaining stable on the forehead, abdomen and thigh. SCH and sebum remained stable in all studied body regions with increasing age. On the buttock, pH increased (p = 0.049), while other body regions exhibited a significant decrease (p ≤ 0.019). TEWL (p < 0.001) and SCH (p ≤ 0.002) revealed significantly higher values on the buttock, compared to other body regions. Conclusions: Stable TEWL, SCH and sebum values may indicate a lack of
© 2014 S. Karger AG, Basel 1660–5527/14/0275–0234$39.50/0 E-Mail [email protected] www.karger.com/spp
skin barrier maturation. Postnatal decrease in skin pH suggests an adaptation process with acid mantle formation. Differences in skin barrier development were observed between anatomical regions. SCH, TEWL and pH values demonstrated a distinct course in the diaper area, indicating an impaired skin barrier function in this region. © 2014 S. Karger AG, Basel
Introduction
In preterm infants, the stratum corneum (SC) layer is thinner and less developed than in term infants and adults, leading to high water loss, percutaneous toxicity and systemic infections, with high morbidity and mortality [1, 2]. Even routine care, such as changing and bathing, can provoke skin irritation, due to compromised skin barrier function [3]. Special skin care regimens and incubator practices are mandatory to optimize and protect postnatal skin barrier function [3–5]. However, no scientifically based guidelines for standard skin care have yet been established for preterm infants, as few data are available about the maturation of skin barrier in this age group. Basic scientific research to gain deeper insight into skin barrier development in preterm infants is therefore important for advances in everyday clinical PD Dr. med. N. Garcia Bartels Department of Dermatology and Allergy Clinical Research Center for Hair and Skin Science, Charité-Universitätsmedizin Berlin Charitéplatz 1, DE–10117 Berlin (Germany) E-Mail natalie.garcia-bartels @ charite.de
issues, such as skin cleansing and use of emollients or oils [4, 6]. Neonatal skin barrier depends on a balance between different functional parameters and shows variability, depending on the body region that is investigated [7– 11]. Previous studies on preterm infants mainly concentrated on the effect of skin care on clinical parameters, like infection rate and morbidity with minor focus on skin functional parameters, such as transepidermal water loss (TEWL), stratum corneum hydration (SCH), surface acidity (pH) and skin surface lipids (sebum) [6, 12]. Limited data are available in preterm infants under adequate neonatal therapy with monitoring and documenting the exact ambient conditions and their correlation to barrier function [13]. In this study, we aimed to characterize postnatal skin barrier development in covered, uncovered and diapered regions in healthy premature infants with gestational age (GA) of 30–37 weeks over a longitudinal observation period and applying a standard minimal skin care to minimize external influence on data [10, 11].
Subjects and Methods Study Site and Population Premature infants were recruited from September 2003 through March 2006 at the Clinic for Neonatology, Charité-Universitätsmedizin Berlin. Inclusion criterion was a GA of 30–37 full weeks and written informed consent provided by guardians [14]. Exclusion criteria were: life-threatening state of health, acute or chronic diseases, body temperature 40 ° C or skin conditions with lesions covering more than 50% of the body surface. The trial was approved by the ethics committee of the Charité-Universitätsmedizin Berlin.
Outcomes Primary outcomes were TEWL, SCH, skin pH and sebum on the forehead, abdomen, thigh and buttock. Secondary outcomes were the effects of the variables GA, room temperature and humidity.
period of 5–10 min. Depending on physical conditions, measurements were performed under radiant warmer or incubator conditions. Room or incubator temperature and humidity were recorded with Room Condition Sensor (Courage & Khazaka). Functional parameters were measured on the forehead, abdomen (lateral to the navel), lateral surface of the upper leg and upper outer quadrant of the buttock. The volar forearm, a commonly used investigational area in children and full-term infants, was not chosen due to practical reasons: in preterm infants, the contact surface of the volar forearm is too small for the measurement device and is not easy to hold still. Standard skin care was practised: newborns were washed twice weekly after birth with tap water and a cotton washcloth. No preventive external therapies were used. Topical products were allowed on areas of skin trauma or diaper dermatitis: zinc paste, optionally with Nystatin; to remove meconium: oil; preventive care in the gluteal area and treatment of fissures on hands and feet: Vaseline. No skin care was performed
