Changes in dermal structure and skin oxidative stress in overweight and obese Japanese males after weight loss: a longitudinal observation study.

BACKGROUND/PURPOSE: Previous studies have reported decreased dermal echogenicity and increased skin oxidative stress in overweight males. However, it is unknown whether these skin parameters of overweight and obese people are similar to those of individuals exhibiting a normal body weight following weight loss. The purpose of this study was to (1) compare the changes in the dermal structure parameters and levels of skin oxidative stress before and after weight loss in overweight and obese people in Japan and (2) to clarify how these aspects changed when body weight would be reduced to normal body weight. METHODS: Male volunteers with a body mass index of ≥25 kg/m2 were recruited. The dermal structure was visualized and dermal echogenicity and thickness were measured using ultrasound scanners. The mRNA expression level of heme oxygenase-1 in the hair follicles was quantitatively analyzed as a marker of skin oxidative stress. RESULTS: When overweight individuals in their 20s to 30s reduced their weight to normal, decreased dermal thickness in the abdominal region was observed in 50% of the subjects; however, no increase in dermal echogenicity was observed. A decrease in dermal thickness and an increase in dermal echogenicity in the thighs was observed in 83.3% of the subjects. No decrease in the level of dermal oxidative stress was observed. CONCLUSION: The dermal structure in the thighs of overweight young individuals can be improved to the level of the structure in those of normal body weight individuals following weight loss.

Wash or wipe? A comparative study of skin physiological changes between water washing and wiping after skin cleaning.

BACKGROUND/PURPOSE: Presently, skin-cleaning agents that claim to be removed by water or wiping alone are commercially available and have been used for the purpose of bed baths. However, there is a lack of knowledge on how water washing and wiping differently affect skin physiological functions or ceramide content. The aim of this study was to compare the effects of water washing and wiping on skin physiological functions and ceramide content. METHODS: Three kinds of the cleaning agents with different removal techniques (ie, water washing and wiping) were used in this study. Skin physiological functions (ie, transepidermal water loss, skin hydration, and skin pH) and skin ceramide content were measured before and after seven consecutive days of the application of each cleaning agent. RESULTS: No significant differences in skin physiological functions or ceramide content were observed between water washing and wiping. CONCLUSION: Cleaning agents that claim to be removed by water washing or wiping do not affect skin physiological functions or ceramide content by either removal method.

Inter-rater and intra-rater reliability outcomes of a rapid bacteria counting system with pressure ulcer samples.

OBJECTIVE: Evaluating bacterial load in pressure ulcers (PUs) is key to combat infection; therefore, using technologies to measure bacterial count can be particularly useful. A rapid bacteria counting system was recently developed and introduced to the wound care field. However, its reliability was not established. This cross-sectional study aimed to evaluate the inter-rater and intra-rater reliability of bacterial count using this rapid counting system. METHOD: We took bacterial swabs from patients with category I or greater PUs to assess inter- and intra-rater reliability. An assessor swabbed the longest axis of the PU once and bacterial counts were measured using a rapid bacteria counting system. To confirm the inter-rater and intra-rater reliability, intraclass correlation coefficients (ICCs) were calculated. RESULTS: We took 63 and 57 pairs of bacterial counts from 13 patients with 16 category I or greater PUs to assess inter- and intra-rater reliability, respectively. Overall ICCs [95% confidence intervals (CI)] for the bacterial counts were 0.83 [0.73-0.90, p<0.001, inter-rater reliability, n=63], and 0.89 [0.82-0.94, p< 0.001, intra-rater reliability, n=57]. CONCLUSION: A high level of reliability for counting bacterial numbers in PU sites was confirmed. The results should encourage clinicians and researchers to use this type of device for the real-time assessment of wound bacterial bioburden at the patient's bedside.

Increased level of tumour necrosis factor-alpha (TNF-α) on the skin of Japanese obese males: measured by quantitative skin blotting.

OBJECTIVE: A state of chronic inflammation, characterized by an increased level of tumour necrosis factor-alpha (TNF-α), is often found in the obese population. The negative effects of elevated TNF-α are not limited to systemic metabolism. It also reportedly affects skin integrity. Recently, the relationship between obesity and skin fragility was reported; however, there has been little insight into how the level of TNF-α in the skin in situ is related to the severity of obesity. In this study, we aimed to measure the level of TNF-α on the skin and to find the relationship between obesity and the level of TNF-α detected on the skin. METHODS: We used a novel, non-invasive method called quantitative skin blotting. Fifty-nine healthy (but some were classified as being overweight or obese) Japanese males were enrolled as subjects. The levels of TNF-α detected on the abdominal and thigh skin along with the body composition were measured, followed by a correlation analysis. RESULTS: Significant positive correlations were found between the levels of TNF-α detected on the skin and the severity of obesity such as body mass index (BMI), body fat weight and visceral fat rating. CONCLUSION: We found that high levels of TNF-α were detected on the skin of Japanese obese males, which implied the higher TNF-α in the skin. The elevation of skin TNF-α may be one factor related to skin fragility that is often found in obese individuals.

Development of an improved method for quantitative analysis of skin blotting: increasing reliability and applicability for skin assessment.

OBJECTIVE: A novel skin assessment tool named 'skin blotting' has been recently developed, which can easily predict the skin status to avoid its deterioration. The aim of this study was to propose a normalization method for skin blotting to compensate for individual differences that can hamper the quantitative comparisons and clinical applications. METHODS: To normalize individual differences, we utilized a total protein as a 'normalizer' with calibration curves. For evaluation, we performed a simple simulation experiment, in which the same concentration of a protein of interest [tumour necrosis factor (TNF)-α] was applied at different volumes as a virtual individual difference. Moreover, to demonstrate the applicability of this normalization, male volunteers were recruited for skin blotting followed by the estimation of TNF-α with normalization. RESULTS: We obtained good calibration curves for total protein (R(2)  = 0.995) and TNF-α (R(2)  = 0.997), both of which were necessary for an exact quantification. In the simulation experiment, we estimated the exact concentration of TNF-α regardless of the applied volume, demonstrating the applicability of this normalization method in skin blotting. Further, skin blotting on human subjects showed a wide range of variation in the total protein content, although the normalization was thought to reduce such individual variations. CONCLUSION: This study has proposed total protein normalization for skin blotting with calibration curves. This method may strengthen the quantitative performance of skin blotting, which may expand the applicability of this method as a skin assessment tool in broader fields, such as nursing and cosmetology.

Nutrition-related status and granulation tissue colour of pressure ulcers evaluated by digital image analysis in older patients.

OBJECTIVE: Granulation tissue colour may be an indicator for nutritional assessment in pressure ulcer (PU) care. This study evaluated the relationship between nutritional status, anaemia and diabetes, and granulation tissue colour of PUs by colour analysis of digital photographs in the clinical setting. METHOD: The cross-sectional study included 42 older patients with 51 full-thickness PUs from 10 institutions. Patient demographics, wound status, nutritional status and dietary intakes were obtained from medical charts. From a wound image, the granulation red index was processed by computer software and the proportion of pixels exceeding the threshold intensity of 80 for the granulation tissue surface (%GRI80) was calculated. RESULTS: Haemoglobin levels were positively associated with %GRI80 levels (p=0.007) in the crude model, but not in the adjusted model (p=0.260). The interaction term between diabetes and protein intake was significantly associated with %GRI80 levels in the adjusted models (p=0.010). At protein intakes of 0.95 g/kg or higher, diabetic wounds exhibited lower %GRI80 levels than non-diabetic wounds (p=0.002). At protein intakes of less than 0.95 g/kg, %GRI80 levels did not differ between diabetic and non-diabetic patients (p=0.247). Protein intakes of 0.95 g/kg or higher were associated with higher %GRI80 levels in non-diabetic patients (p=0.015), but not in diabetic patients (p=0.127). CONCLUSION: Granulation tissue colour, evaluated by the objective and quantitative analysis of digital photography, is related to haemoglobin level, diabetes and dietary intakes in clinical settings.

Physiological and appearance characteristics of skin maceration in elderly women with incontinence.

OBJECTIVE: To identify the physiological and appearance characteristics of skin maceration caused by urine and/or faeces and determine their suitability as risk indicators for incontinence-associated dermatitis. METHOD: This cross-sectional, comparative study involved sixty-nine elderly women with urinary and/or faecal incontinence who provided informed consent to participate. Exclusion criteria included serious medical problems, acute illness and the presence of damaged skin on the buttocks. The physiological and appearance characteristics of macerated skin on the buttocks of the patients were examined. Stratum corneum and dermis hydration levels, transepidermal water loss and skin pH were used to assess skin condition. Skin morphology (sulcus cutis) was confirmed using images at x15 magnification. The erythema index and white index were used to evaluate colour in the macerated skin areas. RESULTS: Forty-four patients exhibited skin maceration. Stratum corneum and dermis hydration levels were significantly greater in the maceration group than in the non-maceration group, as were transepidermal water loss, skin pH and differences in sulcus cutis interval between the buttock of interest and the subumbilical region. Furthermore, differences in the erythema and white indices between these two regions were significantly higher and lower, respectively, in the maceration group than in the non-maceration group. CONCLUSION: To our knowledge, this is the first report to note that there are interesting changes not only in the epidermal layer but also in the dermis layer in patients with skin maceration. This finding confirmed that skin maceration caused by incontinence is a severe condition. Moreover, the erythema index was the best index for identifying skin maceration caused by incontinence, indicating that it can be used for precise and easy identification of the condition in clinical practice.

Influence of differences in washing methods on skin texture.

OBJECTIVE: The objective of this study was to clarify the effects of different body washing methods on skin texture. METHODS: Subjects were nine healthy women in their 20s. Skin on the inside of the forearms was washed every day for 4 weeks with protective washing (right forearm) and with non-protective washing (left forearm). We performed comparison of the right forearm and the left forearm. For the evaluation of skin texture, the interval of the sulcus cutis, and the mean and variance of the thickness of the sulcus cutis on digitized images were measured. Moreover, the numbers of equilateral triangles consisting of sulcus cutis were counted to evaluate skin texture. RESULTS: From the first week, the interval of sulcus cutis was significantly narrower with protective washing than with non-protective washing. The numbers of equilateral triangles increased significantly more with protective washing than with non-protective washing in weeks 1, 2 and 4. Although this study found no significant difference in mean of the thickness of the sulcus cutis, the interval of sulcus cutis and the number of triangles differed significantly with protective washing. The narrower intervals between sulcus cutis mean finer-textured skin and sulcus cutis are formed by triangles or quadrilaterals, and the more uniform these shapes are, the finer and more regular the texture Therefore, skin texture may have become finer as a result of protective washing. CONCLUSION: These findings suggest that protective washing produces an even skin texture. They also suggest that number of equilateral triangles, as used in this study, may be useful as an index of skin texture.

Structural changes in dermal collagen and oxidative stress levels in the skin of Japanese overweight males.

OBJECTIVE: It has been reported that obese people have poorly organized dermal collagen structure because of the degradation of collagen fibers, which is caused by an increase in oxidative stress levels associated with the hypertrophy of subcutaneous adipose cells. However, it is unclear whether an increase in oxidative stress levels caused by the accumulation of subcutaneous adipose tissue and a change in the dermal structure also occur in overweight and obese Japanese people. The objectives of this study are to identify structural changes that occur in the dermis and to measure the levels of oxidative stress in Japanese overweight males. METHODS: The overweight group included 43 Japanese male volunteers aged between 25 and 64 years and with a body mass index (BMI) of ≥25 and <30. The control group included 47 male volunteers aged between 22 and 64 years and with BMI of <25. The 20-MHz Dermascan C® ultrasound scanner with software for image analyses was used. Echogenicity of the upper and lower dermis was measured. The mRNA expression level of heme oxygenase-1 (HMOX1) in hair follicles was quantitatively analyzed by real-time reverse transcription polymerase chain reaction (RT-PCR) and was used as a marker of oxidative stress. Ultrasonographic imaging and collection of hair follicles were performed at the same site on the thigh, abdomen, and upper arm. RESULTS: The HMOX1 mRNA expression level in the abdomen and thigh was significantly lower in the overweight group than in the control group. Moreover, the echogenicity of the upper dermis of the abdomen and the lower dermis of the abdomen and thigh was significantly lower in the overweight group than in the control group. CONCLUSION: We detected an increase in oxidative stress levels and a decrease in the density of dermal collagen at the same site on the thigh, abdomen, and upper arm of Japanese overweight males. These findings suggest the fragility of the dermis of Japanese overweight males, which might have been caused by the accumulation of subcutaneous adipose tissue.

A new objective evaluation method for PU cleansing using a rapid bacteria counting system.

OBJECTIVE: To assess a new rapid bacterial counting device for evaluating wound cleansing effectiveness based on dielectrophoretic impedance measurement. METHOD: Three patients with pressure ulcers with undermining were recruited, and pressure ulcer severity assessed using the DESIGN-R tool. The number of bacteria was measured using this new apparatus both before and after wound cleansing, performed by wound, ostomy, and continence nurses using apH-balanced cleanser for periwound skin and with normal saline for the wound bed and undermining area. RESULTS: The results showed that wound cleansing effectively reduced bacterial counts on the periwound skin, wound bed and undermined site, with a median number of bacteria of 3.6×106 CFU/ml before cleansing, which decreased to 1.1×106 CFU/ml after cleansing. CONCLUSION: This pilot study result suggests the usefulness of this new device for assessing the effectiveness of wound cleansing on reduction of bacterial number. Standardisation of wound cleansing technique may be achieved by hands-on education using this apparatus at bedside.

Quantitative estimation of exudate volume for full-thickness pressure ulcers: the ESTimation method.

OBJECTIVE: To develop an equation for the estimation of exudate volume in millilitres, for full-thickness pressure ulcers, according to wound characteristics. METHOD: In a cross-sectional study, 41 patients aged >60 years with 58 full-thickness pressure ulcers were evaluated. Exudate was collected by covering each wound with a transparent occlusive dressing and the accumulated volume was measured to estimate volume per day. The overall severity of each wound was evaluated by the DESIGN-R tool; a model was then developed to estimate the volume of exudate based on these experimental values. Linear regression analyses were performed to evaluate the precision and accuracy of the model. RESULTS: The model, including exudate score, size score, and total score, showed a higher adjusted coefficient of determination (R²=0.66) than the model with only a traditional exudate score (R²=0.57). After adjustment for age, inclusion of interaction terms, and modification of bias, a model with continuous parameters was finally developed: exudate volume per day (ml/day) = exp([0.86×exudate score]+ [0.21×size score]+[0.12×total score]-[0.013×size score×total score]-[0.04×age]-3.60). Furthermore, a categorical model was developed for clinical simplicity of use. The adjusted R2 was increased to 0.73 for the continuous model and to 0.77 for the categorical model. There were no apparent biases (p>0.05) and no correlations between residuals and measured value (p>0.05) in these models. CONCLUSION: The equation, including the exudate score, size score and total score of DESIGN-R, as well as age, is called the ESTimation method. It will be useful for clinicians to predict the absolute volume of exudate and to select appropriate dressings for full-thickness pressure ulcers. DECLARATION OF INTEREST: The authors have nothing to declare.

Use of ultrasound in assessment of necrotic tissue in pressure ulcers with adjacent undermining.

OBJECTIVE: To reveal the specific ultrasonic imaging findings of non-visible necrotic tissue in pressure ulcers (PUs) with undermining and describe the images objectively. The predictive validity of the specific images of the undermined necrotic tissue was also determined. METHOD: Using digital ultrasonography (12 MHz linear transducer, MyLab25; Hitachi Medical Corporation), we imaged PUs with undermining every 2 weeks. PUs were also monitored by DESIGN-R, a PU assessment tool, at the same time. RESULTS: Ten patients had 11 PUs with undermining and all ulcers were located in the sacral region. The necrotic tissue showed high echogenicity with no layers, unclear borders and an uneven gray level (cloud-like image). Granulation tissue appeared as a low echoic image which had no layers, was of coarse resolution and an even gray level. There were significant differences between the pixel uniformity of the necrotic tissue (84.0) and granulation tissue (53.9) compared with uninjured tissue (65.5; p=0.000 and 0.005, respectively). The sensitivity, specificity, and positive and negative predictive values of cloud-like image were 87.5%, 91.7%, 77.8% and 95.6%, respectively. CONCLUSION: The results suggest that cloud-like image is the most useful diagnostic indicator for non-visible necrotic tissue in PUs with undermining and is the best prognostic indicator for PU healing. DECLARATION OF INTEREST: The authors have no conflicts of interest to declare. There were no external sources of funding for this study.

Does the use of a cleanser on skin surrounding pressure ulcers in older people promote healing?

OBJECTIVE: To determine whether the use of a skin cleanser on the skin surrounding pressure ulcers helps to promote healing. METHOD: The study was conducted over a two-year period in patients with stage II or more pressure ulcers. All subjects were at least 65 years of age and resident in a long-term care hospital. During the first year, skin was cleansed with normal saline. In year two, a pH-balanced cleanser was used. The healing times for the two methods were then compared. RESULTS: Healing time was shorter in the group using the cleanser for every stage of ulcer, with an especially significant difference for stage II ulcers (p=0.002). Analysis using the Cox proportional hazards model found a 1.79-fold improvement in the healing rate of stage II ulcers when the surrounding skin was washed with the cleanser. CONCLUSION: Cleaning the surrounding skin with a cleanser rather than normal saline promotes the healing of pressure ulcers.

Reliability and validity of DESIGN, a tool that classifies pressure ulcer severity and monitors healing.

OBJECTIVE: This study reviews the validity and reliability of DESIGN, a tool for classifying pressure ulcer severity and monitoring progression towards healing. Only the tool's healing progression component was evaluated. METHOD: Inter-rater reliability was evaluated by calculating the agreement rate of scores, based on eight photos of pressure ulcers and six actual ulcers, made by a panel of seven nurses. Validity was assessed, using the same eight photos, by comparing DESIGN scores with those made using the validated Pressure Sore Status Tool (PSST). RESULTS: The DESIGN inter-rater reliability results showed a high correlation of r = 0.98 for the photos and r = 0.91 for the real-life patients with pressure ulcers, respectively, for all seven raters based on total scores. For validity, a correlation greater than 0.91 was found between the DESIGN and PSST scores. CONCLUSION: Based on our results, DESIGN was found to have both high inter-rater reliability and high validity among the seven nurses who quantitatively evaluated the wound-healing progress of the pressure ulcers in this study.

Evaluation of nutritional status and skin condition among elderly residents in a long-term care hospital.

OBJECTIVE: The availability of nutritional screening tools for older adults is limited, depending on their physical characteristics or the setting. We investigated the relationships between various nutritional indicators and skin conditions as possible screening indicators. DESIGN: Cross-sectional study. SETTING: A long-term care hospital in Japan. PARTICIPANTS: 90 elderly residents who were aged ≥65 years old. MEASUREMENTS: The nutritional status of the residents was assessed by body mass index (BMI), involuntary weight loss, arm muscle area, and serum albumin and prealbumin levels. Leg skin condition was evaluated by: 1) functional factors including pH, hydration and transepidermal water loss; 2) skin color including L*, a*, b* and individual typology angle (ITA°) using a tristimulus colorimetric instrument; and 3) skin morphology. Repeated measures analysis of variance was employed, adjusted for demographic characteristics and room temperature, with measurement site as the repeated variable. RESULTS: Among the skin indicators, b* was significantly correlated with BMI (p=0.018), and weight loss over the previous month (p=0.042) and 6 months (p=0.002). Additionally, ITA° was associated with weight loss over 1 month (p=0.013). Both b* and ITA° showed the area under the receiver operating characteristic curve of 0.64 to 0.80 for weight loss >2% over 1 month. CONCLUSIONS: Residents with poorer nutritional status had yellower and darker skin color.

The role of skin blood flow in pressure ulcer development during surgery.

Laser Doppler flowmetry was used to examine the relationships between skin blood flow and pressure ulcer development. Blood flow in the skin over the iliac and sacral bony prominences was measured intraoperatively in 24 consecutive patients undergoing lengthy surgical procedures. Patients who did not develop pressure ulcers postoperatively had a 500% mean increase in blood flow during the procedure as compared with the preoperative levels. Blood flow levels decreased during surgery in patients who developed pressure ulcers postoperatively. There was no statistical difference in the lengths of surgery between the two groups. These results suggest that the body's failure to increase blood flow in response to extended pressure during surgery may contribute to pressure ulcer development.