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The goal of this study was to instrumentally evaluate the skin of healthy infants and to compare it to adult skin. A total of 70 infants, 45 girls and 25 boys, ages 8-24 months, and 30 healthy women were studied by means of transepidermal water loss (TEWL), capacitance, and pH measurements at two different skin sites, the volar forearm and the buttocks. No significant differences in TEWL were found between infants and adults, either on the buttocks or on the volar forearm. On the contrary, capacitance values were higher in infants. Their skin also appeared less acid than that of adults, with high statistical significance. No TEWL, capacitance, or pH variations were observed in infants according to sex and age. On the basis of the above data, the skin of infants 8-24 months of age shows functional signs of immaturity. This may lead to an increased permeability and a reduced capacity for defense against chemical and microbial aggression.
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CLINICAL AND LABORATORY INVESTIGATIONS
Skin Barrier, Hydration, and pH of the Skin
of Infants Under 2 Years of Age
Francesca Giusti, M.D., Alessandro Martella, M.D., Laura Bertoni, Ph.D., and
Stefania Seidenari, M.D.
Department of Dermatology, University of Modena, Modena, Italy
Abstract: The goal of this study was to instrumentally evaluate the skin
of healthy infants and to compare it to adult skin. A total of 70 infants, 45
girls and 25 boys, ages 8–24 months, and 30 healthy women were studied
by means of transepidermal water loss (TEWL), capacitance, and pH mea-
surements at two different skin sites, the volar forearm and the buttocks.
No significant differences in TEWL were found between infants and
adults, either on the buttocks or on the volar forearm. On the contrary,
capacitance values were higher in infants. Their skin also appeared less
acid than that of adults, with high statistical significance. No TEWL, ca-
pacitance, or pH variations were observed in infants according to sex and
age. On the basis of the above data, the skin of infants 8–24 months of age
shows functional signs of immaturity. This may lead to an increased per-
meability and a reduced capacity for defense against chemical and mi-
crobial aggression.
Infant skin is thought to be more sensitive than that of
adults. It follows that the cosmetic industry engages in
studying, producing, and introducing “delicate” products
into the market exclusively for the care and hygiene of
the youngest individuals. However, we should reflect on
whether the presumed higher cutaneous sensitivity to ex-
ternal agents early in life really does exist. Owing to the
difficulty of performing irritation tests on infant skin, we
have to use instrumental methodologies to evaluate
physiologic cutaneous conditions. Besides the advantage
of being noninvasive, these methods enable us to pro-
duce numerical data which are objective, reproducible,
and suitable for statistical processing. Moreover, they
provide a morphologic and functional evaluation of the
skin, which is more informative than mere inspection.
Whereas data referring to transepidermal water loss
(TEWL), capacitance, and pH in patients affected by
skin diseases such as atopic dermatitis, psoriasis, or al-
lergic or irritant contact dermatitis are available in the
literature, little is known about these parameters in
healthy infants (1–7).
The goal of this study was to instrumentally evaluate
the skin of healthy infants and to compare it to adult skin.
Moreover, it was also possible to collect data from dif-
ferent skin sites for an eventual comparison with refer-
ence to certain dermatologic diseases.
METHODS
Study Population
The study was carried out on 70 healthy infants, 25 boys
and 45 girls, ages 8–24 months (mean ± SD 14.30 ±
6.66 months) and on 30 healthy women, ages 25–35
years (mean ± SD 28.34 ± 4.60 years). None of the
Address correspondence to Stefania Seidenari, M.D., Department
of Dermatology, University of Modena, Via del Pozzo 71, 41100
Modena, Italy.
Pediatric Dermatology Vol. 18 No. 2 93–96, 2001
93
subjects had any skin disease. The subjects were asked to
avoid using any skin care product for at least 12 hours
before the measurements were obtained. All infants wore
diapers of the two most common Italian brands. The
instrumental measurements were performed on each sub-
ject at two body sites: the left volar forearm and the
buttocks.
Instruments and Study Procedure
This study was carried out in May, June, and September
1999. During that period, in Modena, the average tem-
perature ranged between 20.4°C and 24°C, and the rela-
tive humidity between 37 and 55.5%. Moreover, all
evaluations were performed after a 10-minute acclima-
tion period in a room with temperature set at 21°C–22°C
and humidity at 45–50% to prevent external influences
from affecting the results.
TEWL was measured using an evaporimeter (EP1;
Servomed, Stockholm, Sweden), which is based on the
vapor pressure gradient estimation (8). During all mea-
surements the probe was hand-held using an insulating
glove to avoid heating the probe. The probe was held in
place for each measurement until a steady TEWL value
was established, approximately 30 seconds.
Skin surface hydration was determined by a corneom-
eter (CM820; Courage, Khazaka, Germany). The instru-
ment measures the electrical capacitance of the stratum
corneum. Since water has the highest dielectric constant
in the skin, an increase in water content will raise ca-
pacitance values, which are displayed in arbitrary units
by the instrument (9).
A pH meter with a flat-surface glass electrode (pH 90,
Schwarzhaupt Medizintechnik, Germany), based on the
electrochemical method, was used to measure the pH of
the test sites (10).
Statistics
Means and standard deviations were calculated. Stu-
dent’s ttest for unpaired values was used to evaluate the
differences between values referring to different skin
sites, age groups, and sexes. A p < 0.05 was considered
significant.
RESULTS
TEWL
TEWL measurements, either at the buttocks or the volar
forearm, did not show significant differences between
the values of infants and adults (Figs. 1 and 2). More-
over, in both populations, differences between the volar
forearm and the buttocks were not noticeable.
Capacitance
Capacitance values, corresponding to stratum corneum
hydration, were higher in infants than in adults at both
tested sites (Figs. 1 and 2). This difference was highly
significant on the volar side of the forearm. Capacitance
values were significantly higher on this area than at the
buttocks in infant skin.
pH
Infant skin appeared less acid than that of adults, both at
the buttocks and at the volar forearm, with high statistical
significance (Figs. 1 and 2). Significantly higher pH val-
ues were noticeable at the buttocks in infants.
No differences were noticeable for TEWL, capaci-
tance, or pH values according to the infant’s sex, nor
were differences observable between values referring to
8- to 12-month-old infants and 12- to 24-month-old in-
fants (Tables 1 and 2).
DISCUSSION
The epidermal barrier function resides in the stratum
corneum, which becomes functionally mature at 32–34
weeks of gestational age (11,12). TEWL is considered
the best indicator of skin barrier function. A correlation
between this parameter and percutaneous absorption of
acetylsalicylic acid, caffeine, benzoic acid, sodium salt,
and hydrocortisone has been noted previously (13,14).
Skin barrier function, as assessed by TEWL, is altered in
various diseases and after experimental exposure to irri-
Figure 2. (A) TEWL, (B) capacitance, and (C) pH values
(mean ± SD) in infants and adults at the volar forearm.
*Significant with respect to adult skin.
Figure 1. (A) TEWL, (B) capacitance, and (C) pH values
(mean ± SD) in infants and adults at the buttocks. *Sig-
nificant with respect to adult skin.
94 Pediatric Dermatology Vol. 18 No. 2 March/April 2001
tants. Topical treatment for relief of inflammation leads
to normalization of TEWL, which can be used as a mea-
surement to assess response to therapy. In patients with
atopic dermatitis, an increase in TEWL has been found
also on dry, but otherwise normal, noneczematous skin
(1,4). Again, in atopic patients, and also in those with
psoriasis, an inverse correlation has been noted between
TEWL and capacitance (4,15), indicating that skin with
an impaired barrier does not hold enough water to main-
tain optimal hydration of the stratum corneum.
TEWL values are higher in premature infants than in
term newborn infants and adults (16). Most authors agree
that normal infants and adults have similar TEWL values
(5). In fact, according to our data, at the age of 8–24
months, both in boys and girls, the skin has already
achieved a barrier efficacy similar to an adult’s. More-
over, when we subdivided our population into two dif-
ferent age groups, TEWL values did not show differ-
ences either between the infants, age 8–12 months, and
those, ages 12–24 months, or between both subgroups
and adults.
In accordance with literature data, in our study the
highest TEWL values were found in the diaper area (17).
However, in this area evaluations may be biased by the
necessity of performing instrumental measurements
shortly after removing the diaper, when the skin may not
be completely dry. Therefore the amount of water mea-
sured by the evaporimeter may also include water evapo-
rating from the upper epidermis after occlusion (4).
Capacitance quantifies the water content of the stra-
tum corneum, which influences barrier function, percu-
taneous absorption, reactivity to irritants, and the skin’s
mechanical properties. Its evaluation is useful for study-
ing and monitoring skin diseases that are associated with
variations of stratum corneum hydration.
Capacitance values are influenced by humidity and
environment temperature (18). Moreover, variations be-
tween different body sites are observable (7,18): in adults
the highest values are detected on the forehead, the soles,
and the palms and the lowest values on the legs. Signifi-
cant variations, according to sex, have also been ob-
served in adults on some skin areas, with higher values in
females (7). On the contrary, we found no differences in
capacitance values between male and female infants.
In atopic skin a significant decrease in capacitance,
both in unaffected and eczematous areas (1,4), has been
described. On the contrary, diaper occlusion induces a
local increase in water content (19). In the development
of diaper dermatitis, an important role is played by ex-
cessive hydration of the stratum corneum, which com-
promises the skin’s integrity, both increasing its fric-
tional coefficient and permeability to irritants and
promoting microbial growth (20). In fact, in infants we
found higher capacitance values than in adults. This ob-
servation is not substantiated by the anatomic character-
istics of infant skin: at birth the thickness of the stratum
corneum is similar to an adult’s (21). The elevation of pH
in the diaper area also helps to induce dermatitis by
enhancing the activity of fecal enzymes and increasing
skin permeability (17).
According to the so-called acid mantle hypothesis,
maintenance of the pH in the 4.5–6 range is considered a
mechanism of skin defense against infections. Korting et
al. (22) confirmed the influence of skin pH on the com-
position of the cutaneous bacterial flora. Moreover, it
was noticed that many enzymes in the upper epidermis
have a pH optimum at 5.6 (23), suggesting that, in the
course of human evolution, certain enzymes have
adapted to the low pH of the human epidermis.
The acid pH of the skin depends on the presence of
lactic acid and free amino acids, and on the amount of
fatty acids in sebum and sweat. The cutaneous acidity
can be altered by the application of alkaline soaps (22) or
by occlusion. Laube reported that a decrease in skin pH
leads to an increase in the permeability of the skin sur-
face (24). It is well known that various cutaneous inflam-
matory diseases are associated with an increase in pH,
which is normalized when recovery occurs (10,25). In
infants affected by atopic dermatitis, the cutaneous acid-
ity is significantly lower in comparison with that of
healthy control infants, both in eczematous areas and in
nonlesional ones (1). The acid mantle develops during
the first weeks of life, and high pH values are noticeable
in the newborn, probably caused by a different chemical
composition of skin surface lipids (26). In our popula-
TABLE 1. TEWL, Capacitance, and pH (Mean ± SD) at the
Buttocks in Relation to Sex and Age
TEWL Capacitance pH
Male infants 9.12 ± 2.77 63.57 ± 12.58 5.97 ± 0.65
Female infants 9.04 ± 2.43 59.65 ± 9.27 5.93 ± 0.64
Infants
8–12 months 8.82 ± 2.30 60.00 ± 9.65 6.06 ± 0.54
Infants
12–24 months 9.27 ± 2.70 62.20 ± 11.58 5.83 ± 0.72
TABLE 2. TEWL, Capacitance, and pH (Mean ± SD) at the
Volar Forearm in Relation to Sex and Age
TEWL Capacitance pH
Male infants 8.57 ± 2.52 70.04 ± 9.95 5.46 ± 0.61
Female infants 8.17 ± 2.20 67.34 ± 9.50 5.45 ± 0.68
Infants
8–12 months 8.67 ± 2.49 66.51 ± 8.61 5.45 ± 0.71
Infants
12–24 months 8.00 ± 2.10 68.20 ± 10.89 5.47 ± 0.58
Giusti et al: Biophysical Parameters of Infant Skin 95
tion, skin pH values were still significantly higher in
infants than in adults, especially on the buttocks.
To summarize, in spite of the seemingly normal ap-
pearance and normal TEWL values, the skin of infants,
ages 8–24 months still presents functional signs of im-
maturity consisting of higher hydration and pH values.
This may lead both to an increased permeability and a
reduced capacity of defense against chemical and micro-
bial aggression.
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96 Pediatric Dermatology Vol. 18 No. 2 March/April 2001
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Purpose: This study aimed to evaluate whether bathing newborns within 36 hours after birth has a temporary negative impact on skin barrier metrics and relates to atopic dermatitis (AD) development. Methods: 55 newborns were bathed with water at 24-36 hours after birth, while 102 newborns did not have bath. Skin barrier metrics, including facial and underarm transepidermal water loss (TEWL), stratum corneum hydration (SCH), and skin humidity, were evaluated 1 hour before and after bath (T0 and T1, respectively), as well as on the next day (T2). A follow-up questionnaire via telephone was conducted 12-month later (T3). AD screening was determined based on the questionnaire. Results: In the non-bathed newborns, no significant alteration in skin barrier function was observed. In the bathed newborns, the underarm SCH significantly deteriorated from 16.60±21.74 at T0 to 8.16±12.27 at T2 (51% deterioration, p=0.009). Deteriorations were also observed for the facial and underarm humidity right after bath (-5%, p=0.017 and -4%, p=0.012) as well as on the next day (-6%, p=0.003 and -5%, p=0.001). At T3, 5% non-bathed newborns were determined to have developed AD during the past 12-month, while this number increased by 4-fold (21%) in the bathed newborns (p=0.010). Conclusion: This study demonstrated a temporary negative impact on newborn’s skin barrier function caused by bathing within 36 hours after birth. Deteriorated skin barrier function in the temporary window may still leave the newborn susceptible to infection and allergy, increasing the risk of triggering AD onset.
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Point-of-Care Detection Devices for Healthcare
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To determine normal levels of transepidermal water loss (TEWL), capacitance and sebum according to different sex and age groups, 93 healthy subjects were studied at 14 different anatomical locations with three different instruments: the Evaporimeter EP 1, the Corneometer CM 820, and the Sebumeter SM 810, evaluating respectively the transepidermal water loss, the capacitance and the causal level of sebum. Differences depending on the anatomical site were noticed. Unlike the capacitance, the transepidermal water loss and the causal level of sebum significantly decreased according to age. Furthermore, in some sites, male subjects showed a significantly higher transepidermal water loss than females, while hydration of the horny layer expressed by the capacitance showed an opposite trend. Correlations between the above-mentioned skin parameters were calculated: a positive correlation between TEWL and hydration was observed only at plantar and palmar areas. Afin d'évaluer les niveaux de ‘transepidermal water loss’(TEWL), de capacitance et du sébum, nous avons examiné 93 sujets sains à niveau de 14 différentes zones cutanées, en utilisant trois instruments: l'Evaporimeter EP 1, le Corneometer CM820 et le Sebumeter SM810. Nous avons relevé beaucoup de variations de ces paramètres en fonction des sites anatomiques. Contrairement à la capacitance, la TEWL et le niveau du sébum ont montré une réduction significative au cours du vieillissement. En outre, à niveau de certaines sites anatomiques, les sujets de sexe masculin ont montré des valeurs de TEWL plus hautes que celles de sexe féminin; par contre l'indice de hydratation de la peau mesuré par le Corneometer CM 820 a montré une tendence opposée. Enfin, nous avons considéré les rapports entre les différents paramètres cutanés, en relevant des corrélations significatives parmi la TEWL et la capacitance seulement aux sites palmaires et plantaires.
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The biophysical properties of non-eczematous skin at three locations in atopics and non-atopics were characterized using non-invasive physical methods. Skin friction was measured with a newly developed sliding friction instrument, the degree of hydration with a capacitance meter (Corneometer CM 820), and the transepidermal water loss (TEWL) was determined using an Evaporimeter EP1. The areas examined (dorsum of the hand, volar forearm and lower back) showed lower values of friction and capacitance in the atopic patients than did corresponding sites in the normal controls. In most areas a significant correlation between friction and capacitance was found. The TEWL was increased in atopic skin, but TEWL seems to correlate neither to friction nor to capacitance.
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Our clinical observations disclosed that most newborn infants showed scaling on at least some parts of the body. To clarify the mechanism for such xerosis, we performed measurements of high-frequency conductance (Gx), which assesses the skin surface hydration and evaporative water loss from the skin. The skin of newborns showed surprisingly lower Gx values and evaporative water loss than those of adults or 1- to 6-month-old infants in a warm environment. These findings may be explained partly by low eccrine activity, which has been reported as characteristic of newborn skin. However, defective stratum corneum function, such as reduced water-holding capacity as demonstrated by the in vivo water sorption-desorption test, also seems to be responsible for the development of dry skin in newborns.
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Hydration and the water-retention capacity of stratum corneum have been investigated in uninvolved psoriatic and atopic skin and compared with that of healthy controls. Thirty-three subjects of either sex and matched for age entered the study. The subjects were free from all signs of skin disease and skin dryness. Hydration was evaluated by means of transepidermal water loss and skin capacitance measurements. Water-retention capacity was investigated using the plastic occlusion stress test. Atopic skin differed significantly from uninvolved psoriatic and control skin which had a reduced water content and an increased transepidermal water loss. Furthermore, the skin surface water loss profile representing the stratum corneum water-retention capacity was significantly lower in normal atopic skin. The data suggest that clinically normal skin may be functionally abnormal, resulting in a defective barrier that could lead to higher risk of irritant or contact dermatitis.
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This report reviews individual-related variables, environment-related variables and instrument-related variables, with a focus on the Evaporimeter EP1 (ServoMed). Start-up and use is described, and guidelines for good laboratory practice given.
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Diaper dermatitis results from the action of a number of physical and chemical factors on the skin. While its etiology is complex, there is agreement that prolonged contact between wet diapers and the skin leading to excessive hydration of the stratum corneum and reduced barrier function is a primary factor. Recent research also indicates that pH elevation resulting from ammonia production increases the probability of skin damage due to fecal enzyme activity. New diapers containing absorbent polymers blended with cellulose fluff in the absorbent core have been developed. The absorbent polymer binds fluids and controls pH in the diaper environment. To assess the effectiveness of these diapers, a clinical study was conducted with approximately 150 infants over 15 weeks, using fluff diapers and absorbent polymer diapers. The results clearly showed that the diapers with absorbent polymer provide a better skin environment than those with fluff only with respect to lower skin wetness and pH control (instrumental measurements). In addition, the clinicians' grades indicated a directional reduction in diaper rash severity.