Clinical study
Skin response to sustained loading: A clinical explorative study

https://doi.org/10.1016/j.jtv.2015.04.002Get rights and content

Highlights

  • Stratum corneum hydration seems to remain stable during immobilisation.

  • Prolonged loading leads to skin barrier impairments.

  • Skin at the heels and the sacrum behaves differently.

Abstract

Background

Severe illness, disability and immobility increase the risk of pressure ulcer development. Pressure ulcers are localized injuries to the skin and/or underlying tissue as a result of long enduring pressure and shear. Little is known about the role of the stratum corneum and the upper skin layers in superficial pressure ulcer development.

Objectives

To investigate possible effects of long enduring loading on the skin barrier function under clinical conditions at two pressure ulcer predilection sites.

Methods

Under controlled conditions 20 healthy females (mean age 69.9 (3.4) years) followed a standardized immobilization protocol of 90 and 150 min in supine position wearing hospital nightshirts on a standard hospital mattress. Before and immediately after the loading periods skin surface temperature, stratum corneum hydration, transepidermal water loss and erythema were measured at the sacral and heel skin.

Results

Prolonged loading caused increases of skin surface temperature and erythema at the sacral and heel skin. Stratum corneum hydration remained stable. Transepidermal water loss increased substantially after loading at the heel but not at the sacral skin.

Conclusions

Skin functions change during prolonged loading at the sacral and heel skin in aged individuals. Accumulation of heat and hyperaemia seem to be primarily responsible for increasing skin temperature and erythema which are associated with pressure ulcer development. Increased transepidermal water loss at the heels indicate subclinical damages of the stratum corneum at the heel but not at the sacral skin during loading indicating distinct pathways of pressure ulcer development at both skin areas.

Introduction

Acute severe illnesses, disability, functional limitations or advanced care dependency are often associated with mobility and activity impairments. Patients or care receivers are confined to beds or chairs and are unable to move themselves and change positions. Maintaining body positions over longer periods of time leads to sustained deformation of soft tissues in contact with the underlying support surface especially over bony prominences [1]. If the duration and intensity of the loading exceeds the structural and functional capacity of the deformed cells and tissues pressure ulcers (PUs) may develop [2]. PUs are localized injuries to the skin and/or underlying tissue as a results of long enduring pressure and shear [1].

Worldwide PU prevalence and incidence are high ranging from 1 to 12% in hospital and acute care settings [3], [4], [5], [6], [7] to 20% in institutional long term and geriatric care [8], [9], [10]. Although PUs do occur in all age groups it is especially a condition of the aged [11]. PUs are associated with pain, reduced quality of life [12] and PU treatment is burdensome and expensive. Among 15 selected common skin conditions in the latest Global Burden of Disease report PUs were regarded as the most severe dermatological diseases contributing to a substantial health loss [13]. Furthermore PU development is regarded as an unintended adverse event and it is therefore a widely accepted indicator for the quality and safety of care [14], [15]. Consequently, efficient PU prevention and maintaining skin integrity are major goals in health care [16].

During the last years the knowledge about PU aetiology increased substantially. It could be shown that strains within deeper tissues especially near bony curvatures are much higher compared to the skin surface [17], [18] and that there is a time depended increase of muscle cell death during sustained deformation [19]. Ischemia, reperfusion damage, and impaired lymphatic functions further contribute to necrosis development in muscle and/or subcutaneous fat tissues [20], [21] leading to so called deep tissue injuries [10], [22], [23]. While this inside-out mechanism of PU development is widely accepted today the distinct role of the skin under sustained deformation has gained less attention. Above all little is known about the role of the epidermis and the stratum corneum (SC), the upper most skin layers, which are in direct contact to the support surface and which contribute to mechanical strength of the skin [24].

Results of previous experimental ex vivo and animal studies indicate that sustained loading or deformation alter or even damage epidermal and dermal layers [25], [26], [27] and that there are associations between temperature and moisture content and biophysical properties of the SC [28], [29] and the whole skin [30]. However, little is known about the functional skin barrier characteristics in vivo under ‘real world’ clinical conditions especially in aged individuals. Based on increased transepidermal water loss (TEWL) values Angelova-Fischer et al. recently showed skin barrier impairments in early stages of chronic venous insufficiency compared to healthy controls [31]. Whether such subclinical epidermal changes also occur prior to early PU development is unknown. Therefore the aim of this investigation was to explore possible effects of long enduring loading on the skin under clinical conditions.

Section snippets

Study design, setting and participants

Between March and June 2013 an explorative clinical study was conducted. The study followed a protocol to simulate immobilization while lying in bed. Healthy volunteers were invited to participate meeting the following eligibility criteria: age 60–80 years, absence of skin diseases, absence of acute diseases, ability to move independently and to maintain supine and prone positions. We included only female subjects at this stage because in aged populations females are generally overrepresented

Results

Demographic characteristics of the included 20 females are shown in Table 2. Mean age was 70 years and the BMI of subjects was comparable. The mean skin temperature, TEWL, SCH and erythema indices are shown in Table 3. Baseline skin temperature was comparable at the sternal and sacral skin (32 °C) and slightly lower at the heel skin (29 °C). After both loading times the skin surface temperature increased but remained nearly stable at the control area. The behaviour of the TEWL was similar. TEWL

Discussion

This is the first study investigating skin barrier changes of the two most important PU predilection sites during loading in vivo in humans. We observed loading and site dependent changes for skin temperature, TEWL, and erythema. SCH seemed to be unaffected by loading.

An increase in skin temperature during prolonged loading is well known. The direct contact of the skin with the linen and mattress reduces air convection leading to a local accumulation of heat [30], [36]. In addition local

Conclusion

Based on the study results we conclude that skin functions change during prolonged loading at the sacral and heel skin in aged individuals on a standard hospital mattress. Accumulation of heat and hyperaemia seem to be primarily responsible for increasing skin temperature and erythema which are associated with PU development. For the first time we showed that the TEWL increases at the heels after loading indicating subclinical damage to the SC. TEWL remained stable at the sacral skin indicating

Conflicts of interest

None.

Funding sources

This study was supported by the Clinical Research Center for Hair and Skin Science and the Charité-Universitätsmedizin Berlin.

Acknowledgements

This research was supported by the Clinical Research Center for Hair and Skin Science and the Hair and Skin Research Foundation.

References (53)

  • K.S. Koutroupi et al.

    Mechanical and failure behaviour of the stratum corneum

    J Biomech

    (1990)
  • K.S. Wu et al.

    Mechanical properties of human stratum corneum: effects of temperature, hydration, and chemical treatment

    Biomaterials

    (2006)
  • R. Sopher et al.

    The influence of foot posture, support stiffness, heel pad loading and tissue mechanical properties on biomechanical factors associated with a risk of heel ulceration

    J Mech Behav Biomed Mater

    (2011)
  • C.G. Mathias et al.

    Transepidermal water loss as a function of skin surface temperature

    J Invest Dermatol

    (1981)
  • W. Sae-Sia et al.

    Elevated sacral skin temperature (T(s)): a risk factor for pressure ulcer development in hospitalized neurologically impaired Thai patients

    Appl Nurs Res

    (2005)
  • J. Kottner et al.

    Weight and pressure ulcer occurrence: a secondary data analysis

    Int J Nurs Stud

    (2011)
  • National Pressure Ulcer Advisory Panel

    European pressure ulcer advisory panel, pan pacific pressure injury alliance

    (2014)
  • S. House et al.

    Benchmarking to the international pressure ulcer prevalence survey

    J Wound, Ostomy, Cont Nurs

    (2011)
  • K. Vanderwee et al.

    Assessing the adequacy of pressure ulcer prevention in hospitals: a nationwide prevalence survey

    BMJ Qual Saf

    (2011)
  • Y. Amir et al.

    Retrospective study of pressure ulcer prevalence in Dutch general hospitals since 2001

    J Wound Care

    (2011)
  • N. Lahmann et al.

    Frequency of pressure ulcers in German hospitals

    Gesundheitswesen

    (2012)
  • De Brauwer et al.

    Prediction of risk of in-hospital geriatric complications in older patients with hip fracture

    Aging Clin Exp Res

    (2012)
  • J. Kottner et al.

    Pressure ulcers in German nursing homes: frequencies, grades, and origins

    Z fur Gerontol Geriatr

    (2011)
  • N.C. van Nie-Visser et al.

    An International prevalence measurement of care problems: study protocol

    J Adv Nurs

    (2013)
  • J. Kottner et al.

    Maintaining skin integrity in the aged: a systematic review

    Br J Dermatol

    (2013)
  • C. Then et al.

    Analysis of mechanical interaction between human gluteal soft tissue and body supports

    Technol Health Care : Official J Eur Soc Eng Med

    (2008)
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    Recipient of the Hans Schaefer Young Researcher Grant, www.hairskinberlin.com.

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