A Practical Method for Rapid Measurement of Skin Condition Marty Visscher, PhD ⁎ Skin Sciences Program, Division of Plastic Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH Cincinnati Children’s Hospital Medical Center, Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH abstract article info Keywords: Neonatal skin Rashes Skin integrity Newborn Infant Premature Maintaining skin integrity is important because of the skin's role in protecting the infant and providing innate im- munity. Achievement of this goal requires constant vigilance and awareness of factors that can negatively impact the skin. The task can be particularly challenging for patients in the neonatal intensive care unit (NICU). Key to optimizing skin condition is methods to quantify the extend of skin compromise. Implementation of such methods allows caregivers to monitor effectiveness of treatments and practices to prevent skin damage. This paper briefly reviews skin breakdown in hospitalized patients and describes a validated, visually based method for rapid measurement of skin condition. Application of the method in the NICU setting is discussed. © 2014 Elsevier Inc. All rights reserved. Neonatal Skin Characteristics Full term newborn infant skin is well-formed with excellent barrier properties, a thick epidermis, and full functionality at birth. The rate of transepidermal water loss (TEWL) from the epidermis is very low, 4–8 g/m 2 /h at birth, 1,2 equal to or lower than adults, and indicating a highly effective skin barrier. 3,4 Premature skin has a markedly thinner epidermis and a poorly formed stratum corneum (SC), i.e., a wounded skin surface, versus full term skin. 5,6 The dermis is deficient in structural proteins, the mechan- ical properties are poor, the skin is not resilient to mechanical stress and is easily torn. 7 The SC develops rapidly, however, one month later TEWL continues to be higher than normal. 8 Skin hydration is much higher in infants less than 30 weeks GA than older infants but decreases markedly by day 5 indicating rapid barrier formation. 9 Low humidity following birth increases epidermal DNA synthesis and triggers cell proliferation. 10 Levels of water binding FFAs are likely to be very low with rapid SC development. 11,12 For very premature infants, skin pH is higher for lon- ger than older infants. 13 The higher pH may negatively impact normal SC functioning. 14 Estimates of complete premature SC maturation vary from 2–9 weeks postnatal age. 8,15–17 The poor skin barrier puts the in- fant at risk for increased permeability, high water loss, electrolyte imbal- ance, thermal instability, infection, skin compromise and delayed barrier maturation. 18 Interventions that facilitate SC development are essential for reducing the negative consequences of an immature barrier. 18,19 Skin and the Neonatal Intensive Care Patient Infants in the neonatal intensive unit (NICU) are at risk for skin com- promise due to immature skin, compromised perfusion, fluid retention, immunocompromised, medical diagnosis, etc., as well as the presence of dressings, tapes, adhesives and various medical devices that are essential to their care. Internal processes, e.g., heart rate, respiration, temperature, are monitored continuously using devices attached to the skin surface. Fig. 1 shows an infant with several leads, a nasogastric tube, an endotracheal tube and a diaper. There are large lifting scales indicating skin dryness, most likely a consequence of premature birth and rapid skin barrier development. As a result and unfortunately, skin compromise can occur. Common examples are (1) erythema and in- flammation from irritant dermatitis or diaper dermatitis, (2) dryness/ scaling, (3) tape stripping, i.e., removal of the upper layer (s) of skin when tapes and dressings are detached, (4) occlusion induced irritation, (5) allergic contact dermatitis, (6) skin infection and (7) pressure ulcers. Figure 2 shows examples of skin compromise in NICU patients, including irritant dermatitis from secretions at a G-tube site, dryness/scaling, com- promise from tape removal, and irritation from occlusion. Measures of “Skin Condition” Skin condition is described by the attributes erythema, dryness/ scaling and rash. Erythema (abnormal redness from capillary dilation and increased blood flow) is the visible indicator of inflammation, infec- tion or irritation. 20 Inherent skin pigmentation (i.e., brown, yellow, red colors due to melanin) influences the interpretation of visual erythema. Changes in blood, e.g., pooling in the tissues, affects the appearance of skin pigmentation. 21 Visual skin dryness is observed as scaling where the outermost layers are clumped together because they did not des- quamate as single cells. Under normal visual conditions the lifting scales first appear as powderiness along the normal dermatoglyphic pattern of the skin surface. As the scales become larger, a cracking pattern appears between regions, indicating greater severity. Rash refers to discrete areas of irritation, called papules, often around a hair follicle and origi- nating in the epidermis. When filled with fluid, the discrete areas are pustules and may be infected. Newborn & Infant Nursing Reviews 14 (2014) 147–152 ⁎ Skin Sciences Program, Division of Plastic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229 USA. Tel.: +1 513 803 0934; fax: +1 513 636 7182. E-mail address: Marty.Visscher@cchmc.org. http://dx.doi.org/10.1053/j.nainr.2014.10.002 1527-3369/© 2014 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect Newborn & Infant Nursing Reviews journal homepage: www.nainr.com