Skincare: Is Less More?

the full references for this article are: Trotter S. (2003) Skincare: Is Less More? Scottish Nurse 7(11): 26-8 and Trotter S. (2003) Skincare: Is Less More? Irish Nurse 5(9): 32-3.

As the amount of manufactured products reaches an all time high, alongside the year on year increase in skin conditions, we, as Nurses, must ask, if there is a correlation between the two?

Introduction
The potential risks associated with early use of manufactured products on the newborn skin, can no longer be ignored (Trotter,2002). This may be just the tip of the iceberg. As a Midwife, this is an important message to get across to new mothers and other Midwifery staff. If these products ( including , baby bath, shampoo, lotions and wipes ) are withheld for the first 2-4 weeks, it is believed the babies skin has a much better chance of avoiding the allergens, associated with modern life ( including, house dust mite, micro-organisms, pollen, chemicals and simple water loss ).
So, what of the older child and indeed adults, who have gone on to develop skin conditions? I would like to highlight these risks to all Nurses that come into contact with anyone experiencing skin problems. This is a simple message, but one that is often overlooked.

Current Research
Carolyn Lund et al ( 1999a;1999b;2001a;2001b) have conducted the most comprehensive research to date on Neonatal Skincare and recommend the use of plain water in preference to manufactured products.
In the UK, Professor Michael Cork and his team (2002) based at Sheffield University have concentrated on the alarming rise in atopic eczema and its possible causes. He also draws attention to the overuse of manufactured baby skincare products.
Professor Jean Golding (2002), who is based at Bristol University and heads up the Avon and Somerset Longitudinal Study of Parents and Children (ALSPAC) has focused public and professional attention on the use of manufactured products and their potential to cause health problems in the long term.
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Anatomy and Physiology of the Skin
It is important to understand how the skin protects us from outside influences and what happens, if this process is interrupted.
The skin is the largest organ in the body and is made up of three main layers: the epidermis, the dermis and the underlying subcutaneous fatty tissue. Within these layers lie the blood vessels, nerves, sweat/oil glands and hair follicles. The epidermis, or outer layer, is further divided into the stratum corneum, stratum granulosum and the stratum germinatum. The latter of these is at the junction of the epidermis and dermis and is where the renewal of the basal cells is carried out. These cells constantly divide and are called keratinocytes.
Simplistically these can be thought of as analogous to a brick wall, with the mortar between, made up of lipids (fat cells). (see diagram)
It is this barrier, which allows the retention of fluids within the epidermal cells, so that they remain plump and therefore prevent the introduction of microorganisms, chemicals and allergens. When intact, this wall regulates temperature, acts as a barrier against infection, balances water/electrolytes, stores fat and insulates against the cold. The skin is also a large tactile area for the interpretation of stimuli.
The stratum corneum itself is made up of 10-20 microscopic layers in an adult and a term infant. In premature infants, this number drops to between two and three layers and in extremely premature infants, of less than 23 weeks gestation, this layer may be virtually non-existent (Holbrook, 1982;Nonato, 1998).
Babies are born with an alkaline skin surface, with an average pH of 6.34 (Behrendt and Green,1971 ). However, within days, the pH has fallen to about 4.95 (acid). This process takes much longer in premature babies (Eaglestein, 1985).
This is known as the ‘Acid Mantle’ and is the skins protector. The development of this mantle takes between 2-8 weeks, depending on gestational age (Evans and Rutter, 1986; Harpin and Rutter, 1983), so it is even more important to avoid damage in the early weeks of life.
The introduction of baby products, wipes and creams, along with the exposure to urine and faeces, could disrupt the delicate protective barrier and lead to problems, including eczema or allergic reactions (Behrendt and Green,1971 ; Berg et al, 1986; Peck and Botwinick, 1964).
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Present Guidelines for Skincare
We do not have national guidelines for the skincare of babies, despite evidence to suggest that allergic reactions develop shortly after birth and are linked to the overuse of manufactured baby skincare products (Lund, 1999).
Surprisingly, the most in-depth study of recent years was sponsored by Johnson & Johnson (Lund et al, 1999a;1999b ;2001a;2001b). This led to the introduction of new guidelines, which were recently published (Washington 2001).
The ‘instructions for use’ of baby products do not warn of the possible dangers of early overuse leading to the development of allergies. In fact, on one leading brand, it actually says: ‘mild enough for newborn babies’.
Today, a full term infant will be bathed using baby products within hours of birth. Babies in Special Care Baby Units (SCBU) will probably be left a little longer, but will also have products used, when warm water would be the wisest alternative. Antiseptic sprays/wipes, iodine lotion and sticky tape are all frequently used to attach the many tubes, leads and wires. These are the necessary by-products of the complex care that a neonate will receive in a modern unit. This extra risk must be balanced against the long-term needs of the infant. Skin damage is common and can include nappy rash, burns, infections and adhesive removal grazes. These can prove difficult and expensive to treat.
However, the cost in physical and emotional pain is incalculable. Anything we can do to help reduce these risks can only be for the good.
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Paediatric Units for Babies and Older Children
Many of the risks associated with the neonate in SCBU, are similar to those in Paediatric units. These babies’ skins are vulnerable to attack from infection, equipment and a multitude of chemical allergens used in their treatment.
We must keep these risks to the absolute minimum and as such, should continue the water-only regime, which was hopefully started in the maternity unit.
If there is a history of atopic eczema in the family, Professor Michael Cork (2002), recommends the following precautions:

• Avoid carpets- fit hard floors and have washable non-slip mats. This will substantially reduce the dust mite levels.
• Bedding to be washed at 60 degrees in order to kill the dust mite.
• Soft toys may be stored in the freezer 0vernight, as this also kills off the dust mite (it may be wise to buy toys in pairs).
• Use anti-dust-mite mattress and pillowcase covers.
• Vacuum regularly
• Keep pets out of the bedroom
• If skin is dry, bathe and moisturise with emollient-based products.
• Use washable roller blinds or curtains
• Keep humidity levels below 70% and the room temperature between 17-19 degrees. [back to top]
  

Possible New Guidelines
Delicate skin, whatever its age, and this can include adult sufferers, needs extra care. It should be acknowledged that anything placed on, in or around the skin has the potential to harm. Tissue viability and protection has always been a major part of nursing care. Trends come and go, but commonsense must prevail. The simple answers are often the most effective.
These are some possible guidelines for practice:

• Avoid the use of products that contain alcohol, colours and perfumes. These have the potential to dry out the skin, by stripping away the precious lipids between the cells of the epidermis.
• If needed, use emollient-based products that protect the skin from excess water loss and moisturise, thus maintaining the skins natural barrier.
• For babies and children with eczema, the withdrawal of products, followed by plain water washing, could even be enough to treat minor skin conditions, which, otherwise, could go on to become more serious in the future.
• Make sure that all bedding or clothes are washed, using non-biological soap powders and are thoroughly rinsed (Halton, 1990).
• Some babies may become sensitive to disposable nappies. In this instance, reusable nappies can be worn and washed in mild non-bio soap powder. A one-way liner will help to keep the baby drier.
• At present Hospital laundries use biological soap powders and wash everything at 80 degrees, due to Health & Safety regulations. Fabric conditioners are used to combat static electricity. Contrary to popular belief, starch is no longer used. The heavy weight of the cotton used in sheets, which is needed for its strength and durability, sometimes gives the impression that starch has been added, although this is not the case.
• There may be a case for introducing a range of linen that has been washed in non-biological powder, which can still adhere to the Health & Safety regulations. These could be used for all areas where young babies and dermatology patients require this extra care.
• For those patients who are allergic to certain foods, special diets are available.
• For young babies, the benefits of breastfeeding should continue to be reinforced and encouragement given to nursing mothers. These benefits are available to the baby for as long as the mother breastfeeds and cannot be underestimated. The cowsmilk protein that is used in formula feeds can sensitise the immature gastrointestinal system, which can then go on to develop eczema and asthma. It has been shown that, even one bottle of formula milk can sensitise a baby (Parsonage and Clark, 1981).
• When introducing mixed feeding, start gradually with pureed fruit and vegetables. Avoid all wheat-based (gluten) products, opting instead for oats and rice cereals for the first nine months. Avoid milk products for 9-12 months. Eggs and nuts should also be withheld until a year old.
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Conclusion
In light of ongoing research, we, as nurses, need to be careful about the products we use on a patients skin. By keeping to a simple regime, we can reduce the skins contact with outside allergens, which may even avoid some conditions arising at all. In our modern world, where chemicals are part of everyday life, we need to reassess the risks and educate accordingly.
It is only, as a result of asking questions and researching the answers that we can hope to provide a safer environment for all those in our care.
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References

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