p ISSN 2723-6927-e ISSN 2723-4339
The Effect of Topical 100%
Sunflower Seed Oil (SSO) Extract on Trans Epidermal Water Loss (Tewl) and Skin PH Levels in a History
of Atopic Dermatitis
Yunitasari Megawati, Retno Indar Widayati,
Diah Adriani Malik
Faculty of Medicine, Universitas Diponegoro, Indonesia
E-mail: [email protected],
[email protected], [email protected]
Abstract
The skin barrier
function can be disturbed in various conditions, one of which is atopic
dermatitis (AD). Efforts to improve the skin barrier can be done by using
various types of moisturizers. Natural oil from sunflower seed oil (SSO) can be
used as "skin barrier therapy" by reducing trans epidermal water loss
(TEWL) and skin pH levels. A randomized single blind clinical trial with a two
parallel group pre and post design was conducted on subjects with a history of
AD who were treated at the Skin and Venereology Polyclinic at Sunan Kalijaga Hospital, Demak. Samples were randomized into 2
groups to receive 100% SSO or petrolatum as a control. TEWL and pH assessments
were carried out at the beginning of the study and at week 4. Bathing habits
and complaints about using moisturizers were also assessed. TEWL values
decreased in the SSO and petrolatum groups (-5.8�1.93 vs -6.1�9.08, p = 0.9). The pH
value in AD patients also decreased after administration of SSO extract and
petrolatum (-0.4�0.10 vs
-0.2�0.75, p = 0.2). The
decrease in TEWL and pH in both groups was not statistically significant. This
may be related to differences in bathing habits and moisturizer use in the two
groups. Most of the samples in the SSO group stated that they had no complaints
regarding usage. The entire sample completed the study without any reports of
allergic reactions or hypersensitivity. Administration of SSO extract was
effective in reducing TEWL and pH in DA with the majority of samples stating
that they had no complaints about use.
Keywords: sunflower seed oil, skin barrier
therapy, TEWL, pH
The skin is
the outermost layer of the body which functions as a protective barrier for
various organs within it, including by limiting passive water loss, chemical
absorption from the external environment, and preventing microbial infections,
both physical, chemical and immunological. The skin barrier function can be
disturbed in dry skin conditions, namely a condition where the skin becomes
flaky, rough, cracked and accompanied by inflammation and secondary infections.
Dry skin can occur due to the influence of internal and external factors,
including the aging process, environments with temperatures that are too cold
or hot, air with low humidity levels, the use of skin cleansing products, and
various pathological skin conditions, one of which is atopic dermatitis ( DA) (Yang et al., 2020).
Atopic dermatitis or eczema is an
inflammatory condition of the skin that is chronic and residive,
has a spongiotic pathological picture, is accompanied by itching, and has a
predilection for certain parts of the body according to age, including the face
in babies and the flexural parts of the extremities in children (Chan
& Zug, 2021). Atopic
dermatitis is a major health problem that affects more than 200 million people
worldwide, (Langan et al., 2017) with a prevalence
ranging from 2�10% in adults,
The diagnosis of atopic
dermatitis can be made based on clinical symptoms and signs, where the Hanifin
and Rajka Criteria are considered the gold standard for establishing the
diagnosis of atopic dermatitis in both children and adults. The major criteria
for AD include the presence of pruritus, typical morphology and distribution of
lesions, recurrent chronic dermatitis, and personal or family history of atopy,
while one of the most frequently encountered minor criteria is the presence of
dry skin or xerosis.
The stratum corneum is the
outermost layer of the epidermis which functions as a physical barrier and
permeability barrier which is tasked with protecting the skin from mechanical
disturbances, ultraviolet (UV) radiation, cold and hot temperatures, exposure
to chemicals and microbes, as well as maintaining the water content in the
skin.
The five
pillars of AD management include educating patients and caring parents,
avoiding and modifying environmental trigger factors, strengthening and
maintaining optimal skin barrier function, providing anti-inflammatory therapy
such as topical corticosteroids, and controlling and eliminating the
itch-scratch cycle (Rubel et al., 2013). Efforts to improve the skin
barrier can be done by using various types of moisturizers, for example
petrolatum which acts as an occlusive ingredient so it is useful in reducing
TEWL and improving the skin barrier. Petrolatum is the main moisturizer choice
that is widely used in AD sufferers, and 5% petrolatum is reported to reduce
TEWL by more than 98%. Unfortunately, this type of moisturizer is less
comfortable to use because it is too thick and oily, thus limiting patient
compliance in using the moisturizer (Kim
& Leung, 2018).
The use of alternative
moisturizing ingredients to improve the skin barrier without causing discomfort
and adverse effects is expected to increase patient compliance in using
moisturizers. Barrier repair-based therapy has recently been widely developed,
especially the use of moisturizers derived from natural oils or essential oils.
Natural oils can come from food ingredients such as coconut oil, olive oil, or
sunflower seed oil (SSO). The "skin barrier therapy" approach, which
aims to improve the condition of the skin barrier, has been proven effective (Egawa
& Kabashima, 2018).,Sunflower seed oil
(SSO) is a natural oil that is rich in linoleic acid.
The success of the skin barrier therapy method in sufferers with a history of AD can be assessed based on improvements in the condition of the skin barrier. Parameters for assessing skin barrier damage can be done by measuring trans epidermal water loss (TEWL) and pH levels in the skin. TEWL measurements are used to measure water evaporation from the skin. The acidity level (pH) of the skin surface, although not directly assessing barrier function, is often used as a parameter because it is related to skin integrity, namely the stratum corneum, lipid production, skin permeability and the skin as a chemical barrier.
The general objective of this research is to understand the effect of
administering 100% SSO extract on TEWL and skin pH in AD sufferers, while the
specific objectives include determining changes in TEWL and skin pH before and
after administering SSO extract and petrolatum and analyzing the differences
between the two. The benefits of this research include aspects of science and
technology by providing additional information regarding the role of SSO
extract in reducing TEWL and increasing skin pH, health service aspects by
providing insight to dermatologists regarding the use of SSO extract in AD
treatment, as well as aspects of information to the public about its
importance. skin care and considerations in choosing care products containing
SSO extract. The authenticity of this research lies in the fact that the effect
of giving SSO extract on TEWL and skin pH in adult AD sufferers has never been
studied in Indonesia, although several studies related to SSO extract have been
carried out previously.
Research
evaluating the use of topical SSO extract therapy in adults with a history of
atopic dermatitis is still rare. Only one previous study used adult subjects
with a history of AD, while the majority of other studies appear to have been
conducted on neonates without a history of AD and children with a history of
AD. The results of a number of previous studies are still very varied, with
some finding that SSO can reduce pH and TEWL, while other studies have found
conflicting results. Research conducted in Indonesia regarding the use of SSO
in sufferers with a history of AD also used only children aged subjects, and
only assessed changes in TEWL without examining skin pH. Therefore, researchers
intend to examine the effect of administering SSO extract on TEWL and skin pH
in children and adults with a history of AD.
This research will be carried out at the Skin and
Venereology Polyclinic at Sunan Kalijaga Regional Hospital, Demak after
obtaining ethical approval until the sample size is met. The type of research
used was a single blind randomized clinical trial with a two parallel group pre
and post design. The design scheme includes treatment (P) and control (K), with
measurements of TEWL and skin pH values before (PO1, KO3) and
after therapy (PO2, KO4) in the treatment group (X1: topical 100% sunflower
seed oil for 4 weeks; X2: topical 100% petrolatum for 4 weeks). The target
population is patients with a history of atopic dermatitis who seek treatment
at the Skin and Venereology Polyclinic at Sunan Kalijaga Hospital, Demak.
Samples were taken based on inclusion and exclusion criteria, using the
consecutive sampling method and the sample size was calculated using the
formula for two parallel group pre and post-test design. Subject allocation was
carried out using block randomization, and dropout criteria included allergic
reactions. The independent variables include the administration of 100%
sunflower seed oil and 100% petrolatum, while the dependent variables are the
TEWL value and skin pH as measured by a tewameter and pH meter. The entire
process including preparation, use of test materials, evaluation, and data
analysis follows strict procedures with compliance monitoring and side effect
evaluation. The research protocol will receive ethical clearance, and the
subject's identity will be kept confidential. The planned schedule includes
preconditions, implementation, data recap, analysis and thesis examination,
with a total budget of IDR 24,610,000 for research implementation.
In the period February 2024 to April 2024 at the Polyclinic and
Venereology of Sunan Kalijaga Hospital, Demak, 34
patients with atopic dermatitis (AD) were found who were research subjects, and
all subjects met the research criteria and were randomly divided into two
groups: the treatment group using Extract moisturizer. Sunflower Seed Oil/SSO (n=17)
and a control group that used petrolatum moisturizer (n=17) for 4 weeks. No
subjects dropped out during the follow-up period, so all subjects were used for
data analysis. The characteristics of the research subjects showed that the
average age was 30.9 � 7.44 years, with the majority being female (67.6%). In
the SSO Extract group, the mean age of the subjects was 32.4 � 8.24 years,
while in the petrolatum group it was 29.4 � 6.43 years, but this difference was
not statistically significant (p = 0.2). The gender in the SSO Extract group
was mostly men (52.9%), while in the petrolatum group the majority were women
(88.2%), this difference was significant (p<0.001). The most recent
education of the subjects in the SSO Extract group was high school/vocational
school (47.1%), while in the petrolatum group most of them were bachelor's
degrees (58.8%), but this difference was not significant (p=0.1). The duration
of suffering from AD in the SSO Extract group averaged 25.0 � 10.41 years,
longer than the petrolatum group which averaged 20.3 � 6.72 years, with a
significant difference (p = 0.008). Bathing frequency, type of bath soap, how
to dry the body, and initial complaints did not show significant differences
between the two groups. However, the habit of bathing in warm water was
significantly different (p=0.02), and the history of using moisturizers showed
a significant difference (p=0.001). There were mostly no complaints about using
moisturizer in the SSO Extract group, whereas in the petrolatum group the
majority experienced complaints of stickiness and oiliness. This difference was
also significant (p<0.001).
TEWL values before and after
using SSO Extract Moisturizer and Petrolatum are shown in table 8.
Table 8.TEWL value before and after using
moisturizer SSO
and Petrolatum Extract.
|
Group |
p |
||
|
(n=17) |
Petrolatum (n=17) |
||
|
Right side |
|
|
|
|
Baseline |
20.4�4.34;
19.5 (12.3-28.4) |
20.5�7.79;
19.7 (12.2-34.1) |
0.9� |
|
4th week |
14.3�3.60;
13.2 (10.3-21.4) |
14.5�3.39;
14.4 (10.3-21.4) |
0.8� |
|
p& |
<0.001 |
0.02 |
|
|
Delta TEWL right side |
-6.1�2.20;
-5.8 (-10.5--2.1) |
-6.0�8.30;
-6.2 (-21.2-9.2) |
1.0� |
|
Left side |
|
|
|
|
Baseline |
21.4�5.34;
19.7 (13.2-31.0) |
21.8�8.66;19.7 (12.2-35.2) |
0.9� |
|
4th week |
15.9�4.70;
13.4 (10.5-24.6) |
15.8�4.55;
14.2 (10.5-24.6) |
1.0� |
|
p& |
<0.001 |
0.03 |
|
|
Delta TEWL left side |
-5.4�2.01;
-5.0 (-9.7--1.6) |
-6.1�10.08;-4.9 (-24.2-10.7) |
0.8� |
|
TEWL # average value |
|
|
|
|
Baseline |
20.9�4.56;
20.3 (12.8-28.1) |
21.2�8.19;
19.7 (12.6-34.5) |
0.9� |
|
4th week |
15.1�3.95;
14.2 (10.9-22.2) |
15.1�3.73;
14.7 (10.9-22.2) |
0.9� |
|
p& |
0.1 |
0.06 |
|
|
Delta TEWL |
-5.8�1.93;
-5.5 (-10.1--1.9) |
-6.1�9.08;
-5.5 (-22.7-9.7) |
0.9 |
|
#Right-left side average �Unpaired t-test �Mann-Whitney test &Baseline vs week 4; Wilcoxon
test |
|||
The results of the homogeneity
test for TEWL value data at baseline on the right side obtained a p value
<0.001, which means the data is not homogeneous, while the left side value
is p = 0.01 and the average of the right and left TEWL values is
p = 0.03, which means the data is not homogeneous. Based on this, data analysis
for the right and left side of TEWL uses non-parametric tests, taking into
account the normality of the distribution.
In table 8 it is known that the right side
TEWL value at baseline in the SSO Extract Moisturizer group was 20.4�4.34 is more or less the same as in the
Petrolatum moisturizer group, namely 20.5�7.79, but the results of statistical tests
showed that this difference was not significant (p=0.6). The right side TEWL
value at week 4 in the SSO Extract Moisturizer group was 14.3�3.60 is more or less the same as in the Petrolatum
group, namely 14.5�3.39. The statistical test results showed that this
difference was not significant (p=0.9).
In table 8, it is known that in the SSO
Extract Moisturizer group, the change in right side TEWL values
from baseline to week 4 was significant (p<0.001).
The TEWL delta of the right side of the
group in the SSO Extract Moisturizing group is -6.1�2.20, while in the Petrolatum moisturizer
group it was -6.0�8.30. This shows that in the SSO Moisturizer and
Petrolatum groups there was a decrease in TEWL values which was
more or less the same. The statistical test results showed that the difference
in TEWL delta value was not significant (p=0.9).
����������� Left
side TEWL value whenbaselinein the SSO Extract
Moisturizer group, namely 21.4�5.34 is more or less the same as in the Petrolatum
moisturizer group, namely 21.8�8.66. The results of statistical tests showed that
this difference was not significant (p=0.9). The left side TEWL value at week 4
in the SSO Extract Moisturizer group was 15.9�4.70 is more or less the same compared to
the Petrolatum moisturizer group, namely 15.8�4.55. The results of statistical tests
show that this difference is not significant (p=1.0). In table 8 it is known
that in the SSO Extract Moisturizer group the change in TEWL value on the left
side from baseline to week 4 was significant (p<0.001). In table 8 it is
also known that in the Petrolatum group the change in left side TEWL values
from baseline to week 4 was significant (p=0.003).
The TEWL
delta of the left side of the group in the SSO Extract Moisturizing group was
-5.8�1.93, while in the
Petrolatum moisturizer group -6.1�10.08.
This shows onBoth the SSO Extract Moisturizer and the
Petrolatum group experienced a decrease in TEWL values, however the decrease in
the Petrolatum group was greater than the SSO Extract group, but the results of
statistical tests showed that this difference was not significant (p=0.08).
����������� The mean value of right and left TEWL at
baseline in the SSO Extract group was 22.0�7.85 is higher than the Petrolatum moisturizer group,
namely 21.6�8.19. The results of statistical tests showed that
this difference was not significant (p=0.9). The mean value of right and left
TEWL at week 4 in the SSO Extract group was 15.1�3.95 is more or less the same as the
Petrolatum moisturizer group, which is 15.1�3.73. The results of statistical tests
showed that this difference was not significant (p=0.9). In table 8, it is
known that in the SSO Extract Moisturizer group, the change in the right and
left TEWL mean values from baseline to week 4 was not significant
(p=0.1). In the Petrolatum group, the change in mean right and left TEWL values
from baseline to week 4 was also not significant (p=0.06).
The mean delta of right and left TEWL in
the SSO Extract group was -5.8�1.93, while in the Petrolatum moisturizer group it was
-6.1�9.08. This shows that in the SSO Extract
and Petrolatum groups there was a decrease in TEWL values, however the decrease
in the Petrolatum group was greater than in the SSO Extract group, but the
results of statistical tests showed that this difference was not significant
(p=0.9).
Changes in TEWL values on
the right side and left side from baseline to week 4 are also shown in Figure
22.
A B
In
Figure 22, it is known that in both research groups there was a decrease in the
average TEWL value on the right and left sides. It appears that the decrease in
the average TEWL value on the right and left sides in both groups was more or
less the same. The delta difference in TEWL value reduction between the right
and left sides is p=0.9.
�
The pH values before and
after using SSO and Petrolatum Extract Moisturizer are shown in table 9.
Table 9. pH value before and after using moisturizer SSO and Petrolatum Extract
|
pH value |
Group |
p |
|
|
Extract SSO (n=17) |
Petrolatum (n=17) |
||
|
Right side |
|
|
|
|
Baseline |
5.5�0.54; 5.4 (4.7-6.4) |
5.3�0.70; 4.9 (4.4-6.4) |
0.4� |
|
4th week |
5.1�0.58; 5.0 (4.2-6.1) |
5.1�0.48; 5.0 (4.5-6.1) |
0.9� |
|
p& |
<0.001 |
0.4 |
|
|
DeltapHright side |
-0.4�0.13; -0.4 (-0.6--0.1) |
-0.2�0.84; -0.1 (-1.8-1.2) |
0.2� |
|
Left side |
|
|
|
|
Baseline |
5.5�0.49; 5.3 (4.8-6.4) |
5.4�0.49; 5.3 (4.3-6.1) |
0.4� |
|
4th week |
5.1�0.52; 5.2 (4.2-6.0) |
5.1�0.43; 5.2 (4.4-6.0) |
1.0� |
|
p# |
<0.001 |
0.2 |
|
|
DeltapHleft side |
-0.4�0.19; -0.4 (-0.8-0.0) |
-0.2�0.71; 0.0 (-1.7-0.8) |
0.4� |
|
Average valuepH� |
|
|
|
|
Baseline |
5.5�0.50; 5.4 (4.8-6.4) |
5.3�0.58; 5.1 (4.4-6.2) |
0.4� |
|
4th week |
5.1�0.52; 5.1 (4.2-6.0) |
5.1�0.42; 5.1 (4.5-6.0) |
1.0� |
|
p# |
<0.001 |
0.2 |
|
|
DeltapH |
-0.4�0.10; -0.4 (-0.6--0.2) |
-0.2�0.75; 0.0 (-1.7-0.9) |
0.2 |
|
�Right-left side average �Mann-Whitney test �Unpaired t-test &Baseline vs week 4; Wilcoxon test #Baseline vs week 4; Paired t-test |
|||
The results of the homogeneity test for
the pH value data at the baseline on the right side obtained a value of p=0.7,
on the left side a value of p=0.7 and the average of the right and left Ph
values was p=0.3. This shows that the pH value data when the
baseline on the right side, the left side and the average right and left pH
values are homogeneous. The choice of hypothesis test is also
based on the normality of the pH data distribution.
In table 9 it is known that the pH value
of the right side at baseline in the SSO Extract Moisturizer group, namely 5.50.54, is higher than in the Petrolatum moisturizer
group, namely 5.3�0.70, but the results of statistical tests show that
this difference is not significant (p=0.4). The pH value of the right side at
week 4 in the SSO Extract Moisturizer group was 5.1�0.58 is more or less the same as in the
Petrolatum group, namely 5.1�0.48. The statistical test results showed that this
difference was not significant (p=0.9). In table 9, it is known that in the SSO
Extract Moisturizer group the change in the pH value of the right side from
baseline to the 4th week was significant (p<0.001), whereas in the
Petrolatum group the change in the pH value of the right side from baseline to
the 4th week is not significant (p=0.4).
The delta pH of the right side of the SSO
Extract Moisturizing group is -0.4�0.13, while in the Petrolatum moisturizer group it is
-0.2�0.84. This shows that in the SSO Extract
Moisturizer group there was a greater decrease in pH value than in the
Petrolatum Moisturizer group. The results of statistical tests show that the
difference in delta pH values is not significant (p=0.2).
The left side pH value at baseline in the
SSO Extract Moisturizer group was 5.5�0.49 is slightly higher than the Petrolatum
moisturizer group which is 5.4�0.49. The results of statistical tests showed that
this difference was not significant (p=0.4). The left side pH value at week 4
in the SSO Extract Moisturizer group was 5.1�0.52 is more or less the same as in the
Petrolatum moisturizer group, namely 5.1�0.43. The results of statistical tests
show that this difference is not significant (p=1.0). In table 9 it is known
that in the SSO Extract Moisturizer group the change in left side pH value from
baseline to the 4th week was significant (p<0.001), whereas in the
Petrolatum group the change in left side pH value from baseline to the 4th week
is not significant (p=0.2).
The delta pH of the left side of the group
in the SSO Extract Moisturizing group is -0.4�0.19, while in the Petrolatum moisturizer
group it was -0.2�0.71. This shows that in the SSO Extract Moisturizer
there was a decrease in the pH value, whereas in both studies there was a
decrease in the Ph value. The results of statistical tests show that this
difference is not significant (p=0.2).
The mean value of right and left pH at
baseline in the SSO Extract group was 5.5�0.50 is higher than the Petrolatum
moisturizer group, namely 5.3�0.58. The results of statistical tests showed that
this difference was not significant (p=0.4). The mean right and left pH value
at week 4 in the SSO Extract group was 5.1�0.52 is more or less the same as in the
Petrolatum moisturizer group, namely 5.1�0.42. The results of statistical tests
show that this difference is not significant (p=1.0). In table 9, it is known
that in the SSO Extract Moisturizer group the change in the right and left pH
mean values from baseline to the 4th week was significant
(p<0.001), whereas in the Petrolatum group the change in the left side pH
value from baseline to the 4th week -4 is not significant (p=0.2).
The average delta pH of the right and left
groups in the SSO Extract group was -0.4�0.10, while the Petrolatum moisturizer
group is -0.2�0.75. This shows that in both groups there was a
decrease in the mean pH value on the right and left sides, however the decrease
in the SSO group was greater than in the Petrolatum group, however the results
of statistical tests showed that this difference was not significant (p=2).
Changes in pH values on the
right and left sides from baseline to week 4 are also shown in Figure 24.
A B
In
Figure 24, it can be seen that the pH values on the right and
left sides in the SSO and Petrolatum Extract groups saw a decrease in the
average pH value, but it appears that in the SSO Extract group the decrease was
greater than in the Petrolatum group. The statistical test results showed that
the decrease in the mean pH value in the SSO Extract group was significant
(p<0.001) while in the Petrolatum group it was not significant (p=0.2).
The mean
changes in pH values on the right and left sides in the SSO
Extract group and the Petrolatum group are shown in Figure 25.
Figure 25.Changes in mean pH values
on the right and left sides in the SSO Extract group and the
Petrolatum group
In Figure 25, it can be seen that the
change in the right and left mean pH values in the SSO group is
more or less the same as the petrolatum group.
Comparison of the delta pH values
on the right side, left side and the average pH value on the
right and left sides in the SSO Extract group and the Petrolatum group is shown
in Figure 26.
Figure 26.Box-plot diagram of delta pH values
on the right side, left side and average pH values
on the right and left sides in the SSO group and Petrolatum
group
Figure 26 shows the median delta pH value
on the right side, left side and the mean pH value on the right and left sides
in the SSO Extract group is more negative than in the Petrolatum group. This
shows that the decline in the SSO Extract group was greater compared to the
Petrolatum group. The statistical test results also showed that the difference
in the right side delta value between the SSO Extract and Petrolatum groups was
not significant (p=0.2), the difference in the left side delta value between
the SSO Extract and Petrolatum groups was also not significant (p=0.4 ) and the difference in the mean pH values
on the right and left sides between the SSO Extract and
Petrolatum groups was also not significant (p=0.4).
The gender of the research subjects in the SSO extract group was
mostly men, namely 52.9%, while in the petrolatum group the majority were
women, namely 88.2%. Based on research, AD in pediatric patients is not related
to gender, but research in adults has provided mixed results. The International
Study of Asthma and Allergies in Childhood (ISAAC) confirmed that AD in
children is more often found in female patients, with a ratio of female/male
sufferers of l.3:1.0. There are fewer studies of AD in adults. Adult-onset
AD has been shown to occur more frequently among women in two large studies
from the UK. This study also does not explain gender differences and their
relationship with AD.
The SSO extract group had a longer
duration of suffering from DA, namely 25.0�10.41 years, while in the petrolatum group
it was 20.3�6.72. The results of statistical tests show that this
difference is significant (p=0.008). There have been no studies that directly
compare the duration of AD patients and data regarding the relationship between
disease duration and onset and disease prognosis is currently still limited.
One study has shown an association between disease duration and prognosis.
Research by Abuabara et al. stated that intermittent
and chronic AD require appropriate management, and many studies have focused
only on �reactive� approaches, including treatment of disease flares or periods
of acute exacerbation of AD. Recent guidelines emphasize the importance of a
�proactive� approach with continued use of topical corticosteroids (1-2
times/week) or topical calcineurin inhibitors (2-3 times/week) after
stabilization of previously involved skin disease to reduce subsequent flares
or recurrences.
Several aspects of AD management are
patient education as well as avoiding and modifying environmental
triggers/lifestyle modifications. Educational material for patients includes
the frequency of bathing, the type of soap used, and the temperature of the
water when bathing. The frequency of bathing in the SSO Extract Moisturizer
Group was mostly once a day, namely 41.2%, while in the Petrolatum Group, most
of it was twice a day, namely 70.6%. The results of statistical tests show that
this difference is not significant (p=0.05). Most of the types of bath soap in
both research groups were antiseptic soap, namely 64.7% each. The results of
statistical tests show that this difference is not significant (p=1.0). The
majority of the SSO Extract Group had the habit of bathing in warm water,
namely 70.6%, while in the Petrolatum group the majority, namely 70.6%, did not
have the habit of bathing in warm water. The results of statistical tests show
that this difference is significant (p=0.02).
AD management guidelines in Indonesia
recommend bathing frequency 1-2 times a day. A higher frequency will cause the
skin to be exposed to water more often.
The effect of bathing water temperature on
skin barrier damage has been proven in various studies. A study in Spain showed
that hands exposed to hot water when washing hands experienced an increase in
TEWL (25.75 to 58.58 g/m2/hour). This suggests that high-temperature water
promotes water mass transfer from the stratum corneum to the environment as
well as changing the morphology of the stratum corneum and increasing hydration
in a dose-dependent manner, thereby facilitating the penetration of extrinsic
irritants or allergens and providing a suitable environment for bacterial
overgrowth (Herrero-Fernandez
et al., 2022).
The AD Diagnosis and Management Guide
recommends bathing 1-2x a day with lukewarm water (temperature 36-37oC), using
soap that contains moisturizers, and avoiding antiseptic soap. Research has
also proven that the type of soap used can be related to the quality of the
skin barrier. The use of antiseptic soap is associated with changes in skin
microbial richness and is not superior to soap containing moisturizers.
Most of the history of using moisturizers in
the SSO Extract Moisturizer Group was rarely using moisturizers, namely 64.7%,
while in the Petrolatum group, most of them had a history of using
moisturizers, namely 88.2%. The results of statistical tests show that this
difference is significant (p=0.001). Education regarding the use of
moisturizers is also an important aspect in the pillars of AD management,
namely to apply moisturizer immediately within 3 minutes after bathing, 2-3
times a day or more often. The frequency of moisturizer use is related to the
amount of moisturizer applied, because it is recommended to give a very
sufficient amount, namely 100-200 g/week in children and 200-300 g/week in
adults.
The majority of complaints about using moisturizer during the
research in the SSO Extract Moisturizer Group, namely 70.6%, were no
complaints, while the majority of the Petrolatum group, namely 76.5%, were
complaints of stickiness and oiliness. The results of statistical tests show
that this difference is significant (p<0.001). The ideal moisturizer for AD
therapy includes a moisturizer that effectively hydrates the stratum corneum,
reduces and prevents TEWL, and is also elegant and cosmetically acceptable.
Petrolatum is an occlusive moisturizer that has a high viscosity, so its use
causes an oily feeling, while the SSO extract moisturizer is more acceptable to
the subjects.
TEWL values in AD patients decreased after
administration of SSO extract and petrolatum compared to before treatment, but
this was not statistically significant. This is shown by the delta TEWL mean
value in the SSO extract moisturizer group being -5.8�1.93, which is smaller than the petrolatum group which is -6.1�9.08 with a significance value of p = 0.9. This shows that the
TEWL value decreased after administration of SSO Extract Moisturizer and
Petrolatum, with a greater decrease in petrolatum but not statistically
significant. This finding is not in accordance with the hypothesis, with a
greater reduction in SSO extract moisturizer. This discrepancy may be due to
differences in characteristics between subjects. Most of the subjects in the
SSO extract moisturizer group rarely used moisturizer, namely 64.7%, while in
the Petrolatum group most of them had a history of using moisturizer, namely
88.2%. This may influence patient habits and compliance in using SSO.
SSO extract can be used as a moisturizer
because it can work as an emollient against the skin barrier. This is caused by
the linoleic acid content in SSO, which is also known as an ingredient that
functions as an emollient type of moisturizer. Emollients are a type of
moisturizer that can affect skin physiology and pathology,and works by filling the gaps between
desquamated corneocytes and increasing cohesion between cells, so that the skin
surface will become smoother and can reflect light well.
The decrease in TEWL in this study is in accordance with previous
research by Summers et al., in their study comparing the effectiveness of
emollient therapy with SSO on the baby's skin barrier, 3 times a day for 14
days, followed by use 2 times a day until the 28th day. Its use for more than 5
weeks resulted in a decrease in TEWL and consistently high relative humidity
between 80-95%.
The pH value in AD patients decreased after administration of SSO
extract and petrolatum compared to before treatment, but this was not
statistically significant. This is indicated by the delta mean pH value in the
SSO extract moisturizer group being -0.4�0.10, which is greater than the petrolatum group worth -0.2�0.75 with a significance value of p = 0.2. This shows that the pH
value decreased after administering SSO Extract Moisturizer and Petrolatum,
with a greater decrease in SSO extract moisturizer but not statistically
significant. These findings are in accordance with the hypothesis, with a
greater pH reduction value in the SSO extract moisturizer, although the results
are not statistically significant.
The improvement in pH in this study is in
accordance with previous research by Cooke et al, which showed that
administering SSO reduced TEWL values, increased SCH hydration and increased
skin pH. Research
by Miska et al. also showed something similar but in neonate subjects. The
study showed that administering SSO extract could increase the rate of skin pH
reduction (maintaining skin pH) during the first week of life, which could be
demonstrated by faster acid mantle development. Sunflower seed oil in neonates
provides protection by reducing pH more rapidly because the acidic environment
in the skin is needed for lipid metabolism, formation of bilayer structure,
desquamation, bacterial homeostasis, skin colonization and inhibition of
pathogenic bacteria. Reducing pH by administering SSO has a good impact on
barrier normalization.
1.
The treatment
was given in a short period of time, namely 4 weeks, so this study did not
assess the efficacy or safety profile of SSO extract moisturizer in the long
term.
2. All research subjects were adult patients
with a history of AD and not active lesions
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Holder: Yunitasari Megawati,
Retno Indar Widayati, Diah Adriani Malik (2024) |
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First Publication Right: Journal of Health Science |
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