:  At this moment, pressure ulcer risk assessment is dominated by subjective measures and does not predict pressure ulcer development satisfactorily. Objective measures are, therefore, needed for an early detection of these ulcers. The current in vitro study evaluates cytokines and chemokines [interleukin 1α (IL‐1α), interleukin 1 receptor antagonist (IL‐1RA), tumor necrosis factor α (TNF‐α) and interleukin 8 (CXCL8/IL‐8)] as early markers for mechanically‐induced epidermal damage. Various degrees of epidermal damage were induced by subjecting commercially available epidermal equivalents (EpiDerm) to increasing pressures (0, 50, 75, 100, 150, and 200 mmHg) for 24 h, using a loading device. At the end of the loading experiment, tissue damage was assessed by histological examination and by evaluation of the cell membrane integrity. Cytokines and chemokines were determined in the culture supernatant. Sustained epidermal loading resulted in an increased release of IL‐1α, IL‐1RA, TNF‐α and CXCL8/IL‐8. This was first observed at 75 mmHg, when the tissue was only slightly damaged. Swollen cells, vacuoles, necrosis and affected cell membranes were observed at pressures higher than 75 mmHg. Furthermore, at 150 and 200 mmHg, the cells in the lower part of the epidermis were severely compressed. In conclusion, IL‐1α, IL‐1RA, TNF‐α and CXCL8/IL‐8 are released in vitro as a result of sustained mechanical loading of the epidermis. The first increase in cytokines and chemokines was observed when the epidermal tissue was only slightly damaged. Therefore, these cytokines and chemokines are potential markers for the objective, early detection of mechanically‐induced skin damage, such as pressure ulcers.

Abstract-Pressure ulcer risk assessment

Pressure ulcers are areas of soft tissue breakdown that result from sustained mechanical loading of the skin and underlying tissues. Today, little is known with respect to the aetiology of these ulcers. This study introduces an in vitro model system to study the effects of clinically relevant loading regimes on damage progression in the epidermis, the uppermost skin layer. Engineered epidermal equivalents (EpiDerm) were subjected to 6.7 and 13.3 kPa for either 2 or 20 h using a custom-built loading device. Tissue damage was assessed by (1) histological examination, (2) tissue viability evaluation, and (3) by the release of a pro-inflammatory mediator, interleukin-1alpha (IL-1alpha). Loading the EpiDerm samples for 2 h increased the IL-1alpha release, although no visible tissue damage was observed. However, in the 20 h loading experiments visible tissue damage and a small decrease in tissue viability were observed. Furthermore, in these experiments the IL-1alpha release increased with magnitude of loading. It is concluded that this in vitro model system can be applied to improve insight in the epidermal damage process due to prolonged mechanical loading and can serve as a sound basis for effective clinical identification and prevention of pressure ulcers.

The diffusion could be measured in epidermal tissues using FRAP. In the future, the diffusion coefficients obtained in the current study will be used to study the difference between the transport in EpiDerm cultures and in human epidermis.

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