Mengevaluasi dan Mengurangi Xerosis pada Perenang Kompetitif: Studi in

Vitro dan Uji Acak Terkontrol

Kimball Sheehan, Darrah Sheehan and Mary Margaret Noland
Department of Dermatology, University of Virginia

ABSTRAK
Pendahuluan: Xerosis adalah masalah umum dengan gejala sisa yang signifikan pada
perenang kompetitif, hal itu disebabkan karena hilangnya cairan transepidermal. Studi ini
mengevaluasi mengenai moisture barriers untuk mengurangi xerosis pada perenang
kompetitif.
Metode: Model kulit buatan digunakan untuk mengevaluasi lima produk. Model diukur untuk
menilai perubahan pada ketebalan dan beratnya selama lebih dari 7 hari. Barrier diuji dalam
uji acak terkontrol (RCT) pada 20 perenang. Kadar air pada kulit diukur secara
bertahap. Mikrograf kulit dinilai dengan cara blinded fashion.
Hasil: Moisture barriers # 1 model kulit yang dirawat pada hari ke 7 dengan mempertahankan
ketebalan rata-rata 7.08mm dengan 2.38mm pada kontrol ( p =.0001). Bobot rata-rata
kelompok 1 yang dirawat dan kelompok kontrol pada hari ke 7 adalah 40.1 dan 8.65g
( p =.03). Dalam RCT, kelompok yang dirawat dengan menggunakan moisture barriers # 1
dan kontrol menunjukkan kadar air rendah dan skor xerosis sedang pada awal. Pada minggu 3,
pengukuran kelembaban untuk kelompok yang dirawat dan kontrol adalah 28,6% dan 18,2%
( p =. 0,003). Skor xerosis rata-rata untuk kelompok yang dirawat dan kontrol adalah 8,5 dan
12,9 ( p =.0008).
Kesimpulan: Keawetan kulit buatan ini bervariasi untuk lima moisture barriers yang tersedia
secara komersial. Aplikasi moisture barriers meningkatkan kadar air dan mengurangi xerosis
pada perenang kompetitif.

Pengantar
Mahasiswa perenang secara rutin menghabiskan 2 jam atau lebih di kolam renang per
hari. Kombinasi dari berjam-jam dalam air yang diklorinasi dan suhu musim dingin
menyebabkan masalah kulit bagi perenang sehingga xerosis menjadi hal yang paling umum
terlihat bagi perenang. Xerosis pada perenang sering dihubungkan dengan kondisi kulit
bersisik, kasar, kemerahan, dan crack/fissure. Hal ini dapat disebabkan oleh kontak yang
terlalu lama dengan air, erosi dari sebum alami kulit menyebabkan kehilangan kelembaban dari
stratum korneum dan menghasilkan kulit kering, gatal, dan bersisik. Hal ini bisa diperburuk
oleh fasilitas kolam renang berpemanas dan cuaca dingin. Kulit tanpa fungsi penghalang yang
tidak memadai pada akhirnya lebih rentan terhadap infeksi kulit.
Anjuran pemakaian lotion, minyak, atau suplemen nutrisi yang disarankan dari orang
tua atau perenang lain yang dapat mengurangi xerosis. Sampai saat ini, studi sistematis dan
kuantitatif mengenai moisture barriers untuk xerosis bagi perenang belum dilakukan. Kami
menduga bahwa moisture barriers dapat membantu melindungi ketebalan dan berat model
kulit buatan, dan moisture barriers efektif diggunakan pada perenang sekolah menengah
karena dapat mengurangi xerosis.

Metode dan bahan

Dalam penelitian ini, pengujian praklinis dan klinis digunakan untuk menentukan
moisture barriers yang tersedia secara komersial untuk mengurangi tanda dan gejala xerosis.

Pengujian in vitro
Model kulit in vitro yang dibuat dari gelatin (Knox Gel, Northfield, IL) digunakan
untuk mengidentifikasi manakah yang memberikan perlindungan terbaik di lingkungan
sekitar. Pada cawan petri 10 cc, 4,5 cc dari gelatin dituangkan dan dibiarkan membeku di atas
piring.
Satu dari lima agent moisture barriers yang berbeda dengan volume setara 2,5 cc /
cawan diaplikasikan secara merata ke permukaan atas model kulit yang bertempat di cawan
petri, dan penutup cawan petri itu diletakkan di atas. Kelima agen tersebut adalah sebagai
berikut :
• Moisture barrier # Kelompok 1: Aquaphor (Biersdorf, Wilton, CT, USA) Healing
Ointment
• Moisture barrier # Kelompok 2: Minyak Kelapa (Ventura Foods, Brea, CA, AS)
• Moisture barrier # Kelompok 3 :Vaseline Pure Ultra White Petroleum Jelly (Unilever,
Engelwood Cliffs, NJ, USA)
• Moisture Barrier # Kelompok 4: Gold Bond Ultimate Skin Therapy Lotion (Chattem,
Chattanooga, Tennessee, USA)
• Moisture Barrier # Kelompok 5: Krim tangan Eucerin (Biersdorf, Wilton, CT, USA)
 • Tidak menggunaka Moisture Barrier (kontrol) # Kelompok 6: Kontrol (tanpa
menggunakan Moisture Barrier)
Kami menilai keawetan dari model kulit buatan berdasarkan tebal dan berat di
awal dan kemudian pada hari ke 3, 5, dan 7 setelah aplikasi atau tidak diaplikasi oleh
Moisture Barrier. Pengukuran ketebalan dilakukan dengan menggunakan caliper
digital (Thomas Scientific, Swedesboro, NJ). Pengukuran massa pada model kulit
buatan dilakukan dengan analytical balance (Sartorius, Bohemia, NY).

Uji Acak Terkontrol - Prosedur, Risiko / Keselamatan, Rekrutmen, Analisis Data, dan
Persetujuan
Setelah mengidentifikasi keoptimalan moisture barrier, keefektifan bahan tersebut
diperiksa secara kelompok dari sekolah menengah atas perenang dan penyelam dibandingkan
dengan kelompok kontrol. Para perenang dan penyelam berusia sekitar mulai dari 14 hingga
19 tahun. Tidak ada pengecualian jenis kelamin, ras, atau kendala etnis untuk penelitian
ini. Sebelum melanjutkan penelitian, subjek yang potensial ditanyakan mengenai ada tidaknya
alergi dengan agen moisture protecting yang tersedia secara komersial. Subjek yang potensial
dikeluarkan jika mereka tidak ingin berpartisipasi, memiliki alergi, atau diantisipasi tidak dapat
mematuhi pengaplikasian moisture protecting sekitar 30 harian di lengan kiri. Rekrutmen
dilakukan melalaui pengumuman kepada tim dengan izin dari pelatih dan sekolah. Informed
consent diperoleh dari semua subjek, dan uji klinis disetujui oleh IRB Virginia Piedmont
Regional IRB. Subjek direkrut secara sukarela dan diacak untuk sebuah kelompok.
Pada kelompok uji, subjek mengoleskan agent 2 cc ke lengan kiri sekali sehari selama
3 minggu. Pengukuran dasar kelembaban kulit menggunakan pengukur kelembaban digital
(model SK-IV, Prosmart, China) diperoleh dari lengan kiri dan kemudian pengukuran
tambahan diambil sekali per minggu untuk seluruh periode. Setiap minggu, pengukuran
kelembaban dilakukan pada pertengahan hari untuk semua subjek. Subjek kontrol
diinstruksikan untuk tidak mengoleskan agen apa pun ke lengan kiri selama masa penelitian.
Penelitian menggunakan mikroskop digital pada 100x (Dino-Lite model
AM4113T; Dunwell Tech, Torrance, CA), gambar kulit lengan masing-masing subjek pada
awal dan akhir studi 3 minggu diambil secara elektronik. Gambar diberi skor menggunakan
skala xerosis yang divalidasi oleh reviewer yang tidak mengetahui identitas kelompok studi
tersebut. Skor xerosis yang diterapkan; Skala dari 0 hingga 16 dengan angka yang lebih tinggi
berarti xerosis yang lebih berat. Mikrografik kulit dicatat untuk setiap subjek di awal (minggu
0) dan akhir masa penelitian (minggu 3); mikrograf kulit diambil pada waktu dan hari yang
sama dengan pengukuran kelembaban.

Analisis data
Pengujian model kulit secara in vitro dilakukan dalam rangkap tiga, dan rata-rata dan
kesalahan standar dihitung untuk setiap kondisi eksperimental dan titik waktu. Tebal dan berat
model kulit juga dianalisis untuk menentukan perbedaan statistik antara bahan yang di tes dan
kontrol pada hari ke 3, 5, dan 7. Tambahan, agen uji moisture barrier pada hari ke 7 secara
statistik dibandingkan dengan uji- t (IBM Corporation, SPSS Statistics for Windows, version
24. Armonk, NY). P <0,05 diangap signifikan secara spesifik.
Perbedaan dalam skor xerosis dan pengukuran kelembaban antara kelompok dinillai
pada awal, tengah, dan akhir dari uji coba. Metode statistik termasuk uji t digunakan untuk
menilai perbedaan pengukuran kelembaban dan skor xerosis antar kelompok.

Hasil
Hasil pengujian in vitro
Model kulit buatan yang dicetak dari gelatin dalam cawan petri dinilai ketebalan dan
berat dari hari ke 3, 5, dan hari ke 7 setelahnya.

Ketebalan kulit tiruan

Ketebalan kulit tiruan secara bertahap menurun dari waktu ke waktu dari hari nol
hingga hari ke 7 ( Tabel 1 (a)). Kelompok kontrol dimulai dengan ketebalan 9,29 ± 0,045mm
dan menurun menjadi ketebalan 2,38 ± 0,22mm pada hari 7. Ini mencerminkan perubahan
persen dari -74% dalam ketebalan kulit buatan sebagai akibat dari hilangnya kelembapan dan
dan massa keseluruhan.
 Pada hari ke 7, kelompok moisture barrier tetap memiliki ketebalan yang lebih besar
dibandingkan dengan kelompok kontrol yang tidak terkendali. Kelompok moisture barrier# 1
kelompok kulit yang dirawat pada hari ke 7 mempertahankan ketebalan rata-rata 7,08 ± 0,32
mm daripada kelompok kontrol dengan ketebalan 2,38 ± 0,22 mm ( p =.0001, uji- t ). Pada hari
ke 7, moisture barrier# kelompok 1 memiliki ketebalan kulit secara statistik lebih unggul
daripada kelompok yang dirawat dengan moisture barrier lainnya ( p <0,05).

Berat kulit tiruan

Berat kulit tiruan dihitung berdasarkan keseimbangan analitik pada hari 0, 3, 5, dan 7
(Tabel 1 (b) ). Serupa dengan ketebalan kulit, berat kulit tiruan menurun dari waktu ke
waktu. Berarti kelompok kontrol berat kulit tiruan menurun dari 44,08 ± 0,32g pada hari 0
menjadi 8,65 ± 0,23g pada hari 7. Hal itu mewakili pengurangan 80% berat kulit tiruan pada
kelompok kontrol yang tidak dirawat selama periode 1 minggu.
Moisture barrier # 1 kelompok yang dirawat menunjukkan dapat mempertahankan
berat kulit tiruan pada hari ke 7. Berat rata-rata (± standar kesalahan rata-rata) dari moisture
barrier # 1 dan kelompok kontrol pada hari ke 7 masing-masing adalah 40,1 ± 1,11 Dan 8,65
± 0,23. Hal ini menunjukkanm moisture barrier # kelompok 1 beratnya lebih tinggi daripada
kelompok kontrol (p = 03, t-test). Semua kelompok yang di rawat menunjukkan beberapa
retensi dari berat kulit tiruan yang lebih unggul daripada kelompok kontrol pada hari ke 3, hari
ke 5, dan hari ke 7 (Gambar 2). Mengingat bahwa moisture barrier # kelompok 1 yang dirawat
juga menunjukkan peningkatan yang signifikan daripada kelompok yang dirawat lainnya pada
hari Ke 7, moisture barrier # 1 dianggap uji klinis terbaik.

Hasil uji klinis

Kadar air pada kulit
Pada awal, pengukuran kelembaban antara subjek dalam moisture barrier # 1 dan
kelompok kontrol adalah 15,3 ± 0,9% (rata-rata ± SEM) dan 16,7 ± 1,4%, masing-masing
( p =.21). Dalam 1 minggu setelah dimulai perawatan dengan moisture barrier, kelompok uji
menunjukkan peningkatan yang signifikan dalam kadar air kulit pada daerah yang dirawat
dibandingkan dengan kelompok kontrol ( p = .04), dan peningkatan kadar air pada kelompok
uji ini berlanjut pada minggu ke 2 (p = .02). Pada minggu 3 (yaitu waktu terakhir), kelompok
moisture barrier menunjukkan peningkatan kadar air pada kulit yang signifikan ( p =
.003). Pada titik waktu uji klinis akhir, tingkat kelembaban pada moisture barrier # 1 yang
dirawat dan kelompok kontrol masing-masing adalah 28,6 ± 3,1% dan 18,2 ± 1,1%.
(Tabel 2(a) dan Gambar 1).

Skor xerosis pada awal dan akhir periode uji

Pada dasarnya, kelompok uji moisture barrier dan kelompok kontrol menunjukkan
xerosis sedang yang dibuktikan dengan skor xerosis. Pada dasarnya, skor xerosis dari moisture
barrier dan kelompok kontrol masing-masing 12,4 ± 0,4 dan 13,1 ± 0,5 ( p = .16) ( Tabel 2
(b) Dan Gambar 1 (b) ). Setelah 3 minggu penggunaan harian dari moisture barrier, kelompok
ini menunjukkan pengurangan (yaitu peningkatan) dalam skor xerosis hingga rata-rata 8,5 ±
0,3. Skor xerosis rata-rata kelompok kontrol pada minggu 3 adalah 12,9 ± 0,4, yang tidak jauh
berbeda dari nilainya pada awal. Pada minggu ke 3, skor xerosis kelompok moisture barrier #
1 secara signifikan meningkat ( p = .0008) di atas kelompok kontrol (Tabel 2 (b)dan Gambar
1 (b)).

Diskusi
Xerosis adalah salah satu penyakit kulit yang paling umum mempengaruhi hingga 60%
pasien setengah baya dan lanjut usia. Perenang kompetitif memiliki risiko xerosis yang cukup
besar. Xerosis termasuk gatal, kasar, kulit bersisik, dan crack/fissure. Xerosis pada perenang
disebabkan oleh reduksi hidrasi dari lapisan luar kulit akibat perendaman dalam air yang
diklorinasi dan udara dingin untuk waktu yang lama. Pengobatan xerosis terdiri dari pelembab,
obat-obatan, dan perubahan aktivitas.
Menggunakan model in vitro, kami menguji kemampuan lima agent berbeda untuk
melindungi kulit buatan. Kelompok kontrol menunjukkan penurunan ketebalan dan berat kulit
74% dan 80% (Tabel 1 (a,b)). Moisture Barrier # 1 menjaga dengan baik ketebalan dan berat
kulit setelah 1 minggu pengujian in vitro; pemeliharaan dari ketebalan dan berat kulit yang
dihasilkan oleh moisture barrier # 1 secara statistik lebih unggul dari kontrol. (Tabel 1 (a,b))
Dalam uji klinis, perenang kompetitif merawat area kulit yang diuji yaitu pada lengan
dengan mengaplikasikan moisture barrier # 1 (subjek uji) sekali sehari atau membiarkan
lengan yang tidak dirawat. Pada awal percobaan, perenang di kedua kelompok menunjukkan
xerosis ringan hingga sedang berdasarkan sistem penilaian dan kadar kelembaban kulit yang
rendah. Kelompok perlakuan moisture barrier menunjukkan peningkatan yang signifikan
secara statistik dalam skor kelembaban kulit dan xerosis dalam waktu 3 minggu. (Tabel 2 (a,b))
Awalnya, semua perenang menunjukkan skor xerosis sekitar 12-13 pada skala 16 poin
(Tabel 2 (b)). Skor tersebut menunjukkan prevalensi xerosis pada perenang dan pentingnya
mengatasi masalah ini. Berdasarkan respon subyek kontrol selama percobaan 3 minggu,
masalah xerosis pada perenang bertahan atau bahkan memburuk saat penelitian berlanjut.
Dengan penggunaan moisture barrier setiap hari, pengurangan xerosis yang ditunjukkan oleh
skor xerosis meningkat secara statistik dan pengukuran kelembaban kulit tercapai. Pendekatan
ini memiliki potensi untuk menghindari efek xerosis seperti pruritis, lepuh, bersisik
perkembangan fisura, infeksi, luka, dan dermatitis atopi.

Keterbatasan studi
Kami tidak dapat memeriksa semua moisture barrier yang tersedia secara komersial,
dan kami menguji sekelompok perenang dari satu tim. Kondisi air yang dialami oleh para
perenang di tim ini mungkin tidak mencerminkan oleh tim perenang kompetitif lainnya. Kami
tidak dapat mengendalikan faktor perancu lainnya seperti kadar air di rumah, waktu
pengaplikasian moisture barrier, pakaian, suhu udara, dan penggunaan sabun yang merusak
sawar kulit.
Gambar 1. (a) Pembacaan kelembaban kulit di berbagai titik waktu selama periode studi 3 minggu
menggunakan moisture barrier # 1 atau kontrol. p <0,05 dibandingkan dengan kontrol. (B) Skor Xerosis
pada awal dan akhir dari uji klinis acak menggunakan moisture barrier # 1 atau kontrol. Skor xerosis 0
adalah yang terbaik (mis. Tidak ada xerosis), dan 16 adalah terburuk (mis. Xerosis parah) seperti yang
dijelaskan dalam sistem penilaian xerosis oleh Kang et al. (2014). p <0,05 dibandingkan dengan kontrol.

Kesimpulan
Xerosis adalah masalah dermatologis umum yang menyerang berbagai jenis individu
termasuk perenang. Produk yang tersedia secara komersial bervariasi dalam hal
kemampuannya untuk mempertahankan model kulit tiruan dari gelatin.
Pengaplikasian moisture barrier setiap harinya secara signifikan dapat menjaga atau
meningkatkan kadar air kulit para perenang dibandingkan dengan kontrol yang tidak diberikan.
Untuk perenang yang dirawat, pengaplikasian moisture barrier setiap harinya dapat
menyebabkan penurunan nilai xerosis kulit secara signifikan dan meningkatkan kadar air pada
kulit dibandingkan dengan perenang kontrol yang tidak dirawat. Pengenalan mengenai xerosis
dan pendidikan tentang manajemen kulit yang tepat untuk perenang dapat dianggap sebagai
bagian dari program sekolah renang.
Ucapan Terima Kasih
Kami ingin mengucapkan terima kasih kepada guru Sains SMA Albemarle Barat Ms.
Stutzman dan Pelatih Berenang Universitas Albemarle Barat Bledsoe atas bimbingan dan
dukungan upaya penelitian kami.
 Journal of Dermatological Treatment

ISSN: 0954-6634 (Print) 1471-1753 (Online) Journal homepage: https://www.tandfonline.com/loi/ijdt20

Evaluating and reducing xerosis in competitive

swimmers: an in vitro study and randomized
controlled clinical trial

Kimball Sheehan, Darrah Sheehan & Mary Margaret Noland

To cite this article: Kimball Sheehan, Darrah Sheehan & Mary Margaret Noland (2019): Evaluating
and reducing xerosis in competitive swimmers: an in vitro study and randomized controlled clinical
trial, Journal of Dermatological Treatment, DOI: 10.1080/09546634.2019.1638882

To link to this article: https://doi.org/10.1080/09546634.2019.1638882

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Accepted author version posted online: 01

Jul 2019.
Published online: 11 Jul 2019.

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JOURNAL OF DERMATOLOGICAL TREATMENT
https://doi.org/10.1080/09546634.2019.1638882

ARTICLE

Evaluating and reducing xerosis in competitive swimmers: an in vitro study and

randomized controlled clinical trial
Kimball Sheehan
, Darrah Sheehan
and Mary Margaret Noland
Department of Dermatology, University of Virginia

ABSTRACT ARTICLE HISTORY

Introduction: Xerosis is a common problem with significant sequelae in competitive swimmers, and it Received 3 June 2019
results from transepidermal water loss. This study evaluates moisture barriers for reducing xerosis in com- Accepted 27 June 2019
petitive swimmers.
KEYWORDS
Methods: An artificial skin model was used to evaluate five products. Models were measured for changes
Xerosis; swimming;
in thickness and weight over 7 days. The optimal barrier was tested in a randomized controlled trial (RCT) dermatology
of 20 swimmers. Skin moisture content was serially measured. Skin micrographs were scored in a
blinded fashion.
Results: The moisture barrier #1 treated skin model at day 7 maintained a mean thickness of 7.08 mm
versus 2.38 mm for control (p ¼ .0001). The mean weights of group 1 treated and control groups at day 7
were 40.1 and 8.65 g (p ¼ .03). In the RCT, the group treated with moisture barrier #1 and the controls
exhibited low moisture content and moderate xerosis scores at baseline. At week 3, moisture measure-
ments for treated and control groups were 28.6% and 18.2% (p ¼ .003). The mean xerosis scores for the
treated and control groups were 8.5 and 12.9 (p ¼ .0008).
Conclusions: Artificial skin preservation varied for five commercially available moisture barriers. Moisture
barrier application improved moisture content and reduced xerosis in competitive swimmers.

Introduction In vitro testing

Varsity swimmers routinely spend 2 or more hours in the pool per
day. The combination of long hours in chlorinated water and cold
winter temperatures leads to dermatological conditions for many
swimmers with xerosis being the most common seen in
swimmers (1–3). Xerosis in swimmers is frequently associated with
scaling, roughness, redness, and cracks/fissures (4,5). As a result of
prolonged exposure to water, erosion of the natural protective
skin sebum leads to loss of moisture from the stratum corneum
and results in dry, itchy, and scaly skin (3,4). This can be exacer-
bated by the heated pool facility and cold weather. Skin without
an adequate barrier function is ultimately more prone to cutane-
ous infections (6).
Anecdotal remedies passed from parents or other swimmers such
as lotions, oils, or nutritional supplements have been suggested to
reduce xerosis (3,7). To date, a systematic and quantitative study of
commercially available moisture barriers to reduce xerosis in
swimmers has not been undertaken. We hypothesized that a mois-
ture barrier can help to protect the thickness and weight of a simu-
lated human skin model over time, and that effective use of a
moisture barrier in high school swimmers may reduce xerosis.
Methods and materials
In the current study, preclinical and clinical testing was utilized to
determine the optimal commercially available moisture barrier to
reduce the signs and symptoms of xerosis.
An in vitro skin model made of gelatin (Knox Gel, Northfield, IL)
was employed to identify the one that provided the best protec-
tion in an ambient environment (8). In a 10-cc petri dish, 4.5 cc of
gelatin was poured and allowed to solidify in the dish.
One of five different moisture barrier agents of equivalent vol-
ume of 2.5 cc/dish was evenly applied to the upper surface of the
skin model housed in a petri dish, and the petri dish cover was
placed on top. The five agents were as follows:
 Moisture Barrier # 1 Group: Aquaphor (Biersdorf, Wilton, CT,
USA) Healing Ointment
 Moisture Barrier # 2 Group: Coconut Oil (Ventura Foods, Brea,
CA, USA)
 Moisture Barrier # 3 Group: Vaseline Pure Ultra White
Petroleum Jelly (Unilever, Engelwood Cliffs, NJ, USA).
 Moisture Barrier # 4 Group: Gold Bond Ultimate Skin Therapy
Lotion (Chattem, Chattanooga, Tennessee, USA)
 Moisture Barrier # 5 Group: Eucerin Advanced Repair Hand
Cream (Biersdorf, Wilton, CT, USA)
 No moisture barrier (i.e. control) Group #6: Control (no mois-
ture protecting barrier)
We assessed the preservation of height and weight of an artifi-
cial skin model at baseline and then at the 3, 5, and 7-day time
points after application or no application of a moisture barrier.
Measurement of height was performed using a digital caliper
(Thomas Scientific, Swedesboro, NJ). Measurement of the mass of
the skin model was performed on an analytical balance (Sartorius,
Bohemia, NY).

CONTACT Kimball Sheehan kimballsheehan@gmail.com Department of Dermatology, University of Virginia

These authors are the co-first authors.
Supplemental data for this article can be accessed here.
ß 2019 Taylor & Francis Group, LLC
2 K. SHEEHAN ET AL.

Table 1. (a) Artificial skin thickness as a function of time.

Thickness (cm)
(mean þ/ SEM)
Day Day 0 Day 3 Day 5 Day 7
Test group
Moisture Barrier 9.34 þ/ 0.11 8.09 þ/ 0.37 7.36 þ/ 0.44 7.08 þ/ 0.32
#1 (n ¼ 3)
Moisture Barrier 9.54 þ/ 0.12 6.89 þ/ 0.74 5.38 þ/ 0.44 4.93 þ/ 0.34
#2 (n ¼ 3)
Moisture Barrier 9.32 þ/ 0.11 7.27 þ/ 0.42 6.40 þ/ 1.27 3.94 þ/ 0.47
#3 (n ¼ 3)
Moisture Barrier 9.14 þ/ 0.07 7.77 þ/ 0.76 5.52 þ/ 0.58 4.8 þ/ 0.42
#4 (n ¼ 3)
Moisture Barrier 9.41 þ/ 0.17 7.48 þ/ 0.11 5.83 þ/ 0.51 4.28 þ/ 0.23
#5 (n ¼ 3)
No Moisture Barrier 9.29 þ/ 0.05 5.86 þ/ 0.39 3.35 þ/ 0.11 2.38 þ/ 0.22
(Control) #6 (n¼ 3)

Randomized clinical trial – procedure, risk/safety, recruitment,
data analysis, and consent
After identifying the optimal moisture barrier, the efficacy of that
agent was explored in a cohort of varsity high school swimmers
and divers and compared it to a control group. The swimmers
and divers ranged in age from 14 to 19 years old. There were no
gender, racial, or ethnic constraints for the study. Prior to accrual
to the study, potential subjects were asked of any allergies to
commercially available moisture protecting agents. Also, potential
subjects were excluded if they did not wish to participate, had an
allergy, would be unavailable for weekly testing during the study
period, or anticipated not being able to comply with the approxi-
mately 30 s/day application of the moisture protecting agent to
the left forearm. Recruitment occurred through an announcement
to the team and with the permission of the coach and school.
Informed consent was obtained from all subjects, and the clinical
trial was approved by the Virginia Piedmont Regional IRB.
Subjects were recruited on a volunteer basis and randomized to
a cohort.
In the test group, subjects applied a 2-cc amount of the agent
to the left forearm once daily for 3 weeks. Baseline measurements
of skin moisture with a digital moisture meter (model SK-IV,
Prosmart, China) were obtained from the left forearm and then
additional measurements were taken once per week for the entire
period (9). Each week, moisture measurements were taken at mid-
day for all subjects. Control subjects were instructed not to apply
any agent to the left forearm during the study period.
Also, using a digital microscope at 100 (Dino-Lite model
AM4113T; Dunwell Tech, Torrance, CA), images of each subject’s
forearm skin at baseline and the end of the 3-week study were
electronically captured. Images were scored using a validating
xerosis scale by a reviewer blinded to the identity of the individu-
al’s study group. A xerosis score applied; this is a scale from 0 to
16 with a higher number meaning worse xerosis (10). Skin micro-
graphs were recorded for each subject at the start (week 0) and
end of the study period (week 3); skin micrographs were taken at
the same time and day as moisture measurements.
Data analysis
In vitro skin model testing was performed in triplicate, and mean
and standard error were computed for each experimental condi-
tion and time point. The height and weight of the skin models
were also analyzed for statistical differences between the test
agent and control at the 3, 5, and 7-day time points. In addition,
the test moisture barrier agents at day 7 were statistically
compared via a t-test (IBM Corporation, SPSS Statistics for
Windows, version 24. Armonk, NY). P < .05 was considered statis-
tically significant.
Differences in the xerosis scores and moisture measurements
between groups were assessed at the start, intermediate, and fin-
ish points of the trial. Statistical methods including t-test were
used to assess for differences in moisture measurements and
xerosis scores between cohorts.
Results
In vitro testing results
Artificial skin models of gelatin molds in petri dishes were
assessed for thickness and weight at baseline, and day 3, day 5,
and day 7 thereafter.
Artificial skin thickness
Artificial skin thickness gradually declined over time from time
zero to day 7 (Table 1(a)). The control group started with a mean
thickness of 9.29 ± 0.045 mm and decreased to a thickness of
2.38 ± 0.22 mm at day 7. This reflects a percent change of 74%
in the thickness of the artificial skin as a result of loss of moisture
and overall mass.
At day 7, the moisture barrier groups had maintained greater
thickness than the untreated control group. The Moisture Barrier
#1 treated ‘skin’ group at day 7 maintained a mean thickness of
7.08 ± 0.32 mm versus the control group thickness of
2.38 ± 0.22 mm (p ¼ .0001, t-test). At day 7, the Moisture Barrier #1
group’s preservation of ‘skin’ thickness was statistically superior to
the other moisture barrier treated groups too (p < .05)
(Supplemental Figure 1).
Artificial skin weight
Artificial skins weights were measured on an analytical balance at
day 0, 3, 5, and 7 (Table 1(b)). Similar to ‘skin’ thickness, the artifi-
cial skin weight decreased over time. The control group’s mean
weight decreased from 44.08 ± 0.32 g at day 0 to 8.65 ± 0.23 g at
day 7. This represents an 80% reduction in artificial skin weight in
the untreated control group over a 1-week period.
The Moisture Barrier #1 treated group exhibited superior
weight retention at day 7. The mean weights (±standard error of
the mean) of the Moisture Barrier #1 and control groups at day 7
were 40.1 ± 1.11 and 8.65 ± 0.23 g, respectively. The Moisture
Barrier #1 group’s weight was appreciably greater than the

Table 1. (b) Artificial skin weights as a function of time.
Day Day 0
Test group
Moisture Barrier 45.95 þ/ 0.42
#1 (n ¼ 3)
Moisture Barrier 45.43 þ/ 0.31
#2 (n ¼ 3)
Moisture Barrier 46.44 þ/ 0.58
#3 (n ¼ 3)
Moisture Barrier 45.95 þ/ 0.78
#4 (n ¼ 3)
Moisture Barrier 45.19 þ/ 0.47
#5 (n ¼ 3)
No Moisture Barrier 44.1 þ/ 0.32
(Control) Group
#6 (n ¼ 3)
control group (p ¼ .03, t-test). All of the moisture treated groups
exhibited some weight retention of the artificial skin that was
superior to the control group at day 3, day 5, and day 7
(Supplemental Figure 2). Given that the Moisture Barrier #1
treated group also exhibited significant improvement over the
other treated groups at day 7, Moisture Barrier #1 was deemed
the best agent to test for the clinical trial.
Clinical trial results
Moisture content of the skin
At baseline, moisture measurements between the subjects in the
Moisture Barrier #1 and control groups were 15.3 ± 0.9%
(mean ± SEM) and 16.7 ± 1.4%, respectively (p ¼ .21). Within 1 week
after starting moisture barrier treatment, the test group showed a
statistically significant increase in skin moisture content of the
treated area as compared to the control group (p ¼ .04), and this
improvement in moisture content in the test group continued at
week 2 (p ¼ .02). At week 3 (i.e. the final time point), the moisture
barrier group showed a statistically significant increase in skin
moisture content (p ¼ .003). At the final clinical trial time point,
the moisture levels in the Barrier #1 treated and control groups
were 28.6 ± 3.1% and 18.2 ± 1.1%, respectively (Table 2(a) and
Figure 1(a)).
Xerosis score at the beginning and end of the test period
At baseline, the members of the test moisture barrier and control
groups exhibited moderate xerosis as evidenced by their xerosis
scores. At baseline, the xerosis scores of the moisture barrier and
control groups were 12.4 ± 0.4 and 13.1 ± 0.5, respectively (p ¼ .16)
(Table 2(b) and Figure 1(b)). After 3 weeks of daily application of
the moisture barrier, the moisture group demonstrated a reduc-
tion (i.e. improvement) in the xerosis score to a mean of 8.5 ± 0.3.
The control group’s mean xerosis score at week 3 was 12.9 ± 0.4,
which was not appreciably different from its score at baseline. At
week 3, the Moisture Barrier #1 group’s xerosis score was signifi-
cantly improved (p ¼ .0008) over the control group (Table 2(b)
and Figure 1(b)).
Discussion
Xerosis is one of the most common dermatological conditions
affecting up to 60% of middle-aged and elderly patients (11,12).
Competitive swimmers are at appreciable risk for xerosis (1,3,13).
JOURNAL OF DERMATOLOGICAL TREATMENT 3
Weight (g)
(mean þ/ SEM)
Day 3 Day 5 Day 7
43.89 þ/ 0.91 42.03 þ/ 0.75 40.1 þ/ 1.11
35.63 þ/ 0.49 31.48 þ/ 0.81 26.48 þ/ 1.27
38.39 þ/ 1.03 35.01 þ/ 1.25 31.42 þ/ 1.46
40.13 þ/ 0.59 37.53 þ/ 1.11 33.16 þ/ 0.66
40.06 þ/ 0.63 37.6 þ/ 1.0 34.34 þ/ 1.62
27.67 þ/ 0.28 18.5 þ/ 0.32 8.65 þ/ 0.23
Xerosis may include itching, rough, scaly skin, and cracks/fissure
formation (7,10,14,15). Xerosis in swimmers is caused by hydration
reduction from the outer layers of the skin secondary to immer-
sion in chlorinated and cold water for extended periods of time
(2,3,16–18). Xerosis treatment comprises moisturizers, medications,
and activity changes (3,19).
Using an in vitro model, we tested the ability of five different
agents to protect an artificial ‘skin’. The control group demon-
strated 74% and 80% reductions in skin thickness and weight,
respectively (Table 1(a,b)). Moisture Barrier #1 best preserved the
skin’s thickness and weight after 1 week of in vitro testing; preser-
vation of thickness and weight provided by Moisture Barrier #1
was statistically superior to controls (Table 1(a,b)).
In the clinical trial, competitive swimmers either treated the
test skin area on the arm with once daily application of Moisture
Barrier #1 (test subjects) or left the arm untreated. At the start of
the experiment, swimmers in both groups exhibited mild to mod-
erate xerosis based upon the scoring system and low skin mois-
ture content. The moisture barrier treated group exhibited
statistically significant improvement in skin moisture and xerosis
scores within 3 weeks (Table 2(a,b)).
Initially, all swimmers exhibited xerosis scores of approximately
12–13 on a 16-point scale (Table 2(b)). Such scores demonstrate
the prevalence of xerosis in swimmers and importance of address-
ing this problem. Based upon the control subjects’ response dur-
ing the 3-week trial, the problem of xerosis in swimmers persisted
or even worsened as the study progressed. With daily use of a
moisture barrier, xerosis reduction demonstrated by statistically
improved xerosis scores and skin moisture measurements was
accomplished. This approach has the potential to avoid down-
stream xerosis effects such as pruritis, blisters, scaling, fissure
development, infection, ulcers, and atopic dermatitis (4,6,7,20).
Study limitations
We were unable to test all commercially available moisture bar-
riers, and we tested a cohort of swimmers from one team. The
aquatic conditions experienced by the swimmers on this team
may not precisely mirrored by other competitive swim teams.
Also, we were unable to control for other confounding factors
such as home moisture content, timing of moisture barrier appli-
cation, clothing, water temperature, and use of skin damaging
soaps (1–3).
4 K. SHEEHAN ET AL.

Table 2. (a) Moisture readings results for the test and control groups; mean ± standard error of the mean (SEM).
Moisture reading (% þ/ SEM)
Group Time Week 0 Week 1 Week 2 Week 3
Moisture Barrier #1 Group (N ¼ 10) 15.3 þ/ 0.9 26.9 þ/ 2.8 25.2 þ/ 1.7 28.6 þ/ 3.1
Control group (N ¼ 10) 16.7 þ/ 1.4 20.7 þ/ 2.1 20.1 þ/ 1.4 18.2 þ/ 1.1
p-value .2 .04 .02 .003

Figure 1. (a) Skin moisture readings at various time points during the 3-week study period using moisture barrier #1 or control.
p < .05 as compared to control. (b)
Xerosis scores at the onset and conclusion of the randomized clinical trial using moisture barrier #1 or control. Xerosis score of 0 is best (i.e. no xerosis), and 16 is
worst (i.e. severe xerosis) as described in the xerosis grading system by Kang et al. (2014).
p < .05 as compared to control.

Table 2. (b) Xerosis score results for the test and control groups at the start Acknowledgements
and end of the study period; mean ± standard error of the mean (SEM).
Xerosis score (0–16) We wish to thank Western Albemarle High School Science teacher
Mean þ/ SEM Ms. Stutzman and Western Albemarle High School Varsity Swim
Group Time Week 0 Week 3 Coach Bledsoe for guidance and support of our
Moisture Barrier #1 Group (N¼ 10) 12.4 þ/ 0.4 8.5 þ/ 0.3 research endeavors.
Control group (N ¼ 10) 13.1 þ/ 0.5 12.9 þ/ 0.4
p-value .2 .0008
Disclosure statement
The authors report no conflict of interest.
Conclusions
Xerosis is a common dermatological problem afflicting various types ORCID
of individuals including swimmers. Commercially available products
Kimball Sheehan http://orcid.org/0000-0003-0439-5073
vary in terms of their ability to preserve a gelatin skin model.
Daily application of a moisture barrier significantly preserved
or increased the moisture content of swimmers’ skin as compared References
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