Volume 73, No.6: 2021 Siriraj Medical Journal
https://he02.tci-thaijo.org/index.php/sirirajmedj/index
386
Rattanavalai Nitiyarom, M.D., Nampen Siriwat, M.D., Wanee Wisuthsarewong, M.D.
Division of Dermatology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, ailand.
Transepidermal Water Loss after Water Immersion
ABSTRACT
Objective: To observe changes in transepidermal water loss (TEWL) at dierent times aer water immersion.
Materials and Methods: TEWL values were measured before water immersion and at 3, 5, 10, 15, 20, and 30 minutes
aer immersion of the skin in water for 5 minutes.
Results: Forty-one healthy volunteers were enrolled with an average age of 30.4±5.5 years. Twenty-ve subjects
were female and sixteen were male. e TEWL value before water immersion (TEWL
baseline
) was 13.16±7.27 g/m
2
/h
and TEWL values at 3, 5, 10, 15, 20 and 30 minutes aer immersion were 23.21±7.67, 16.12±3.42, 14.76±6.36,
14.45±6.67, 13.53±4.67 and 12.96±5.18 g/m
2
/h, respectively. Aer immersion, TEWL values at 3 and 5 minutes
statistically increased compared to TEWL
baseline
(p<0.001). TEWL values between 10 to 30 minutes gradually dropped
with no statistically signicant dierence compared to the previous period and TEWL
baseline
. Although total water
loss from the skin occurred within 30 minutes, 56.9% of it occurred within 10 minutes aer immersion. ere was
no signicant dierence between TEWL
baseline
in males and females but the TEWL values at 3, 5 and 15 minutes
aer immersion in males was higher than in females (p<0.05).
Conclusion: TEWL statistically increased aer water immersion for only 5 minutes. e cumulative percentage
of TEWL was high within 10 minutes. Gender did not aect TEWL values before immersion; however, males
experienced more water loss from the skin than females aer immersion. erefore, moisturizer should be applied
immediately before TEWL occurs.
Keywords: Immersion; TEWL; transepidermal water loss (Siriraj Med J 2021; 73: 386-390)
Corresponding author: Wanee Wisuthsarewong
E-mail: wanee.wisuth@gmail.com
Received 5 February 2021 Revised 19 March 2021 Accepted 22 March 2021
ORCID ID: http://orcid.org/0000-0002-2139-5246
http://dx.doi.org/10.33192/Smj.2021.51
INTRODUCTION
e skin has multiple defensive and regulatory
functions. However, its most important function is to act
as barrier against external stresses and the percutaneous
penetration of chemicals, allergens, and organisms. is
barrier function is almost entirely present in the epidermis
and in particular the stratum corneum (SC). e skin
also maintains water and electrolyte homeostasis and
thermoregulation.
1,2
e functional state of the skin can be investigated
by assessing non-invasive biophysical parameters which
are influenced by several factors.
2-5
For example, in
vivo evaluation by measurement for TEWL has proven
to be a reliable indicator of the function of the skin
barrier.
3-9
A defective skin barrier leads to increased
TEWL along with dry skin.
9,10
erefore, TEWL values
are directly related to the clinical severity of lesions in
various skin diseases with altered barrier function such
as atopic dermatitis, ichthyosis, contact dermatitis, and
psoriasis.
1
To manage dry skin, bathing and application
of moisturizer is necessary. How the skin changes at
dierent time periods aer bathing can provide useful
information for skin care recommendations.
e purpose of this study was to characterize the
function of skin barrier as evaluated by TEWL values
at dierent time points aer immersion.
Nitiyarom et al.
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Original Article
SMJ
MATERIALS AND METHODS
A prospective study was conducted at the Department
of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol
University. e study protocol was approved by the
Siriraj Ethical Review Board (Si 702/2015) and the written
informed consent was obtained from all participants.
Healthy participants with no pre-existing dermatoses
or any systemic disorders that could alter the biophysical
parameters were enrolled. e participants were asked
not to apply any skin product for at least 12 hours prior
to testing and to avoid washing the area to be tested on
evaluation day. Before any measurements were made,
participants were asked to rest for 15 minutes in a room
with controlled environmental conditions to help them
acclimatize. All measurements were made in highly
comparable temperatures and humidity-controlled
conditions in accordance with the guidelines for standardized
skin parameter measurements in the European Group
on Ecacy Measurement and Evaluation of Cosmetics
and Other Products (EEMCO) guidelines and by the
Standardization Group of the European Society of Contact
Dermatitis.
11
e TEWL value was measured using a
Tewameter
TM
TM 300 (Courage and Khazaka electronic,
Köln, Germany) and expressed in g/m
2
/h. Participants
were asked to immerse the test area in water rather than
bathe. e volar region of the forearm, which is oen
selected as the test site in dermatological research, was
selected as the test area. Aer baseline TEWL readings
were recorded, the volunteer’s forearms were immersed in
the water bathtub for ve minutes followed by pat drying
with towels and then measuring TEWL again at 3, 5, 10,
15, 20, and 30 minutes later. To avoid inaccuracies, each
measurement was repeated three times at the nearby areas
and the mean value was used for analysis. e patients
were monitored for side eects aer the measurements
were completed.
e data was analyzed using SPSS Statistical soware,
version 20 (IBM, Chicago, IL, USA). A normal distribution
of the data was examined by Kolmogrov-Smirnov test.
e demographic data was presented through descriptive
statistics with an average ± standard deviation (SD) for
normally distributed values and median and range for
non-normally distributed data. For normally distributed
data, an independent t-test was used to compare the
age between genders (Mann-Whitney U test for non-
normal distribution). To compare TEWL values at
each time point and between genders, an analysis of
variance (ANOVA) with Bonferroni post-hoc test was
used (Friedman’s test with Bonferroni post-hoc test for
non-normal distribution). A p-value of less than 0.05
was regarded as being statistically signicant.
RESULTS
is study contained forty-one healthy volunteers
(61% female and 39% male) with an average age of
30.4±5.5 years. ere was no statistical dierence in
age between both genders (p=0.190). e average room
temperature was 23.20±0.89°C, and the relative humidity
was 47.00±7.38%.
e TEWL value before water immersion (TEWL
baseline
)
was 13.16±7.27 g/m
2
/h. Aer immersion, the TEWL
value statistically increased at 3 minutes, and 5 minutes,
(p<0.001) before rapidly decreasing during 10 to 30
minutes aer immersion when it showed no statistical
dierence compared to the baseline (Table 1).
Cumulative TEWL aer immersion, which reects
total water loss from the skin, was 23.2, 39.3, 54.1, 68.5,
82.1, 95.0 g/m
2
/h at 3 minutes, 5 minutes, 10 minutes,
15 minutes, 20 minutes, and 30 minutes, respectively
(Fig 1). Regarding the percentage of cumulative TEWL at
dierent time points, 24.4%, 41.4% and 56.9% of TEWL
occurred within 3 minutes, 5 minutes, and 10 minutes
aer immersion, respectively.
e baseline TEWL value in males was the same
as in females (p=0.121). e TEWL values in both male
and female volunteers increased aer immersion in
water (p<0.001), however, it became equal to before
immersion at 10 minutes (p>0.05). e TEWL values
in males were statistically higher than in females at 3
minutes, 5 minutes, and 15 minutes aer immersion
(Table 2). No side eects were reported from the testing.
DISCUSSION
Non-invasive biophysical skin parameters such as
TEWL are widely accepted as a reliable tool for assessment
of the skin barrier function. Dry skin is a common condition
in many skin diseases. Regular bathing and application
of moisturizer to hydrate the skin and prevent water
loss is necessary. is study demonstrated a signicant
increase in TEWL post water immersion compared to
the baseline, however, the value returned to the baseline
levels aer 10 minutes. e cumulative TEWL value
within 10 minutes of testing was 56.9% of all water
loss in 30 minutes. e baseline TEWL values showed
no statistical dierence between male and female, but
TEWL values in males was higher than females until at
least 15 minutes aer immersion.
Our data conrmed results from previous studies which
showed that TEWL increased aer water application.
10,12-14
Although an increase in TEWL values usually relate
to impairment of the skin barrier,
7-9,15
the increased in
TEWL aer immersion was not only due to an impaired
skin barrier function. It is assumed that the skin absorbs
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Nitiyarom et al.
Fig 1. Cumulative TEWL at every time point aer
immersion.
TABLE 1. Comparison of TEWL values at dierent time points.
TEWL p-value p-value
Time (mean±SD) g/m
2
/h compare to baseline compare to previous
measurement
Before immersion (baseline) 13.16±7.27 - -
3 min after immersion 23.21±7.67 <0.001* <0.001*
5 min after immersion 16.12±3.42 <0.001* <0.001*
10 min after immersion 14.76±6.36 1.000 0.166
15 min after immersion 14.45±6.67 1.000 0.656
20 min after immersion 13.53±4.67 1.000 1.000
30 min after immersion 12.96±5.18 1.000 1.000
*p-value <0.05 = statistical signicance
TABLE 2. Comparison of TEWL values between genders at dierent time points.
TEWL p-value
Time (mean±SD) g/m
2
/h compare between genders
Male Female
Before immersion (baseline) 14.77±9.09 12.05±5.55 0.121
3 min after immersion 25.93±10.34 21.34±4.32 0.012*
5 min after immersion 16.84±3.34 15.61±1.79 0.048*
10 min after immersion 16.14±8.25 13.80±4.50 0.130
15 min after immersion 16.78±9.14 12.84±3.53 0.013*
20 min after immersion 14.32±4.84 12.98±4.53 0.237
30 min after immersion 12.94±2.52 12.97±5.18 0.979
*p-value <0.05 = statistical signicance
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Original Article
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water instantaneously aer being immersed; however, the
water-holding capacity of the SC is maintained only for
a short period of time aer which the remaining excess
water evaporates from the skin leading to a gradual
return to baseline levels.
10,14,16,17
According to results obtained, immersion increased
TEWL values and its accumulation correlates to an
absolute total amount of water loss from the skin was
high (56.9%) within 10 minutes aer immersion.
15
If
the TEWL continues, dry skin will get worse. Apply
occlusive moisturizer as soon as possible aer bathing
to maintain SC water content should be recommended
as part of the skin care regimen.
1,10,18
Patients with dry
skin will benet from occlusive moisturizer application
when skin hydration is still retained.
10,18,19
Although a precise denition of normal TEWL value
does not exist,
8,20
variations in TEWL values have been
well-documented.
2,5-7,20
A wide ranges of TEWL values
are inuenced by several endogenous, exogenous, and
environmental factors.
8,20
ere is insucient evidence
to conclude that gender aects TEWL.
20
While some
studies did not observe much of a dierence in TEWL
values between genders,
4,15,21
others noticed higher TEWL
values in males.
2,4,5,9,21
e baseline TEWL value in our
study was not dierent between genders but the TEWL
value aer immersion was signicantly higher in males
who experienced more water loss from the skin than
females, possibly due to dierent hormonal eects, skin
conditions, barrier functions, and outdoor working
habits and activities.
21
is study has limitations because the duration
of water exposure was only ve minutes, which may
be too short to reveal profound eects of skin barrier
function structurally and functionally. Furthermore, this
study measured only TEWL values, other biophysical
parameters such as skin capacitance and pH might add
more information about dynamic changes in the skin
aer water immersion. Hence, future studies with longer
immersion duration, more frequent measurements, and
a range of biophysical skin parameters should provide
more helpful information.
CONCLUSION
In conclusion, this study evaluated the eects of
the routine practice of water exposure through water
immersion of the skin. Since the TEWL value increased
signicantly for a short period, it is reasonable to encourage
the application of moisturizer immediately aer bathing
to prevent water loss from SC
ACKNOWLEDGEMENTS
is study was supported by a grant for the Research
Development and Medical Education, Faculty of Medicine
Siriraj Hospital, Mahidol University. Bangkok, ailand
(grant no. R015931013).
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