Skin care for preterm and term neonates

Neonatal skin experiences a progressive adaptation to the extrauterine environment during which special care is needed. The immaturity of the epidermal barrier in the neonatal period may cause dry skin, vulnerability to trauma, rapid onset of microbial colonization and percutaneous drug toxicity. This article reviews the practical implications for hygiene, bathing practices, skin integrity, emollient use, infection control and exposure to percutaneous toxic agents in preterm and term infants.     

Overview of Dermatologic Disorders of Neonates in a Central Regional Intensive Care Unit in Hungary

The immaturity and vulnerability of the skin and epidermal barrier function and the frequent iatrogenic complications following diagnostic and therapeutic procedures are often associated with skin manifestations in infants in neonatal intensive care units (NICUs). The aim of the current study was to investigate dermatologic disorders in neonates in our NICU. A prospective cohort study was conducted in the NICU at the Department of Pediatrics at the University of Szeged between January 2012 and January 2013. All full‐ and preterm infants hospitalized in the NICU underwent whole‐body skin examinations and all dermatologic disorders and treatment modalities were recorded. Eighty‐nine dermatologic conditions were detected in 64 of the 211 neonates admitted to the NICU. A wide variety of clinical symptoms accompanied these conditions in these preterm and severely ill full‐term infants. A considerable proportion of the disorders that were seen resulted from the immaturity of the skin and various iatrogenic complications. Dermatologic disorders are frequent in neonates requiring intensive care. Prevention, early detection, and optimal treatment of these disorders with modern, standardized skin care management strategies can result in significant improvements in barrier function and in the integrity of the skin, increasing the overall efficacy of neonatal intensive care.     

Evidence‐based skin care in preterm infants

Most guidelines on neonatal skin care emphasize issues pertaining to healthy, term infants. Few address the complex task of skin barrier maintenance in preterm, very preterm, and extremely preterm infants. Here, we provide an evidence‐based review of the literature on skin care of preterm neonates. Interestingly, the stratum corneum does not fully develop until late in the third trimester, and as such, the barrier function of preterm skin is significantly compromised. Numerous interventions are available to augment the weak skin barrier of neonates. Plastic wraps reduce the incidence of hypothermia while semipermeable and transparent adhesive dressings improve skin quality and decrease the incidence of electrolyte abnormalities. Tub bathing causes less body temperature variability than sponge bathing and can be performed as infrequently as once every four days without increasing bacterial colonization of the skin. Topical emollients, particularly sunflower seed oil, appear to reduce the incidence of skin infections in premature neonates—but only in developing countries. In developed countries, studies indicate that topical petrolatum ointment increases the risk of candidemia and coagulase‐negative Staphylococcus infection in the preterm population, perhaps by creating a milieu similar to occlusive dressings. For preterm infants with catheters, povidone‐iodine and chlorhexidine are comparably effective at preventing catheter colonization. Further studies are necessary to examine the safety and efficacy of various skin care interventions in premature infants with an emphasis placed on subclassifying the patient population. In the interim, it may be beneficial to develop guidelines based on the current body of evidence.     

Functional skin adaptation in infancy – almost complete but not fully competent

Please cite this paper as: Functional skin adaptation in infancy – almost complete but not fully competent. Experimental Dermatology 2010; 19: 483–492. Abstract: Early postnatal life is a period of active functional reorganization and cutaneous physiological adaptation to the extrauterine environment. Skin as the outermost organ of mammalians is endowed of multiple functions such as protection, secretion, absorption and thermoregulation. Birth stimulates the epidermal barrier maturation and the skin surface acidification especially in premature infants. In full‐term infants the developed stratum corneum accomplishes competent barrier function, in contrast to prematures. Complete barrier maturation in preterm infants is fulfilled by 2–4 weeks of the postnatal life. However, in preterms with 23–25 weeks gestational age this process takes longer. Versatile regulatory mechanisms, namely skin surface acidity, calcium ion gradient and nuclear hormone receptors/ligands are interrelated in the complex postnatal newborn adaptation. The skin of newborns is adjusting quickly to the challenging environmental conditions of the postpartum. However, certain functions, for example, microcirculation, continue to develop even beyond the neonatal period, that is, up to the age of 14–17 weeks. Different environmental factors (for instance, dry and cold climate, diapers and cosmetic care procedures) influence the postnatal development of skin functional parameters such as stratum corneum hydration and the permeability barrier especially in premature infants. The aim of this article is to summarize the current knowledge on skin physiology in newborn and infants with a practical approach and to discuss the possible clinical consequences. This review offers the readership a critical and practical overview of skin physiology in newborns and infants. It emphasizes possible new research fields in neonatal and infantile skin physiology.     

Newborn Transepidermal Water Loss Values: A Reference Dataset

Transepidermal water loss (TEWL) is a simple noninvasive measurement of inside‐out skin barrier function. The goal of this research was to establish normal values for TEWL in early life using data gathered from the Cork BASELINE Birth Cohort Study. TEWL was recorded in a standardized fashion using a well‐validated open‐chamber system. A mean of three readings was recorded from 1,036 neonates (37–42 weeks gestational age) and 18 late preterm infants (34–37 weeks gestational age) within 96 hours of birth in an environmentally controlled room. Full‐term neonatal TEWL measurements have a normal distribution (mean 7.06 ± 3.41 g of water/m² per hour) and mean preterm neonatal TEWL measurements were 7.76 ± 2.85 g of water/m² per hour. This is the largest evaluation to date of TEWL in a normal‐term neonatal population. It therefore constitutes a reference dataset for this measurement using an open‐chamber system.     

Pressure injury and risk in the inpatient paediatric and neonatal populations: A single centre point-prevalence study

IntroductionPrevention and management of pressure injury is a key nurse-sensitive quality indicator. From clinical insights, pressure injury effects hospitalised neonates and children, however it is unclear how prevalent this is. The aim of this study was to quantify prevalence of pressure injury, assess skin integrity risk level, and quantify preventive interventions in both neonatal and child inpatient populations at a large children's hospital in the UK.MethodsA cross-sectional study was undertaken, assessing the skin integrity of all children allocated to a paediatric or neonatal bed in June/July 2020. A data collection tool was adapted from two established pressure ulcer point prevalence surveys (EUPAP and Medstrom pre-prevalence survey). Risk assessment was performed using the Braden QD scale.ResultsEighty-eight participants were included, with median age of 0.85 years [range 0–17.5 years), with 32 (36%) of participants being preterm. Median length of hospital stay was 11 days [range 0–174 days]. Pressure ulcer prevalence was 3.4%. The majority of participants had at least two medical devices, with 16 (18.2%) having more than four. Having a medical device was associated with increased risk score of developing pressure injury (odds ratio [OR] 0.03, 95% Confidence Interval [CI] 0.01–0.05, p = 0.02). Most children (39 (44%)) were reported not having proposed preventive measures in place aligned to their risk assessment. However, for those that did, 2 to 4 hourly repositioning was associated with a risk reduction on pressure damage (OR 0.13, 95% CI 0.03–0.23, p = 0.01).ConclusionOverall, we found a low prevalence of pressure injury across preterm infants, children and young people at a tertiary children's hospital. Accurate risk assessment as well as availability and implementation of preventive interventions are a priority for healthcare institutes to avoid pressure injury.     

Chlorhexidine-methanol burns in two extreme preterm newborns

Safe and effective antiseptic use in neonatal intensive care units is mandatory. High efficacy and a low number of side-effects from chlorhexidine have permitted avoidance of the use of mercurials and iodine derivatives, but methanol use can be unsafe in extreme preterm newborns. We report two cases of chemical burn after skin cleansing, due to alcoholic chlorhexidine (0.5%) use in extremely premature infants used for umbilical catheter insertion. Although this formulation is less concerning for use in full-term newborns, nonalcoholic preparations are preferable for use in preterm newborns.     

Loss of cutaneous microbial diversity during first 3 weeks of life in very low birthweight infants

Neonatal sepsis (NS) is a frequent problem in neonatal intensive care, especially in preterm and very low birthweight (VLBW) infants. The objective of the study was to characterize the cutaneous bacterial microbiome in VLBW infants treated in the neonatal intensive care unit (NICU). Non‐invasive skin microbiome specimens were taken repeatedly from 12 VLBW infants during treatment in NICU starting on the first day of life. All infants received benzylpenicillin and netilmicin during the first 1‐5 postnatal days. Samples were also collected from incubators. High cutaneous microbial diversity was present at birth in 11 of 12 of the infants, but the diversity decreased substantially after the first weeks of life in all infants regardless of their infection status. After the loss of diversity, one Staphylococcus operational taxonomic unit dominated the skin microbiome. Recovery of microbial diversity was seen in six of 12 neonates. The microbiome of incubators showed typical environmental bacterial genera. Maternal antibiotic treatment, the aetiology of the preterm birth or being born by C‐section did not appear to affect the diversity of skin microbiota at birth, and no correlation was found between cutaneous microbiome and NS.     

Adnexal polyp of neonatal skin

The adnexal polyp of neonatal skin is a small, usually solitary tumour of the skin occurring mostly on the areola of the nipple of the neonate. Our statistics reveal an incidence of 4-0% in 3,257 newborn infants. Histologically it always contains hair follicles, eccrine glands and vestigial sebaceous glands, hence the term 'adnexal polyp of neonatal skin' is proposed. No similar report has been hitherto recorded.     

Phototherapy Rash in Newborn Infants: Does It Differ Between Conventional and Light Emitting Diode Phototherapy?

Data comparing the cutaneous side effects of light emitting diode (LED) phototherapy (LP) and conventional phototherapy (CP) devices in jaundiced newborn infants are very limited. We investigated the incidence and extent of skin eruptions caused by different phototherapy devices in preterm infants who are more prone to neonatal jaundice. This prospective, randomized controlled trial was conducted in the neonatal intensive care unit (NICU) of Hacettepe University Ihsan Dogramaci Childrens’ Hospital in Ankara, Turkey. Preterm infants without skin lesions before and requiring phototherapy in the first week of life were included in the study. The infants were randomly assigned to receive CP or LP and were monitored closely for skin eruptions during phototherapy. Fifty‐eight infants were included in the study: 25 (43.1%) received CP while 33 (56.9%) received LP. The duration of phototherapy was similar in the two groups (30.4 ± 9.6 hours and 31.8 ± 15.6 hours, respectively). Baseline and control bilirubin levels were similar for the two groups (p = 0.101 and p = 0.105, respectively). The frequency of skin eruptions was 36% in the CP group and 33% in the LP group (p = 0.83). The skin eruptions were macules in 13 (22.4%), papules in 5 (8.6%), and maculopapular rashes in 2 (3.4%) infants.There were no differences in the incidence and extent of skin eruptions in preterm infants who received CP or LP.     

Neonatal eosinophilic pustulosis in a 2-month old

Abstract:  We describe a 2-month-old preterm neonate presenting with neonatal eosinophilic pustulosis, manifesting as grouped pustules on the cheeks, leukocytosis and marked blood eosinophilia, and histology demonstrating abundant eosinophils without follicular involvement. Complete resolution of his skin lesions occurred spontaneously by 4 months of age, paralleling a decline in his eosinophil count. We discuss the relationship of this eruption to other pustular disorders of infancy and hypothesize a mechanism that may initiate the eruption.     

A Diagnostic Challenge: A Case of Acrodermatitis Enteropathica without Hypozincemia and with Maternal Milk of Low Zinc Level

Abstract: Acrodermatitis enteropathica is a rare and distinct form of zinc deficiency with a requirement of life‐long zinc supplementation and inherited in a recessive manner. Transient nutritional zinc deficiency is also a well known condition mimicking acrodermatitis enteropathica like skin changes in preterm and term infants who are generally breastfed with a low level of zinc containing milk. Here, a 4‐month‐old male, term and fully breastfed acrodermatitis enteropathica case without hypozincemia and with maternal milk of low zinc level is presented.     

Characterization of pigmented dermo‐epidermal skin substitutes in a long‐term in vivo assay

In our laboratory, we have been using human pigmented dermo‐epidermal skin substitutes for short‐term experiments since several years. Little is known, however, about the long‐term biology of such constructs after transplantation. We constructed human, melanocyte‐containing dermo‐epidermal skin substitutes of different (light and dark) pigmentation types and studied them in a long‐term animal experiment. Developmental and maturational stages of the epidermal and dermal compartment as well as signs of homoeostasis were analysed 15 weeks after transplantation. Keratinocytes, melanocytes and fibroblasts from human skin biopsies were isolated and assembled into dermo‐epidermal skin substitutes. These were transplanted onto immuno‐incompetent rats and investigated 15 weeks after transplantation. Chromameter evaluation showed a consistent skin colour between 3 and 4 months after transplantation. Melanocytes resided in the epidermal basal layer in physiological numbers and melanin accumulated in keratinocytes in a supranuclear position. Skin substitutes showed a mature epidermis in a homoeostatic state and the presence of dermal components such as Fibrillin and Tropoelastin suggested advanced maturation. Overall, pigmented dermo‐epidermal skin substitutes show a promising development towards achieving near‐normal skin characteristics and epidermal and dermal tissue homoeostasis. In particular, melanocytes function correctly over several months whilst remaining in a physiological, epidermal position and yield a pigmentation resembling original donor skin colour.     

皮肤表面pH值及其临床意义

皮肤表面pH值是皮肤的生理指标之一,它随机体的不同生长发育时期和皮肤的生物状态的不同而不同。老年人及新生儿皮肤表面pH值较高;某些皮肤病可导致皮肤表面pH值升高。皮肤表面pH值升高可直接或间接影响角质形成细胞的代谢,从而引起角质形成细胞增生、分化的异常,皮肤屏障功能改变,角质层致密性降低等。因此,测量皮肤表面pH值对判断表皮乃至整个机体的生物状态具有重要参考价值;皮肤表面pH值维持在最佳生理水平对延缓皮肤老化、防止和治疗某些皮肤病具有一定的指导意义。     

Skin permeability in the newborn

Skin permeability to drugs was assessed in the newborn infant using an in vitro method. Excised skin samples were studied in a Franz-type cell, and permeability to 0.1 M sodium salicylate was measured. Fourteen samples were studied, from infants of 25-41 weeks gestation and up to 8 days old. Gestation markedly affected skin permeability to salicylate, absorption being 10(2)-10(3) times greater in infants of 30 weeks gestation or less than in term infants. There are important implications for the high permeability of the preterm infant's skin; accidental poisoning from absorption of topically applied agents can easily occur, and the percutaneous route offers an alternative method of therapeutic drug administration.     

Influence of neonatal and maternal factors on the prevalence of vernix caseosa

At birth, vernix caseosa can cover the whole body surface or accumulate only on the back and in the skin folds. Interest in its composition and function and its possible applications in adults has increased in recent years. The objective of this study was to determine the prevalence of vernix caseosa in newborn infants in the health care area of Ferrol, Spain, and to assess its relationship with neonatal and maternal factors. We performed a prospective study of 1000 newborns seen within the first 3 days of life in our hospital. Vernix caseosa was observed in 42.9% of cases. The clinical profile associated with the presence of vernix caseosa was the following: healthy newborn girl with a high birth weight, born at term by normal vaginal delivery to a multiparous mother who had received medication and dietary supplements during pregnancy. The absence of vernix caseosa was associated with the presence of physiological scaling of the newborn and erythema toxicum neonatorum.     

Epidermolysis bullosa in three Chinese neonates

Epidermolysis bullosa (EB) is one of the rare blistering diseases that may present in the neonatal period. Diagnosis is based on clinical symptomatology, histopathology, electron microscopy and genetic studies. Age of onset, symptomatology and prognosis of the various subtypes are varied. We describe three cases of EB dystrophica (EBD) followed at the paediatric dermatology clinic. All of them were symptomatic and diagnosed in the neonatal period. One patient had very severe disease and was confirmed to have the Hallopeau-Siemens subtype with both copies of his entire chromosome three from his mother. This extremely rare mode of inheritance is known as uniparental isodisomy. The clinical course of the other two neonates was milder and suggested that they had the dominant form of EBD. Many issues associated with the disease may be encountered. Specifically, details in skin care, counselling and advice were provided and reinforced to the parents. A multidisciplinary approach with inputs from the neonatologists, paediatricians, dermatologists, plastic surgeons, dietitians, physiotherapists, occupational therapists, and special nurses are required to assure optimal outcome.     

Percutaneous Absorption in Preterm Infants

The skin of preterm infants varies considerably in its level of maturity. To understand skin absorption in premature infants better, we report a technique for the assessment of percutaneous absorption at various gestational and postnatal ages using stable, isotope-labeled (13C6) benzoic acid. Our results indicate that in the preterm infant, this method detects enhanced skin absorption in the first postnatal days, which declines over three weeks to that expected of a full-term infant. This approach also indicates an inverse relationship between gestational age and skin absorption, as well as postnatal age and skin absorption. The reported technique is a safe and noninvasive method using a model skin penetrant for the study of percutaneous absorption in preterm infants from which basic data may be derived to add to our understanding of skin barrier function.     

Neonatal sebaceous glands: fine structure of sebaceous and dendritic cells.

Ultrastructural features of sebaceous glands in newborns were examined in adnexal polyp lesions of neonatal skin. Material for electron microscopy was obtained from the nipple areola of 10 Japanese newborn babies of both sexes, less than 8 days of age. The cell organization of the neonatal sebaceous acini consisted of undifferentiated, differentiating, and mature sebaceous cells, and the sequence of sebaceous transformation seemed to be consistent with that described in the postnatal acini. The sheet of continuous basal lamina covering the sebaceous acini was neither distorted nor convoluted. This configuration in the basal lamina revealed no convincing evidence for physiological involution of the neonatal sebaceous cells were identified at the outer periphery of the sebaceous glnads. Melanocytes in symbiosis with the sebaceous acini in concurrent presence of Langerhans cells.     

Neonatal Erythema Multiforme: A Case Report

Erythema multiforme (EM) is an extremely rare condition in infancy. To the best of our knowledge, there have been only three cases of neonatal EM described in the literature, and no such cases have been reported in Korea. A preterm neonate born at 35 weeks and six days of gestation presented with multiple annular erythematous patches with a targetoid shape over his entire body at 36 days of age (corrected age of 7 days). He had no systemic symptoms except for transient mild fever. No triggering factor except for hepatitis B and BCG vaccination was found. Neutropenia was noted upon laboratory analysis. Skin biopsy specimens showed findings suggestive of erythema multiforme. The skin lesions improved rapidly upon administration of intravenous methylprednisolone; however, neutropenia continued for a much longer period. The significance of neutropenia with respect to the development of EM was not clarified. There has been no recurrence of skin lesions over a one-year follow-up period.