A Consensus About the Importance of Ceramide Containing Skincare for Normal and Sensitive Skin Conditions in Neonates and Infants

August 2020 | Volume 19 | Issue 8 | Original Article | 769 | Copyright © August 2020

Published online July 31, 2020

Lawrence A. Schachner MD FAAD FAAPa, Anneke Andriessen PhDb, Latanya Benjamin MD FAAP FAADc, Alanna F. Bree MDd, Peter A. Lechman MD MBA FAAPe, Ayleen A. Pinera-Llano MDf, Leon Kircik MD FAADg

aDivision of Pediatric Dermatology, Department of Dermatology & Cutaneous Surgery, Department of Pediatrics, Leonard M. Miller School of Medicine, University of Miami, FL bRadboud UMC, Nijmegen and Andriessen Consultants, Malden, The Netherlands cFlorida Atlantic University, Boca Raton, FL dBaylor College of Medicine and Texas Children’s Hospital, Houston, TX; A Children’s House for Pediatric Dermatology, Houston, TX eNorthwestern Medical Group, Chicago, IL; Northwestern University Feinberg School of Medicine, Chicago, IL fKing Bay Pediatrics, Maimi, FL, General Pediatrics, Nicklaus Children’s Hospital, Miami, FL gIchan School of Medicine at Mount Sinai, New York, NY; Indiana University Medical Center, Indianapolis, IN; Physicians Skin Care, PLLC, Louisville, KY; DermResearch, PLLC, Louisville, KY

skin barrier.15 Neonates and infants are particularly susceptible to toxicity through the skin of non-therapeutic and therapeutic topical agents, which may lead to systemic signs and symptoms that can be severe.15 Systemic toxicity resulting from percutaneous absorption of substances is rare but increases in those with impaired skin barrier function, eg, neonates and infants, AD, and ichthyosis.15 When no obvious source of poisoning is found in infants, children, and adolescents, transcutaneous exposures must be considered.15 Dermatologists, emergency physicians, and pediatricians need to be comfortable diagnosing and managing such cases of poisoning through percutaneous absorption.15

Topical agents that are harmless in adults may cause methemoglobinemia, respiratory distress, neurological toxicity, and even death in the pediatric and neonatal age groups depending upon how much has been absorbed systemically.15 These agents include, among others, isopropanol, benzocaine, pyrethrin, hexachlorophene, and salicylic acid.15

A compromised skin barrier susceptible to toxicity through the skin may be seen in up to 25% of infants and young children.15 Increased vulnerability is secondary to increased body surface area to weight ratio, taking into consideration that full maturity of the epidermis may take one to three years or more.1-4, 7-9,15

An ideal moisturizer for neonates and infants is safe, effective, inexpensive, and fragrance as well as sensitizing agent-free. Additionally, the skincare should be pleasant to use, containing ingredients that benefit the lipid and water content of the SC.

Statement 6: Daily use of moisturizers that contain humectants and ceramides reduces the rate of AD flares and reduces the need for topical steroid treatment.

Vernix caseosa contains cholesterol (52.8%), which forms the significant barrier lipid fraction, followed by free fatty acids (27.7%) and ceramides (20.1%).11,36 Topical formulations that contain ceramides mimic physiological lipids supporting homeostasis and improving skin condition.11,22,36-42 Those with dry and sensitive skin and particularly neonates and infants with AD prone skin or having AD greatly benefit from frequent moisturizer use.23-25,36-57 Moisturizer use decreases pruritus and symptoms as well as the severity of AD, improving quality of life.36-41 Moreover, the number of AD flares reduces as well as the time to flaring when ceramide-containing skincare is frequently applied.38,39

A ceramide-containing cleanser and moisturizer substantially improved clinical outcomes and quality of life in adult and pediatric patients with mild-to-moderate AD when used over six weeks.41 The study products were easy to use, with no adverse reactions reported. 41

Although direct comparisons between various types of moisturizers are lacking, those moisturizers that contain ceramides showed benefits over standard emollients.58

Statement 7: Parents and caregivers need to understand how to avoid irritants and triggers, cleanse and hydrate the skin, and how to apply moisturizers. Cleansers close to physiological skin (pH 4–6) containing emollients are preferable to water alone or soap (pH 8–10).

Barrier development continues during the first year of life. Exposure to common unwanted irritants, including saliva, nasal secretions, urine, feces, fecal enzymes, dirt, and microbial pathogens for long periods can lead to discomfort, irritation, infection, and skin barrier disruption. To maintain a healthy skin barrier, several aspects of the SC, such as skin surface pH, filaggrin, pH-dependent lipid processing, and serine proteases, must be protected.57 Skin surface pH usually is acidic (4.0–6.0), while the body’s internal pH is neutral to slightly alkaline (~7.4).57 Soaps, surfactants, and detergents, especially those products with an alkaline pH, may excessively remove NMF and skin lipids, elevating skin surface pH, which is explicitly damaging to neonatal and infant skin.57 Liquid skin cleansers with a near physiologic skin surface pH (4.0–6.0) containing ceramides and no soap are less aggressive than alkaline soaps and may reduce skin irritation (Table 6).41, 57

When applied from birth onwards, gentle cleansers and moisturizers containing barrier lipids help to maintain the protective skin barrier and soothe the skin with long-term moisturizing benefits.41,57

The choice of cleanser and moisturizer is dependent on individual preference.

Maintaining a high diversity of skin microbiome using appropriate skincare is another area of interest for the prevention of skin irritation and elevated inflammation, especially in neonates and infants who a prone to AD or have AD.59,60