The Importance of Skincare for Neonates and Infants: An Algorithm

November 2021 | Volume 20 | Issue 11 | Original Article | 1195 | Copyright © November 2021

Published online October 27, 2021

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, Adelaide Hebert MD FAADh

aPediatric Dermatology, University of Miami School of Medicine, Miami, FL 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 Sciences, PLLC, Louisville, KY
hDepartments of Dermatology and Pediatrics, UT Health McGovern Medical School, Houston, TX

Background: The skin of neonates and infants undergoes a maturation process from birth and is susceptible to barrier disruption. The current algorithm follows a US-based consensus paper on skincare approaches using gentle cleansers and moisturizers in neonatal and healthy infant skin. This summary provides clinical information for pediatric dermatologists, dermatologists, and pediatric healthcare providers treating neonates and infants.
Methods: The project used a modified Delphi process comprising virtual discussions followed by an online follow-up replacing the use of a questionnaire. During the virtual meeting, the systematic literature review results and a draft algorithm addressing over-the-counter skincare for neonates and infants with healthy skin were discussed and adopted using evidence coupled with the expert opinion and experience of the panel.
Results: The algorithm addresses three clinical signs: xerosis, erythema, and erosion/bulla. A growing body of evidence recognizes the benefits of ongoing daily use of non-alkaline cleansers and ceramides containing moisturizers to reduce inflammation and maintain a healthy skin barrier function. Diaper rash is common in infants presenting as erythema or, in more severe cases, skin erosion. Skin protection with a barrier cream and frequent diaper changes using disposable diapers resolves most cases; however, if the rash continuous despite appropriate care, rule out a candida infection.
Conclusion: The current algorithm focuses on neonatal and infant healthy skin that can benefit from skincare. When applied from birth onwards, gentle cleansers and moisturizers containing barrier lipids help maintain the protective skin barrier.

J Drugs Dermatol. 2021;20(11):1195-1205. doi:10.36849/JDD.6219


At birth, human skin is structurally and functionally immature, with elevated skin surface pH, lower lipid content, and lower resistance to chemicals and pathogens.1-5 From birth, the dynamic skin maturation process takes two years or longer, during which the neonate and infant skin is susceptible to barrier disruption.1-3

Compared to the adult stratum corneum (SC), the infant skin barrier is thinner and more subject to higher trans-epidermal water loss (TEWL) and skin conductance.2-7

The SC and supra-papillary epidermis structures were thinner in infants than adults in two systematic reviews, indicating a continuous structural maturation process of the infant skin.6,7 These reviews further showed a functional maturation process of the infant skin expressed by a higher TEWL and elevated skin surface conductance values for infant skin than adults.6,7

Further studies comparing SC properties of infants and adults also showed higher TEWL and conductance rates and a significantly thinner supra-papillary epidermis for infants compared to adults at three months to twenty-four months.2-4 These studies also showed that the proteolytic enzymatic activity was higher for infants than adult skin.2-4