heat, chemical irritants, and mechanical trauma that are small and or localized.9,14,21-23,44,48
Due to mechanical trauma such as caused by repeated friction, bullae develop just below the stratum granulosum.48 Burns and scalds can be accidental or intentional in the case of child abuse. A careful history and physical examination with attention to the child and caregiver interactions is needed.48 In inflicted burns, there is often a delay in seeking care from healthcare professionals, therefore look for lesions in various stages of healing and also with unusual patterns or locations.48
Neonates and infants with skin erosions are particularly at risk for infection, especially as their skin is immature.3-6,21 For closed bullae, cleanse the skin using a gentle cleanser and lukewarm water followed by the application of a moisturizer while leaving the bullae intact. A wound dressing may be required for open bullae. Select a dressing depending on the wound bed condition and exudate levels. Various dressings may be used, such as a foam dressing, a hydrofiber dressing, or a non-adherent wound contact layer, including silicone-coated dressings. The frequency of dressing changes depends on exudate level and are typically twice/week (Figure 2C). For infants at risk for infection, use an antiseptic cleanser, such as chlorhexidine aqueous solution. Avoid the use of prophylactic topical antibiotics to comply with antimicrobial stewardship preventing antibiotic resistance.51
Due to mechanical trauma such as caused by repeated friction, bullae develop just below the stratum granulosum.48 Burns and scalds can be accidental or intentional in the case of child abuse. A careful history and physical examination with attention to the child and caregiver interactions is needed.48 In inflicted burns, there is often a delay in seeking care from healthcare professionals, therefore look for lesions in various stages of healing and also with unusual patterns or locations.48
Neonates and infants with skin erosions are particularly at risk for infection, especially as their skin is immature.3-6,21 For closed bullae, cleanse the skin using a gentle cleanser and lukewarm water followed by the application of a moisturizer while leaving the bullae intact. A wound dressing may be required for open bullae. Select a dressing depending on the wound bed condition and exudate levels. Various dressings may be used, such as a foam dressing, a hydrofiber dressing, or a non-adherent wound contact layer, including silicone-coated dressings. The frequency of dressing changes depends on exudate level and are typically twice/week (Figure 2C). For infants at risk for infection, use an antiseptic cleanser, such as chlorhexidine aqueous solution. Avoid the use of prophylactic topical antibiotics to comply with antimicrobial stewardship preventing antibiotic resistance.51
LIMITATIONS
Although limited evidence was available to guide the
development of the algorithm, the project will hopefully spur
more skincare studies in neonates and infants. Until then, we
kno wit is important to maintain a healthy skin barrier, which is
accomplished by using skincare products that are sensitizer and
fragrance free and also containing lipids, such as ceramides.
CONCLUSONS
The algorithm focuses on neonatal and infant healthy skin that
can benefit from skincare. A growing body of evidence recognizes
the benefits of ongoing daily use of non-alkaline cleansers and
ceramides containing moisturizers. When applied from birth
onwards, gentle cleansers and moisturizers containing barrier
lipids help maintain the protective skin barrier.
DISCLOSURES
The authors disclosed receipt of an unrestricted educational
grant from CeraVe USA for support with the research of this
work.
REFERENCES
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2. Nikolovski J, Stamatas GN, Kollias N, Wiegand BC. Barrier function and water-holding and transport properties of infant stratum corneum are different from adult and continue to develop through the first year of life. J Invest Dermatol 2008;128(7):1728–36.
3. Fluhr JW, Lachmann N, Baudouin C, et al. development and organisation of human stratum corneum after birth: Electron microscopy isotropy score and immunocytochemical corneocyte labeling as epidermal maturation’s markers in infancy. Br J Dermatol 2014;171(5):978–86.
4. Fluhr JW, Darlenski R, Lachmann N, et al. Infant epidermal skin physiology: adaptation after birth. Br J Dermatol 2012;166:483–490.
5. Visscher MO, Narendran V. Neonatal infant skin: development, structure and function. Newborn Infant Nursing Reviews 2014;14(4):135-141.
6. Ludriksone L, Garcia Bartels N, Kanti V, Blume-Peytavi U, Kottner J. Skin barrier function in infancy: A systematic review. Arch Dermatol Research 2014;306(7):591–599.
7. Kottner J, Lichterfeld A, Blume-Peytavi U. Transepidermal water loss in young and aged healthy humans: a systematic review and meta-analysis, Arch Dermatol Research 2013;305(4):315–323.
8. Boiten WA, Berkers T, Absalah S, et al. Applying a vernix caseosa based formulation accelerates skin barrier repair by modulating lipid biosynthesis. J Lipid Research 2018;59(11):259-260. http://www.jlr.org
9. Blumeâ€Peytavi U, Hauser M, Stamatas GN, et al. Skin care practices for newborns and infants: review of the clinical evidence for best practices. Pediatr Dermatol 2012;29:1– 14.
10. Dominguez-Bello MG, Costello EK, Contreras M, et al. Delivery mode shapes the acquisition and structure of the initial microbiota across multiple body habitats in newborns. Proc Natl Acad Sci USA 2010;107:11971–11975.
11. Grice EA, Kong HH, Conlan S, et al. Topographical and temporal diversity of the human skin microbiome. Science 2009;324:1190–1192.
12. Cices A, Bayers S, Verzi AE, Schachner LA, West DP, Micali G. Poisoning through pediatric skin. Am J Clin Dermatol 2017;18(3):391-403.
13. Lowe AJ, Leung DYM, Tang MLK, Su JC, Allen KJ. The skin as a target for prevention of the atopic march. Ann Allergy Asthma Immunol 2018;120(2):145-151.
14. Schachner LA, Andriessen A, Benjamin L, et al. A Consensus about the Importance of Ceramide containing Skincare for Normal and Sensitive Skin conditions in Neonates and Infants. J Drugs Dermatol 2020;19(8):769-776. DOI: 10.36849/jdd.2020.5252 PMID: 32845590
15. Ananthapadmanabhan KP, Mukherjee S, Chandar P. Stratum corneum fatty acids: their critical role in preserving barrier integrity during cleansing. Int J Cosmetic Science 2013;35(4):337-345.https://doi.org/10.1111/ics.12042)
16. Sahle FF, Gebre-Mariam T, Dobner B, Wohlrab J, Neubert RH. Skin diseases associated with the depletion of stratum corneum lipids and stratum corneum lipid substitution therapy. Skin Pharmacol. Physiol 2015;28:42–55.
17. Trevelyan EG, Robinson N. Delphi methodology in health research: how to do it? Eur J Integrative Med 2015;7(4):423-428.
18. Brouwers M, Kho ME, Browman GP, et al.; AGREE Next Steps Consortium. AGREE II: advancing guideline development, reporting and evaluation in healthcare. Can Med Association J 2010,182:E839-42.
19. Smith Begolka W, Elston DM, Beutner KR. American Academy of Dermatology evidence-based guideline development process: responding to new challenges and establishing transparency. J Am Acad Dermatol. 2011 Jun;64(6):e105-12. doi: 10.1016/j.jaad.2010.10.029.
20. Lund, CH, Osborne JW. Validity and reliability of the Neonatal Skin Condition Score. JOGNN: J Obstet Gyn Neonatal Nurs 2014;33(3), 320-327.
21. Schachner LA, Hansen RC. Pediatric Dermatology 4th edition December 30, 2010:952-990. eBook ISBN: 9780702062698
22. Albahrani Y, Hunt R. Newborn skincare. Pediatr Ann. 2019 Jan 1;48(1):e11-e15. doi: 10.3928/19382359-20181211-01.
23. Gregory J, Anschau N, McCutchan D, Patterson J, Martin S, Allwood M. Skincare Guidelines for babies in NICU. Kaleidoscope, The Children’s health network. 2011
24. Younge NE, Araujo-Perez F, Brandon D, Seed PC. Early-life skin microbiota in hospitalized preterm and full-term infants. Microbiome 2018;6(1): 98. doi: 10.1186/s40168-018- 0486-4
25. Strugar TL, Kuo A, et al. Connecting the Dots: From Skin Barrier Dysfunction to Allergic Sensitization, and the Role of Moisturizers in Repairing the Skin Barrier. Journal of drugs in dermatology. J Drugs Dermatol 2019;18(6):581.
26. Rawlings AV. Molecular basis for stratum corneum maturation and moisturization. Br J Dermatol 2014;171(Suppl 3):19-28
27. Chittock J, Cooke A, Lavender T, et al. development of stratum corneum chymotrypsinâ€like protease activity and natural moisturizing factors from birth to 4 weeks of age compared with adults. Br J Dermatol 2016;175(3):713-720.
28. Tessema EN, Gebre-Mariam T. Neubert RHH, Wohlrab J. Potential applications of phyto-derived ceramides in improving epidermal barrier function. Skin Pharmacol Physiol 2017;30:115-138. https://doi.org/10.1159/00 0464337
29. Meckfessel MH, Brandt S. The structure, function, and importance of ceramides in skin and their use as therapeutic agents in skincare products.
2. Nikolovski J, Stamatas GN, Kollias N, Wiegand BC. Barrier function and water-holding and transport properties of infant stratum corneum are different from adult and continue to develop through the first year of life. J Invest Dermatol 2008;128(7):1728–36.
3. Fluhr JW, Lachmann N, Baudouin C, et al. development and organisation of human stratum corneum after birth: Electron microscopy isotropy score and immunocytochemical corneocyte labeling as epidermal maturation’s markers in infancy. Br J Dermatol 2014;171(5):978–86.
4. Fluhr JW, Darlenski R, Lachmann N, et al. Infant epidermal skin physiology: adaptation after birth. Br J Dermatol 2012;166:483–490.
5. Visscher MO, Narendran V. Neonatal infant skin: development, structure and function. Newborn Infant Nursing Reviews 2014;14(4):135-141.
6. Ludriksone L, Garcia Bartels N, Kanti V, Blume-Peytavi U, Kottner J. Skin barrier function in infancy: A systematic review. Arch Dermatol Research 2014;306(7):591–599.
7. Kottner J, Lichterfeld A, Blume-Peytavi U. Transepidermal water loss in young and aged healthy humans: a systematic review and meta-analysis, Arch Dermatol Research 2013;305(4):315–323.
8. Boiten WA, Berkers T, Absalah S, et al. Applying a vernix caseosa based formulation accelerates skin barrier repair by modulating lipid biosynthesis. J Lipid Research 2018;59(11):259-260. http://www.jlr.org
9. Blumeâ€Peytavi U, Hauser M, Stamatas GN, et al. Skin care practices for newborns and infants: review of the clinical evidence for best practices. Pediatr Dermatol 2012;29:1– 14.
10. Dominguez-Bello MG, Costello EK, Contreras M, et al. Delivery mode shapes the acquisition and structure of the initial microbiota across multiple body habitats in newborns. Proc Natl Acad Sci USA 2010;107:11971–11975.
11. Grice EA, Kong HH, Conlan S, et al. Topographical and temporal diversity of the human skin microbiome. Science 2009;324:1190–1192.
12. Cices A, Bayers S, Verzi AE, Schachner LA, West DP, Micali G. Poisoning through pediatric skin. Am J Clin Dermatol 2017;18(3):391-403.
13. Lowe AJ, Leung DYM, Tang MLK, Su JC, Allen KJ. The skin as a target for prevention of the atopic march. Ann Allergy Asthma Immunol 2018;120(2):145-151.
14. Schachner LA, Andriessen A, Benjamin L, et al. A Consensus about the Importance of Ceramide containing Skincare for Normal and Sensitive Skin conditions in Neonates and Infants. J Drugs Dermatol 2020;19(8):769-776. DOI: 10.36849/jdd.2020.5252 PMID: 32845590
15. Ananthapadmanabhan KP, Mukherjee S, Chandar P. Stratum corneum fatty acids: their critical role in preserving barrier integrity during cleansing. Int J Cosmetic Science 2013;35(4):337-345.https://doi.org/10.1111/ics.12042)
16. Sahle FF, Gebre-Mariam T, Dobner B, Wohlrab J, Neubert RH. Skin diseases associated with the depletion of stratum corneum lipids and stratum corneum lipid substitution therapy. Skin Pharmacol. Physiol 2015;28:42–55.
17. Trevelyan EG, Robinson N. Delphi methodology in health research: how to do it? Eur J Integrative Med 2015;7(4):423-428.
18. Brouwers M, Kho ME, Browman GP, et al.; AGREE Next Steps Consortium. AGREE II: advancing guideline development, reporting and evaluation in healthcare. Can Med Association J 2010,182:E839-42.
19. Smith Begolka W, Elston DM, Beutner KR. American Academy of Dermatology evidence-based guideline development process: responding to new challenges and establishing transparency. J Am Acad Dermatol. 2011 Jun;64(6):e105-12. doi: 10.1016/j.jaad.2010.10.029.
20. Lund, CH, Osborne JW. Validity and reliability of the Neonatal Skin Condition Score. JOGNN: J Obstet Gyn Neonatal Nurs 2014;33(3), 320-327.
21. Schachner LA, Hansen RC. Pediatric Dermatology 4th edition December 30, 2010:952-990. eBook ISBN: 9780702062698
22. Albahrani Y, Hunt R. Newborn skincare. Pediatr Ann. 2019 Jan 1;48(1):e11-e15. doi: 10.3928/19382359-20181211-01.
23. Gregory J, Anschau N, McCutchan D, Patterson J, Martin S, Allwood M. Skincare Guidelines for babies in NICU. Kaleidoscope, The Children’s health network. 2011
24. Younge NE, Araujo-Perez F, Brandon D, Seed PC. Early-life skin microbiota in hospitalized preterm and full-term infants. Microbiome 2018;6(1): 98. doi: 10.1186/s40168-018- 0486-4
25. Strugar TL, Kuo A, et al. Connecting the Dots: From Skin Barrier Dysfunction to Allergic Sensitization, and the Role of Moisturizers in Repairing the Skin Barrier. Journal of drugs in dermatology. J Drugs Dermatol 2019;18(6):581.
26. Rawlings AV. Molecular basis for stratum corneum maturation and moisturization. Br J Dermatol 2014;171(Suppl 3):19-28
27. Chittock J, Cooke A, Lavender T, et al. development of stratum corneum chymotrypsinâ€like protease activity and natural moisturizing factors from birth to 4 weeks of age compared with adults. Br J Dermatol 2016;175(3):713-720.
28. Tessema EN, Gebre-Mariam T. Neubert RHH, Wohlrab J. Potential applications of phyto-derived ceramides in improving epidermal barrier function. Skin Pharmacol Physiol 2017;30:115-138. https://doi.org/10.1159/00 0464337
29. Meckfessel MH, Brandt S. The structure, function, and importance of ceramides in skin and their use as therapeutic agents in skincare products.
