In utero, the epidermis’ final differentiation and the SC formation in the last trimester coincide with vernix caseosa covering the fetal skin surface.8 The lipid content of vernix caseosa comprises cholesterol (52.8%), free fatty acids (27.7%), and ceramides (20.1%).8 The vernix caseosa increases hydration, suppleness and decreases skin surface pH facilitating bacterial commensal development.8-11
Neonates and infants are particularly vulnerable to transcutaneous toxin exposure as they have a high surfaceto- weight ratio, immature epidermis, and a compromised skin barrier.12 Depending on systemic absorption, topical agents, which are harmless for adults, may cause respiratory distress, neurological toxicity, and even death in the neonatal and infants age groups.13 Topical agents that may cause toxic reactions include isopropanol, benzocaine, pyrethrin, hexachlorophene, and salicylic acid, among others.13
During the skin’s maturation process, the SC barrier of neonates and infants is especially vulnerable.14 Exposure to common 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.14 Furthermore, the epidermal unsaturated fatty acids are easily extracted during cleansing, compromising SC barrier function.15
In neonatal and infant skin, the ratio of free fatty acids/ cholesterol/ceramides (CERs) is not static.14 Without the proper CERs ratio, the SC barrier function can become incompetent impairing barrier homeostasis, leading to dryness, irritation, erythema, and itching.16
There is a growing body of evidence supporting safe and effective skincare starting early in life. The evidence recognizes the benefits of ongoing daily use of non-alkaline cleansers and ceramides containing moisturizers to reduce inflammation and maintain skin barrier function.14 When applied from birth onwards, gentle cleansers and moisturizers containing barrier lipids help maintain the protective skin barrier and soothe the skin with long-term moisturizing benefits.14
Scope
The current algorithm follows a US-based consensus paper on skincare approaches using gentle cleansers and moisturizers in neonatal and healthy infant skin.14 The algorithm applies the recommendations discussed in the consensus paper to provide clinical information for pediatric dermatologists, dermatologists, and pediatric healthcare providers treating neonates and infants.14 Other skin conditions that differ from neonatal and infant healthy skin are outside the scope of this publication.
Neonates and infants are particularly vulnerable to transcutaneous toxin exposure as they have a high surfaceto- weight ratio, immature epidermis, and a compromised skin barrier.12 Depending on systemic absorption, topical agents, which are harmless for adults, may cause respiratory distress, neurological toxicity, and even death in the neonatal and infants age groups.13 Topical agents that may cause toxic reactions include isopropanol, benzocaine, pyrethrin, hexachlorophene, and salicylic acid, among others.13
During the skin’s maturation process, the SC barrier of neonates and infants is especially vulnerable.14 Exposure to common 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.14 Furthermore, the epidermal unsaturated fatty acids are easily extracted during cleansing, compromising SC barrier function.15
In neonatal and infant skin, the ratio of free fatty acids/ cholesterol/ceramides (CERs) is not static.14 Without the proper CERs ratio, the SC barrier function can become incompetent impairing barrier homeostasis, leading to dryness, irritation, erythema, and itching.16
There is a growing body of evidence supporting safe and effective skincare starting early in life. The evidence recognizes the benefits of ongoing daily use of non-alkaline cleansers and ceramides containing moisturizers to reduce inflammation and maintain skin barrier function.14 When applied from birth onwards, gentle cleansers and moisturizers containing barrier lipids help maintain the protective skin barrier and soothe the skin with long-term moisturizing benefits.14
Scope
The current algorithm follows a US-based consensus paper on skincare approaches using gentle cleansers and moisturizers in neonatal and healthy infant skin.14 The algorithm applies the recommendations discussed in the consensus paper to provide clinical information for pediatric dermatologists, dermatologists, and pediatric healthcare providers treating neonates and infants.14 Other skin conditions that differ from neonatal and infant healthy skin are outside the scope of this publication.
MATERIALS AND METHODS
Literature Review
A systematic literature review explored present clinical guidelines and clinical research on skincare regimens for neonatal and infant healthy skin. Priority was given to studies addressing skin barrier function in newborns and infants and the clinical and quality of life (QoL) benefits of skincare in this population. Excluded were duplications, articles of insufficient quality [small sample size, poor methodology], and the latest version was used in the case of a review article. The results of the searches on 13-15 January 2020 for the consensus paper14 were updated with searches on 01-02 October 2020. PubMed and on Google Scholar, as a secondary source, were searched for English-language literature (2010– 2020) using the following terms:
Pediatric skin; maturation; skin physiology of neonates and Infants; vernix; infant skin barrier physiology; function; pathology; dysfunction; epidermal maturation’s markers; erythema in neonates and infants; skin breakdown in neonates and infants; diaper care, umbilical cord care, protection infant skin barrier; fragility of epidermis in infants; depletion of stratum corneum lipids; cleansers; moisturizers; emollients; skincare in newborns and infants; ceramides; ceramide containing skincare; skin maturation and moisturization.
The selected publications were manually reviewed for additional sources by LS and AA and then graded using the American Academy of Dermatology evidence-based guideline development process.17-19 For grading study type: A = clinical double-blind, randomized controlled trial [RCT] of high quality, B = RCT of lesser quality, and C = comparative trial with severe methodologic limitations.19 For grading clinical evidence, four grades apply [1 = further research is unlikely to change confidence in the estimate of effect, to 4 = any estimate of effect is very uncertain].19
The searches yielded 106 papers deemed clinically relevant to healthy neonatal and infant skin, the use of over-the-counter (OTC) skincare, and ceramides containing skincare. After excluding duplicates and articles not related to neonatal and infant skin or OTC skincare, the summary included fifty-one publications. The selected articles comprised sixteen clinical studies (Table 1), fourteen systematic reviews, consensus papers or guidelines (Table 2), and twenty-one others.
Development of the Algorithm
The project used a modified Delphi process, a communication technique for interactive decision-making for medical projects.17,18 The process entailed preparing the project, selecting the panel, and conducting systematic literature searches followed by two steps (Figure 1). Step 1 has been completed and yielded the consensus paper.14
A systematic literature review explored present clinical guidelines and clinical research on skincare regimens for neonatal and infant healthy skin. Priority was given to studies addressing skin barrier function in newborns and infants and the clinical and quality of life (QoL) benefits of skincare in this population. Excluded were duplications, articles of insufficient quality [small sample size, poor methodology], and the latest version was used in the case of a review article. The results of the searches on 13-15 January 2020 for the consensus paper14 were updated with searches on 01-02 October 2020. PubMed and on Google Scholar, as a secondary source, were searched for English-language literature (2010– 2020) using the following terms:
Pediatric skin; maturation; skin physiology of neonates and Infants; vernix; infant skin barrier physiology; function; pathology; dysfunction; epidermal maturation’s markers; erythema in neonates and infants; skin breakdown in neonates and infants; diaper care, umbilical cord care, protection infant skin barrier; fragility of epidermis in infants; depletion of stratum corneum lipids; cleansers; moisturizers; emollients; skincare in newborns and infants; ceramides; ceramide containing skincare; skin maturation and moisturization.
The selected publications were manually reviewed for additional sources by LS and AA and then graded using the American Academy of Dermatology evidence-based guideline development process.17-19 For grading study type: A = clinical double-blind, randomized controlled trial [RCT] of high quality, B = RCT of lesser quality, and C = comparative trial with severe methodologic limitations.19 For grading clinical evidence, four grades apply [1 = further research is unlikely to change confidence in the estimate of effect, to 4 = any estimate of effect is very uncertain].19
The searches yielded 106 papers deemed clinically relevant to healthy neonatal and infant skin, the use of over-the-counter (OTC) skincare, and ceramides containing skincare. After excluding duplicates and articles not related to neonatal and infant skin or OTC skincare, the summary included fifty-one publications. The selected articles comprised sixteen clinical studies (Table 1), fourteen systematic reviews, consensus papers or guidelines (Table 2), and twenty-one others.
Development of the Algorithm
The project used a modified Delphi process, a communication technique for interactive decision-making for medical projects.17,18 The process entailed preparing the project, selecting the panel, and conducting systematic literature searches followed by two steps (Figure 1). Step 1 has been completed and yielded the consensus paper.14
