Transcript Children and newborn skin care

Children and newborn skin care
Vernixa caseosa
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Vernixa caseosa is a naturally occurring, complex, lipid rich substance clinging to the
skin surface of the newborn and is produced partly by the fetal sebaceous glands. It
consists of sebaceous secretions, shed epithelium and lanugo. It is composed of
water (81%), lipid 19% (epidermal triglycerides and cholesterol; and dermal-squalene
and waxes) and proteins (10%). There is considerable inter-individual variation in the
quality of vernix caseosa. The role of the vernix caseosa at birth are multiple such
as barrier to water loss, temperature regulation and innate immunity.
At birth, the newborn’s skin is covered with vernix caseosa, blood, meconium and
cellular debris and it is better to clean this from the head and neck area, soon after
birth.
Vernixa caseosa
How is newborns
yellow jaundice (Hyperbilirubinemia)
treated?
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If your baby's bilirubin level is high, he will be started on phototherapy (light
treatment). The blue wave length of natural light is absorbed by the bilirubin chemical
in his skin when it is exposed to the light. The light wave changes the shape of the
bilirubin molecules (the process is called photo-isomerization). This different–shaped
bilirubin molecule is more easily taken out of the baby's body by his kidneys. His
urine will turn a dark, dusty color during phototherapy.
The light treatment is safe and effective.
TOPICAL PREPARATIONS
External variables affecting newborn skin
Neonate skin barrier
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Newborn (NB) or neonate: from birth to 28 days old..
Premature or preterm new born or: baby born before the 37th week of gestation.
Term new born: baby whose gestational age is between 37 weeks and 41 weeks and 6 days.
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@ It was previously thought that the skin barrier function reached its maturity at about 34 weeks of gestation.
However, recent data show that it continues to develop until 12 months after birth. The skin of the neonate is
subjected to a gradual process of adaptation to the extrauterine environment, and special care becomes
necessary during this period. The neonate's skin is characterized by being sensitive, thin and fragile. Moreover,
when compared with the skin of term NB, the skin of premature new born is even thinner, with a thinner stratum
corneum, reduced cohesion between the epidermis and dermis and a less effective skin barrier function. As a
consequence, there is greater transepidermal water loss, increased percutaneous absorption of chemicals and
easilyinduced skin trauma, even with the removal of any adhesive bandage. This leads to tendency to infections,
toxicity and difficulties in fluid homeostasis. Moreover, baby wash does not damage baby's skin barrier function
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@ The acidic pH of skin surface seen in adults and adolescents (pH <5) has a protective effect against
microorganisms. In new born, especially in premature ones, skin surface pH tends to be neutral, which
significantly reduces protection against excessive microbial growth. This may also promote increased
transepidermal water loss, signaling an alteration of epidermal barrier function.
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@ Epidermal lipids play an important role in maintaining skin barrier function and skin integrity. However, the
lipid content of the skin of infants is lower due to the low activity of the sebaceous glands. On the other hand, their
skin has a high water content. In nurselings, the hydrolipid film is gradually replaced by nonglandular epidermal
lipids, which are less effective in protecting the skin. In addition, the protective lipid barrier may not be reproduced
by artificial means, so maximum care is needed not to destroy this barrier. Destruction occurs primarily by the use
of inappropriate chemical products.
ACID MANTLE DEVELOPMENT IN THE NEWBORN INFANT
Pediatric Research (1997) 41, 172
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Epidermal barrier development is essential for transition to a terrestrial
environment after birth. In addition to water impermeability and a plasticized
biomechanical interface, the skin surface in adults exhibits an acidic pH(4.55.5). This “acid mantle” is considered to be important for infection control
and barrier lipid organization. Although the precise cellular and molecular
mechanisms underlying acid mantle development in humans are unknown,
there appear to be striking similarities with the developing lung and the
acidification of the alveolar surfactant hypophase.
Acid mantle development in the newborn infant
1) The skin surface of the term infant is acid neutral at birth.
2) acid mantle development is initiated within the first 16 hours of age.
3) standard bathing practices alkalinize the skin transiently followed by rapid
reprotonation.
4) regional differences in skin surface pH may be accompanied by shifts in
surface temperature.
• Babies’ skin needs particularly careful protection, because it doesn’t
yet have the natural acid mantle, which has a pH value of 5.5.
• The special characteristics of babies’ skin
• @ In babies the ratio of skin surface area
to body volume insignificantly larger than in adults.
• @ The dermis is thinner than in adults.
• @ The water content of the horny layer
is higher, and its structure is looser.
• @ The skin hardly produces any sebum before puberty.
• @ Sweat is not able to regulate a baby’s body temperature
as effectively as it does in adults.
• @ The acid mantle only begins to develop after a
baby has been born and is liable to break down
during childhood.
Infant skin-cleansing product versus water
BMC Pediatrics 2011, 11:35
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The main role of the baby's skin is to provide a barrier which prevents infection, the
loss of water from the body, and penetration of irritants and allergens. These
functions depend on the maintenance of skin integrity and pH balance. Babies are
born with a pH of 6.4 which reduces over three to four days to around 4.9 . A baby's
skin has a less developed epidermal barrier than adults and thus is more prone to
damage; recent research suggests that the stratum corneum of infants becomes
'adult-like' only after one year of life . The immaturity of babies' skin creates the
potential for a number of skin problems, including atopic eczema, infant Candida,
cradle cap, baby acne and napkin dermatitis . These problems emphasize the
importance of appropriate skin cleansing routines.
Water is the basic component of any cleansing routine. In many countries, despite
the lack of strong evidence in one direction or the other, water alone has been
considered the least harmful of all alternatives . However, water may not be the
optimal skin cleanser for newborns. The buffering capacity of water is being
questioned, as it might increase skin pH; after washing with water the skin surface pH
may rise from 5.5 to 7.5. This brings the pH to a level that maximizes the activity of
the skin proteases and therefore enhances skin barrier breakdown . The other
problem with water alone is that it is a poor cleanser as it does not remove fat-soluble
substances such as feces and sebum . On the extreme, over-exposure to water leads
to higher trans-epidermal water loss (TEWL) and a weakened skin barrier . An
appropriately formulated cleansing product may reduce these potential problems but
would need to be carefully evaluated.
An. Bras. Dermatol. vol.86 no.1 Rio de Janeiro Jan./Feb. 2011
TOPICAL PREPARATIONS IN NEWBORN BABIES
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Due to the characteristics of the skin of newborn babies, infants, and children. One of the paramount conditions in cosmetic preparations
is that all the ingredients that may be potentially aggressive to the skin be excluded.
The percutaneous absorption of drugs and topical agents is influenced by the physical and chemical characteristics of the drug and also
by the properties of the skin barrier. The higher the body surface area : body weight ratio, the greater the risk of percutaneous toxicity.
Many products designed for use by children have potentially toxic substances which are harmful to the skin of newborn babies. Not even
labels containing such phrases as "dermatologically tested" or "balanced pH" or "natural or organic ingredients" guarantee the safety of
the ingredients.
@ Although the skin of the newborn, still immature, is relatively impervious to alcohol, this substance can cause hemorrhagic necrosis in
premature babies when used as a topical antiseptic on occluded skin. Moreover, the alcohol present in cleaning solutions can cause skin
burns, mainly in low birthweight NB, so these solutions must be avoided in neonatal units.
@ It is reported that pure clorexedine 0.5% is an effective topical antiseptic agent and is considered a safer alternative, when not
associated with alcohol, for use in term NB with no known percutaneous toxicity .
@ The use of iodine solutions in the skin of the neonate can result in a significant overburden of iodine and a serious and transient
hypothyroidism. The exposure of newborn babies to these solutions should be avoided whenever possible..
@ Prilocaine, a component of topical anesthetic, can cause methemoglobinemia when it is overdosed. Up to 25mg may be applied to a
maximum area of 10cm2. Tetracaine gel, another topical anesthetic, does not cause methemoglobinemia, but can cause contact
dermatitis in premature babies.
@ Propylene glycol, an ingredient in many emollients, can cause burning and skin irritation, especially if used at a concentration greater
than 5%. propylene glycol has been associated with central nervous system toxicity in premature new born. In addition, excessive enteral
and parenteral use of this substance offers risk of hyperosmolality and seizures.
@ Other ingredients should also be avoided in newborn babies, infants and children, such as:
- Sodium lauryl sulfate (SLS): It is a potent skin irritant that damages the lipid barrier, causing inflammation and detachment of the skin
layers. When combined with other products such as triclosan, it tends to adhere to the skin for hours or days.
- Sodium laureth sulfate (SLES) and ammonium laureth sulfate: They are agents that may produce lather in products such as toothpaste,
shower gel, baths foams. They are irritants, may damage proteins and cause oral ulcers.
- Methylisothiazolinone: Found in shampoos and conditioners, it has been associated with neurological defects.22
- Parabens (methyl paraben, propyl paraben, ethyl paraben and butylparaben): found in shampoos and lotions for babies and also wipes
for cleaning. They can cause contact dermatitis and skin rash.
In the hygiene of babies and children, products containing perfumes and dyes should also be carefully avoided (due to the risk of contact
dermatitis)
Some Percutaneous Toxicities Reported in Infants and Children
PEDIATRICS , 2004 . 113 no. Supplement 3 1114-1119
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Agent (Vehicle/Use)
Toxicity
Comment
Alcohols (topical antiseptic) Hemorrhagic necrosis
Primarily a risk on occluded skin
Aniline (diaper dye)
Methemoglobinemia
Dye stamps from freshly labeled diapers
Boric acid (diaper powder) Vomiting, diarrhea, severe dermatitis, death
Corticosteroids (topical anti-inflammatory agents) Adrenal suppression Dermatitis markedly increases risk
Hexachlorophene (antiseptic cleanser) Neurotoxicity
Encephalopathy, seizures
Lidocaine-prilocaine cream (EMLA, local anesthetic cream) Methemoglobinemia, seizures, petechiael
reactions
Seizures from lidocaine, methemoglobinemia from prolocaine
Lindane (scabicide lotion) Neurotoxicity
Seizures
Mercuric chloride (diaper rinses) Acrodynia Also linked to mercury in tinctures, teething powders
N,N-dimethyl-meta-toluamide (DEET, insect repellant) Neurotoxicity
Seizures,
encephalopathy; risk limited to incorrect use or high concentration
Neomycin (topical antibiotic)Ototoxicity, deafnessPremature infants
Pentachlorophenol (laundry detergent) Sweating, tachycardia, metabolic acidosis
Povidone-iodine (topical antiseptic) Hypothyroxinemia, goiter Especially premature infants
Salicylates (keratolytic ointment) Salicylism, encephalopathy, metabolic acidosis In patients
with defective epidermal barrier, ie, ichthyosis
Silver sulfadiazine (topical antibiotic) Kernicterus, agranulocytosis
Tacrolimus (Protopic, topical anti-inflammatory ointment) Elevated serum tacrolimus level
Patients had barrier dysfunction as a result of Netherton syndrome
Clorexidine shampoo
Chlorhexidine
Iodine solutions
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The use of iodine solutions in the skin of the neonate can result in a significant
overburden of iodine and a serious and transient hypothyroidism. 3 The exposure of
newborn babies to these solutions should be avoided whenever possible. If such
exposure occurs, levels of thyroid hormones must be measured, especially in
premature babies, whose skin permeability is even higher and the thyroid, immature
Prilocaine cream
• Prilocaine, a component of topical anesthetic, can cause
methemoglobinemia when it is overdosed. Up to 25mg may be
applied to a maximum area of 10cm2. it is often used in dentistry. It
is also often combined with lidocaine as a topical preparation for
dermal anesthesia (lidocaine/ prilocaine or EMLA), for treatment of
conditions like paresthesia. As it has low cardiac toxicity, it is
commonly used for intravenous regional anesthesia
(IVRA). prilocaine, may cause methemoglobinemia, which may be
treated with methylene blue. Prilocaine may also be contraindicated
in people with sickle cell anemia, anemia, or symptomatic hypoxia.
• People with pseudocholinesterase deficiency may have difficulty
metabolizing this anesthetic.
Prilocaine cream
Tetracaine topical
Tetracaine
It is mainly used topically in ophthalmology (Tetracaine drops)
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and as an antipruritic, and it has been used in spinal anesthesia. Tetracaine gel,
another topical anesthetic, does not cause methemoglobinemia, but can cause
contact dermatitis in premature babies. This product is available in the following
dosage forms:
Cream
Ointment
Gel/Jelly
Solution
Propylene Glycol
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Propylene glycol, an ingredient in many emollients, can cause burning and
skin irritation, especially if used at a concentration greater than 5%. 6 Also
used as a vehicle of some vitamins taken orally, propylene glycol has been
associated with central nervous system toxicity in premature NB.19.20 In
addition, excessive enteral and parenteral use of this substance offers risk
of hyperosmolality and seizures.
Propylene glycol is widely used in
food and tobacco products,
pharmaceuticals, and
cosmetics.
In certain medicines, cosmetics, and food products, propylene glycol acts as
an emulsifying agent,
industrial drying agent,
surfactant, and
solvent.
Propylene Glycol
ingredients should be avoided in newborn babies, infants and children
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Sodium laureth sulfate, or sodium lauryl ether sulfate (SLES),
is an anionic detergent and surfactant found in many personal care
products (soaps, shampoos, toothpaste etc.). SLES is an inexpensive and
very effective foaming agent. SLES, SLS, ALS and sodium pareth
sulfate are surfactants that are used in many cosmetic products for their
cleansing and emulsifying properties. They behave similarly to soap.
Bottle of solution of sodium dodecyl sulfate for use in the laboratory
ingredients should be avoided in newborn babies, infants and children
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used preservatives in cosmetic and pharmaceutical products. Chemically,
they are a series of parahydroxybenzoates or esters of parahydroxybenzoic
acid (also known as 4-hydroxybenzoic acid). Parabens are effective
preservatives in many types of formulas. These compounds, and their salts,
are used primarily for their bactericidal and fungicidal properties. They can
be found in shampoos, commercial moisturizers, shaving gels, personal
lubricants, topical/parenteral pharmaceuticals, spray tanning
solution, makeup, and toothpaste. They are also used as food additives.
Their efficacy as preservatives, in combination with their low cost, the long
history of their use, and the inefficacy of some natural alternatives
like grapefruit seed extract (GSE), probably explains why parabens are so
commonplace. No effective direct links between parabens and cancer have
been established. However, there is concern that the estrogen-mimicking
aspect of parabens may be a factor in the increasing prevalence of early
puberty in girls.
Parabens
An. Bras. Dermatol. vol.86 no.1 Rio de Janeiro Jan./Feb. 2011
TOPICAL PREPARATIONS IN NEWBORN BABIES
VEHICLES
Since any active product needs a vehicle or excipient
to keep it in good condition, some considerations about
certain types of vehicles must be made, as some of
them may also pose risks or harm to the newborn. In
addition, certain types of vehicles should be used only
in appropriate situations
Baby powder
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Baby powder is an astringent powder used for preventing diaper rash, as
a deodorant, and for other cosmetic uses. It may be composed of talc (in which case
it is also called talcum powder) or corn starch. Talcum powder is dangerous if
inhaled since it may cause aspiration pneumonia or granuloma. Drugs such
as cocaine are sometimes cut with talcum powder. It is also an ingredient
in counterfeit pharmaceuticals and food products as a bulking agent in order to give
the appearance of a larger quantity than actually present. Pediatricians generally
prefer cornstarch to talc because it is unlikely to be easily inhaled. Baby powder can
also be used as a shampoo, cleaning agent, and freshener
Talcum
powder
Lipophilic Excipients
Pharmaceutical Technology Europe:24, Issue 9, 2O12
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Fat or lipophilic excipients: they have occlusive properties and can be
fluid or oil (sweet almond oil, liquid paraffin), semisolid (lanolin, petroleum
jelly) or solid (solid paraffin and waxes).They should not be used in
inflammatory and/or exudative dermatoses or skin flexures for their
occlusive powder
Solubilizers play an important role in dissolving poorly soluble molecules. As
the number of poorly soluble lipophilic and/or hydrophobic molecules
increases—whether as "brick dusts" or waxy substances—the industry is
struggling to identify the appropriate lipophilic excipients (surfactants,
solubilizers, solvents or polymers) that can be used to develop such poorly
soluble formulations into solid dosages and other forms of pharmaceutical
products. Furthermore, the complexity of such formulations is increasing
and often two or more solubilizers and/or cosolvents are required to develop
stable and efficacious formulations with enhanced bioavailability
As pharmaceutical manufacturers develop generic and new molecules that
require high-quality, functional excipients, several excipient manufacturers
are now streamlining the structure, nomenclature and functionality of their
excipients, including solubilizers.
Lipophilic Excipients
Lipophilic Excipients
Lipophilic Excipients
Lipophilic Excipients
Lipophilic Excipients
Emulsion
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An emulsion is a mixture of two or more liquids that are normally immiscible (unmixable or
unblendable). Emulsions are part of a more general class of two-phase systems of matter called .
Although the terms colloid andemulsion are sometimes used interchangeably, emulsion should be
used when both phases, dispersed and continuous, are liquids. In an emulsion, one liquid (the
dispersed phase) is dispersed in the other (the continuous phase). Examples of emulsions
include vinaigrettes, milk, mayonnaise, and some cutting fluids for metal working.
The word "emulsion" comes from the Latin word for "to milk", as milk is an emulsion of fat and
water, among other components.
According to the dispersed phase, there are two types of systems: water-in-oil (W/O) or oil-inwater (O/A) emulsions, to which a multiplicity of agents are associated, whose composition is not
always known and can be irritating to the skin of newborn babies. If the aqueous phase is greater
than 45%, O/W emulsions are obtained (such as creams and lotions ),which are more fluid. If it
is less than 45%, the continuous phase becomes oily and we have w/o emulsions (such
as creams or ointments), which are greasier and more occlusive. When there is the need for the
therapeutic use of O/W emulsions in babies and children, these emulsions should be used in
acute and exudative dermatitis and in the folds, where occlusion caused by greasier emulsions is
not recommended. On the other hand, W/O emulsions, due to their predominantly occlusive
power, should be used in babies and children when treatment is necessary, such as in cases of
dry skin, xerosis and chronic eczema, because they allow better absorption of the active product.
Emulsion
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A. Two immiscible liquids, not yet emulsified
B. An emulsion of Phase II dispersed in Phase I
C. The unstable emulsion progressively separates
D. The surfactant (outline around particles) positions itself on the interfaces between
Phase II and Phase I, stabilizing the emulsion Emulsifiers
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An emulsifier is a substance that stabilizes an emulsion by increasing its kinetic stability. One
class of emulsifiers is known as "surface active agents", or surfactants.
Examples of food emulsifiers are:
@ Egg yolk – in which the main emulsifying agent is lecithin.
@ Mustard
@ Soy lecithin is another emulsifier and thickener
@ Sodium phosphates
@ Sodium stearoyl lactylate
DATEM (Diacetyl Tartaric (Acid) Ester of Monoglyceride) – an emulsifier used primarily in baking
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Detergents are another class of surfactants, and will physically interact with both oil and water,
thus stabilizing the interface between the oil and water droplets in suspension. This principle is
exploited in soap, to remove grease for the purpose of cleaning.
What Is An Emulsion?
Oil emulsions
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water-in-oil emulsion
oil-in-water emulsion.
water-in-oil-in-water
emulsion.
How The Emulsification Process Works
E45 MOISTURISING LOTION
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A light, easily absorbed lotion that can be used all over the body, face and hands to
care for dry skin.
Available in 200ml and 500ml.
Suitable for adults, children and infants over 1 month.
Risks of transcutaneous absorption of topical products in newborn
babies, infants and children
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Compound
Toxicity
Aniline (dye used in laundry)
Methemoglobinemia
Pentachlorophenol (laundry disinfectant): Tachycardia, sweating, hepatomegaly, metabolic
acidosis
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Hexachlorophene (topical antiseptic)
Resorcinol (topical antiseptic)
Boric acid (baby powder)
Lindane (scabicide)
Salicylic acid
Isopropyl alcohol under occlusion
Urea (exfoliating, emollient)
Povidone-iodine (topical antiseptic)
Neomycin
Corticosteroid
Benzocaine (topical antiseptic)
Prilocaine (topical anesthetic)
Methylene blue (dye)
Vacuolar encephalopathy
Methemoglobinemia
Vomiting, diarrhea, erythroderma, seizures
Neurotoxicity
Metabolic acidosis
Hemorrhagic skin necrosis
Uremia
Hypothyroidism, goiter
Neural deafness
Cutaneous atrophy, adrenal suppression
Methemoglibinemia
Methemoglobinemia
Methemoglobinemia
EMOLLIENTS
Practical considerations for emollient product selection
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Practical considerations for emollient product selection.
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Efficacy considerations
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(i) Appropriate tests should testify to the efficacy of the product formulation
@ Safety considerations: overall
(i) The margin of safety for each ingredient at the concentration used in the formulation should be considered
(ii) Ingredients in a product can behave differently than in isolation; therefore, it is important to evaluate the full
formulation for safety andpotential dermal effects, including irritation and sensitization
@ Safety considerations: fragrance
(i) The use of fragranced products for healthy neonates and infants should be supported by evidence for safety
and tolerance
(ii) Fragrances should be compliant with the International Fragrance Association (IFRA), which is a body that helps
to ensure the safety offragrance materials
@ Safety considerations: preservatives
(i) Products should be microbiologically robust
(ii) “Natural” does not always mean safer (e.g., some natural oils (eucalyptus, sage, and tea tree oils) can be toxic
at certain levels)
(iii) Preservative ingredients can be natural or synthetic as long as their safety profile is documented; identical
chemical structure meansidentical safety profile
@ Safety considerations: labeling and packaging
(i) Directions for product use should communicate and educate parents on safe and appropriate use
(ii) Package design should help to minimize product contamination (e.g., loose top or seal could expose product to
microbes)
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Emollients
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Emollients are moisturising treatments applied directly to the skin
to reduce water loss and cover it with a protective film.
They are often used to help manage dry or scaly skin conditions such as
eczema and psoriasis.
Emollients are available as:
moisturising creams, ointments, lotions and sprays
bath oils and shower products
soap substitutes .
There are varieties of emollients that can be applied to the skin to help with
specific problems. For example:
occlusive emollient creams and ointments – these create a film over the
skin to prevent water evaporating
humectant-containing emollients – these contain additives such as urea
glycerol, popylene glycol and lactic acid to attract and hold water in the top
layer of skin
antipruritic emollients – these contain ingredients to help treat itching
antiseptic emollients – these contain ingredients to prevent infection
Emollients
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Emollients work by:
helping skin retain water
moisturising dry skin
easing itching
reducing scaling
softening cracks
protecting the skin
helping other creams and ointments to be absorbed into the skin
Possible reactions to emollients can include:
irritant reactions – such as an overheating, burning sensation or stinging, usually caused by a
reaction to a certain ingredient contained in the cream or lotion
folliculitis – some emollients can occasionally cause hair follicles to become blocked and
inflamed (folliculitis) and cause boils
facial rashes – some facial emollients may cause rashes on the face that can aggravate acne
Safety advice when using emollients
- if you are using paraffin-based emollients, keep away from fire, flames and cigarettes
- if you keep your emollients in a pot or tub, use a clean spoon or spatula to remove the
product
- take care when using emollients in a bath, shower or on a tiled floor as there's a risk of
slipping
–avoid using aqueous cream
Emollients
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Lotions, creams and ointments are all moisturizers (also called emollients). However, they have
different water content. Lotions have the most water so absorb easily into the skin; however,
lotions don't provide enough moisture to the skin to be used in toddler or baby eczema. Ointments
have the most moisturizing quality but can be greasy on the skin and can clog up washing
machines - if clothing has lots of ointment on it, soak in hot water before washing.
Should one use Aqueous Cream as a moisturizer or soap substitute?
No. Aqueous cream contains sodium lauryl sulphate and it has been found that it causes thinning
of the top layer of the skin which makes the skin more prone to irritation. In eczema, this makes
things worse, so aqueous cream should not be used in toddler or baby eczema.
What shampoo can be used in toddler and baby eczema?
Aqueous cream can be used as a shampoo
2% ketaconazole shampoo (Nizoral, Dandrozol)
20% cetrimide shampoo
Can my child have all the usual immunizations?
Virtually all children with eczema can have their normal immunizations (including measles). This
includes children who have not eaten egg and those with an egg allergy.
Can my child go swimming?
Yes. Your child should shower after swimming if the chlorine or the swimming seems to worsen
the eczema. Apply moisturizer after swimming and if necessary, before swimming as well.
Emollients
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Emollients are non-cosmetic moisturisers which come in the form of creams,
ointments, lotions and gels. Emollients help skin to feel more comfortable and less
itchy. They keep the skin moist and flexible, helping to prevent cracks.
Soap is very drying to the skin and is best avoided by people with eczema. The
hands are particularly at risk, as they are washed more frequently. Liquid
soaps/cleansers and perfumed products should also be avoided as they tend to
irritate skin with eczema.
Emollient soap substitutes do not foam but are just as effective at cleaning the skin
as soap. Soap substitutes can either be applied before bathing, showering or
washing, or while in the water.
How are emollients applied and when?
Apply emollients after bathing, while water is still trapped in the skin for extra
hydration
Use liberally and frequently – at least three times a day.
Apply gently in the direction of the hair growth. Never rub up and down vigorously as
this could trigger itching, block hair follicles or create more heat in the skin.
Continue to use the emollient, even when the eczema has improved as this will help
prevent flare ups.
Emollients
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Emollients are non-cosmetic moisturisers which come in the form of creams,
ointments, lotions and gels. Emollients help skin to feel more comfortable and less
itchy. They keep the skin moist and flexible, helping to prevent cracks.
Soap is very drying to the skin and is best avoided by people with eczema. The
hands are particularly at risk, as they are washed more frequently. Liquid
soaps/cleansers and perfumed products should also be avoided as they tend to
irritate skin with eczema.
Emollient soap substitutes do not foam but are just as effective at cleaning the skin
as soap. Soap substitutes can either be applied before bathing, showering or
washing, or while in the water.
How are emollients applied and when?
Apply emollients after bathing, while water is still trapped in the skin for extra
hydration
Use liberally and frequently – at least three times a day.
Apply gently in the direction of the hair growth. Never rub up and down vigorously as
this could trigger itching, block hair follicles or create more heat in the skin.
Continue to use the emollient, even when the eczema has improved as this will help
prevent flare ups.
An. Bras. Dermatol. vol.86 no.1 Rio de Janeiro Jan./Feb. 2011
TOPICAL PREPARATIONS IN NEWBORN BABIES
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The term "child" to refer to the age range of 12 months to 12 years, the term
"adolescent" to refer to individuals from 12 to 18 years of age and the term "adult" to
refer to individuals from 18 to 65 years of age.
BATHING
An. Bras. Dermatol. vol.86 no.1 Rio de Janeiro Jan./Feb. 20
Children and newborn skin care
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The skin of newborn babies undergoes a gradual process of adaptation to the extrauterine
environment during which special care is necessary. Their skin is sensitive, thin and fragile, with
neutral pH on the surface, which significantly reduces the protection against excessive bacterial
growth. Its lipid content is lower, but it has a higher water content. It is soft, since the stratum
corneum is thinner, and the epidermis and dermis are thinner than those of adults. Immaturity of
the epidermal barrier more frequently leads to dry skin, significantly reduces the protection against
excessive microbial proliferation, and makes the skin more susceptible to injury and toxicity by
percutaneous absorption of drugs.
Due to the characteristics of the skin of newborn babies and children, cosmetic products intended
for their care and protection require special attention in the formulation. Many products designed
for use by babies and children have potentially toxic substances that are harmful to their skin. An
essential condition is that all the ingredients that may be potentially aggressive to the skin be
excluded. This is obviously true to all cosmetic products, but it is certainly more difficult to
implement in products for use on the fragile skin of babies and children.
Since effective skin barrier function is vital for the newborn and its operation is limited by the
immaturity of this period, optimal skin care is very important and may minimize the morbidity and
mortality associated with this problem in the neonatal period. In order to preserve skin integrity
and reduce the risks caused by improper care of the skin of newborn babies, infants and children,
this article reviewed the key recommendations in relation to hygiene, bathing, use of cleaning
agents, topical products and percutaneous toxicity.
Knowing that the cosmetics market, including products meant for pediatric use, has evolved in
recent years becoming quite appealing to excessive consumption, physicians must take on the
responsibility to reject consumerist habits and be very cautious in prescribing these products
Newborn Bathing
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The bath of the newborn should not last more than 5 minutes, prolonged bath increases the hydration of the skin
and reduces the threshold for friction. however, according to World Health Organization (WHO), it is recommended
that the first bath be given only six hours after birth due to the risk of hypothermia during and after bathing .For the
initial bath, sterile or potable clean water is sufficient. Frequency of bathing varies greatly between certain regions
and countries depending on the culture of each place. In fact, in many places, particularly those with warmer
weather, mothers prefer to bath their babies every day, even if not really necessary. However, it is recommended
that baths not be given daily. They should be given approximately twice a week until the baby starts to crawl .
Gloves can be worn for the initial bath to reduce contact with blood on the infant’s skin. Soaps and cleansers are
best avoided in the first few weeks of life. The neonate should be bathed in a warm room, and should be dried
quickly and thoroughly from head to toe, followed by wrapping in a warm dry towel and placing next to the
mother. After the bath, if the skin of the newborn and infant shows any sign of dryness or cracking, an appropriate
emollient should be applied, which, in addition to treating dry skin, protects the integrity of the stratum corneum
and skin barrier.
CLEANSING AGENTS
Cleansing is a process of removal of dirt, bacteria, dead skin cells, sweat and other debris from the skin surface.
Newborn skin is more sensitive to cleansers. Cleansers can be broadly categorized into two categories, @
alkaline soaps and @ acidic or neutral synthetic detergents (syndets). A cleanser is composed of a surfuctant or
detergent; a skin conditioner like glycerine; fragrance, color and preservatives. Ideally, a baby soap or cleanser
should be devoid of fragrance and colors to avoid irritation.
@ Soaps are obtained by the reaction of a base with a mixture of fatty acid esters. Traditional bar soaps have
good detergency, emulsifying power and produce enough lather, but they have an irritant action and their alkaline
pH can destroy the superficial lipid layer of the skin of the baby, leading to excessive skin dryness. Therefore,
they should be avoided. Glycerine soaps, due to the excessive content of glycerin, which is a potent humectant,
can absorb excess water out of the skin, potentially causing more dryness and irritation.
@ Syndets, also called synthetic detergents or 'soap without soap', do not have the disadvantages of soap and
can be a good choice. They consist of surfactants with a good detergent effect, have neutral or slightly acidic pH,
are low-lather substances and cause little irritation. They may be solid or liquid, and although pleasant, they should
not be used excessively
Types of Bar Soaps
• Soap is made by mixing an alkali (lye) with oil or fat in a process
known as saponification. Commonly used oils include vegetable oils
and non-vegetable oils.
• Vegetable Oils
• palm oil
• rice bran oil
• ground nut oil
• castor oil
• coconut oil
• palm kernel oil
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• Non-Vegetable Oils
• tallow (beef fat)
• lard (pig fat)
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Syndet
and Lipid Free Cleanser
it is clear from the above picture that it is not
a good start to use a product in the 9-10/blue
range on skin that is more in the 4-6/orange
range.
Newborn Bathing
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CARE OF THE DIAPER AREA
The diaper area represents a large moist and humid, occluded environment which is
more prone to maceration and attack by microorganism. The skin is also in contact
with strong alkalinizing agents e.g. urine and feces and the high pH damages the skin
integrity. The mother should be advised to frequently change napkins, whether they
are home laundered or of the superabsorbant variety. The skin should be dried and
aired between napkin changes. If frequent changes are not feasible, mineral oil can
be used on buttocks to form a physiologic barrier. Warm water and soft cotton wool
can be used to wipe napkin area. The bottoms should be wiped from front to back.
For feces that sticks, an emulsion like baby lotion can reduce the surface tension and
clean the debris. If a napkin rash occurs, petrolatum jelly or zinc oxide containing
pastes can be used. For home laundered diaper, usually washing in lukewarm water
followed by rinsing and drying is sufficient.
BABY POWDERS
Although they are useful to absorb moisture during hot and humid weather and
prevent maceration in skin folds, they are best avoided in the newborn period.
Excessive use can also lead to blockade of sweat duct pores and can lead to miliaria
formation . Accidental inhalation is another potential hazard
CARE OF THE DIAPER AREA
CLEANING AGENTS
An. Bras. Dermatol. vol.86 no.1 Rio de Janeiro Jan./Feb. 2011
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CLEANING AGENTS
Soaps are obtained by the reaction of a base with a mixture of fatty acid esters. Traditional bar soaps have good detergency, emulsifying power and
produce enough lather, but they have an irritant action and their alkaline pH can destroy the superficial lipid layer of the skin of the baby, leading to
excessive skin dryness. Therefore, they should be avoided. Glycerine soaps, due to the excessive content of glycerin, which is a potent humectant, can
absorb excess water out of the skin, potentially causing more dryness and irritation
Syndets, also called synthetic detergents or 'soap without soap', do not have the disadvantages of soap and can be a good choice. They consist of
surfactants with a good detergent effect, have neutral or slightly acidic pH, are low-lather substances and cause little irritation. They may be solid or
liquid, and although pleasant, they should not be used excessively.
Ideal cleaning agents should be liquid, mild, soap free, fragrance free, with neutral or slightly acidic pH; they should not irritate the skin or eyes of the
baby nor change the protective acid mantle of the skin surface. Some studies show that use of these liquid cleaners is better than use of only water in
the bath, both in terms of hygiene (fecal matter and urine) and drying of the skin. An additional protective effect to the skin of the baby and child can be
achieved using a liquid cleaning agent containing an emollient. Although this is the routine recommendation, studies regarding the use of cleaning
agents are still limited. In a recent study, the effects on the development of the skin barrier of newborn babies who were given a bath with water,
cleansing gel and topical lotion and of those who had a bath with only water were compared. Adverse effects were not observed on the epidermal
barrier in any of the groups. Regarding the appropriate time to introduce cleaning agents into the bath of infants, some studies recommend their use
soon after the umbilical cord falls, while others specify a time ranging from 2-4 weeks 2 to 6 weeks after birth. However, this time varies according to
the personal preference of each mother.
Regarding shampoos, there is not a standard pediatric formula. They are usually based on amphoteric, nonionic agents. While the hair is short, thin and
fragile, it is not necessary to use shampoos. The same product can be used for the body and hair. This, however, is a matter of choice. When
shampoos are used, the same aspects should be considered: they should be gentle, only slightly detergent with a pH close to the tear not to burn and
irritate the eyes or skin, and they should not change the roots of the hair or be aggressive to the scalp, which are fragile in infancy.
Despite the fact that cleaning wipes are practical and have a pleasant smell, they are not recommended by most authors due to the risk of removing the
lipid film of the skin and causing sensitization. It should be noted that they contain soap, and that their continued contact with the skin can damage its
barrier, causing contact dermatitis. It would be appropriate to rinse after use. Antiseptic soap and lotions should also be avoided.
OTHER SKIN CARE RECOMMENDATIONS FOR NEWBORN BABIES, INFANTS AND CHILDREN
Some other precautions that should be taken to preserve baby's skin:
- In infants, regular cleaning of the umbilical cord with clorexedine in the first 10 days of life until the cord falls can greatly reduce the risk of infection and
the risk of neonatal death.
- The nails of babies should be kept clean and short to avoid injuries to the skin.
- Diapers should be changed frequently and superabsorbent disposable diapers should be used because they have greater capacity of maintaining the
diaper area dry. The hygiene of the diaper area with warm water and cotton without soap is sufficient for the daily cleaning of urine. For stools, mild
soap is recommended. The routine use of topical preparations to prevent diaper dermatitis is not necessary for children with normal skin. Additives in
these preparations have the potential to cause contact sensitization, irritation and/or percutaneous toxicity.
- The use of adhesive bandages on the skin of babies, particularly preterm ones, should be avoided to the maximum due to the risk of lacerating their
skin, which is very thin. If their use is really necessary, very small pieces should be used, and they should be removed carefully. To facilitate removal,
an emollient can be used
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The appearance of eczema in very young babies is one of the most
common worries for new parents, affecting 25 per cent of newborns
Today, babies and children are exposed to harsher soaps and detergents, containing
more synthetic ingredients, than they were 60 years ago
Emollient enhancement of the skin barrier from birth offers effective
atopic dermatitis prevention
J Allergy Clin Immunol. 2014 ; 134(4): 818
pH and Common Baby Skin Conditions
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Managing Baby Skin Problems
We have pharmaceutical steroids, antibiotics, anti-yeast treatments and a whole variety of
aggressive approaches to manage skin problems, but one of the most simple and effective tactics
is also one of the most overlooked. With skyrocketing rates of eczema and other baby skin
problems, it is time to pay closer attention to maintaining a healthy pH level on baby’s skin. Even a
small shift in skin pH can create a dramatic change in skin functionality.
For example, There is a type of enzyme (the protease SCCE) in the skin structure that effectively
alters skin thickness. Fundamentally, these enzymes help thin out older skin cells so new ones
can grow. The enzymes are pH sensitive and will cause over-thinning when the skin pH rises
above the ideal level. The effect is quite significant – if the skin pH rises only 2 points on the 14
point scale – from 5.5 to 7.5 – the increase in activity of the thinning enzymes is 50%. When those
enzymes are working overtime, the skin barrier is weakened and more susceptible to the
penetration of allergens and irritants, which can trigger eczema flair-ups.
Intrinsic vs Extrinsic Eczema
Further, more than half of baby Eczema cases are a specific kind of eczema called Intrinsic Atopic
Eczema. This type of eczema is not associated with allergies or raised antibody levels in the body.
Unlike its counterpart, Extrinsic eczema, Intrinsic eczema may be wholly preventable by
maintaining a proper pH and moisture level on the skin surface. That means that with proper pH
balancing skincare and minor lifestyle adjustments over half of the children suffering with eczema
could be easily helped without pharmaceutical interventions.
Skin pH levels are directly correlated with skin permeability, sensitivity and resilience. To maintain
a healthy skin barrier, use pH balanced skin cleansers, avoid over bathing, and use lotions,
ointments and moisturizers that are free from harsh chemicals, fragrances, parabens and
petroleum byproducts.
Infant Cleansing
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On February 2007, a group of clinical experts in pediatrics and dermatology
formed the first European Round Table meeting on “Best Practice for Infant
Cleansing.” The consensus panel recommended that caregivers use liquid,
pH-neutral, or mildly acidic cleansers over traditional alkaline soaps on
neonates and infants . In addition, the consensus panel made the following
recommendations:
(i)Liquid cleansers are preferable to water alone.
(ii)Liquid cleansers cleanse and hydrate skin better than water alone.
(iii)Liquid preparations, which often contain emollients, are preferable to
cleansing bars.
(iv)Liquid cleansers should contain adequate and appropriate preservatives.
(v)An “ideal cleanser” is one that does not cause irritation, alterations to skin
surface pH, or eye stinging.
(vi)Skin care products should be selected on the basis of evidence acquired
in practical use conditions.
Newborn Bathing
• EMOLLIENTS FOR THE NEWBORN
• An emollient in as agent that softens and smoothens the skin. They
are also referred to as “moisturizers” and “lubricants”. They are
essentially composed of lipids which may be animal or vegetable
derived, or obtained from mineral oils or alternatively, may be
synthetic in origin(22). Emollients can be of the following kinds: •
Hydrocarbons – Vaseline, paraffin • Fatty substance – Cetyl or
stearyl alcohol • Waxes – Bees wax, lanolin • Oils – mineral oil,
vegetable oils such as coconut oil, palm kernel oil, ground nut oil,
olive oil, mustard oil, synthetic oil. There are two important types of
emollient formulations i.e. oil in water emulsion (cream) or water-inoil emulsion (ointment), out of which cream preparations are
generally preferred. The application of an emollient serves the
following purposes in a neonate, namely: safe and effective way to
decrease neonatal peeling and scaling dermatitis, maintains barrier
function, reduces irritation in the napkin area, and also has a role in
massage
Infant and adult skin: stratum corneum (SC) hydration and water transport
properties. The SC of infant skin (a) and adult skin (b) is hydrated (small blue
spheres) under normal conditions. Infant SC is more hydrated but also loses
water at higher rates than adult SC
(a)
(b)
Stratum corneum (SC) moisture retention following application of mineral oil
emollient. In (a), transepidermal water loss (TEWL) from the SC is shown under
ambient temperature, humidity, and pressure. In (b), TEWL is reduced following
emollient application. Oils in the emollient create a semiocclusive layer. The
reduction in water evaporation leads to greater water retention in the SC.
Infants & Toddlers
How Does Infant Skin Differ from Adult Skin?
How Does Infant Skin Differ from Adult Skin?
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The functions of the skin remain essentially the same at all phases of life, including: barrier, photoprotection, thermoregulation, immune
surveillance, hormonal synthesis, insensible fluid loss prevention, and sensory perception. However, there are several important structural
differences between the skin of babies and adults, differences immediately accentuated as the newborn transitions from the intrauterine
environment to the outside world.
Barrier function of the skin is vital for survival for all human beings. With increasing prematurity, there is increasing barrier dysfunction
with higher transepidermal water loss (TEWL) and increased percutaneous absorption of chemicals. As a result, there is greatly increased
mortality in premature infants with impaired barrier function, generally due to microbial invasion. Although the TEWL in full-term infants is
generally agreed to be close to that of healthy adults. Infant skin is found to have higher water content and is able to absorb more water
and lose excess water faster than adult skin. Other microstructural differences include thinner stratum corneum and papillary dermis in
infant skin.
Beyond these structural points, however, several factors converge to make infants more susceptible to percutaneous toxicity. Their high
surface area-to-volume ratio, immature drug metabolism systems, and decreased subcutaneous fat stores effectively increase the
absorptive area while decreasing the volume of distribution of a drug or toxin.This is compounded by the fact that once absorbed, the
infants lack fully developed drug carriage and detoxification systems. Furthermore, direct barrier injury can occur because of the
increased fragility of infant skin, particularly from the removal of adhesive tapes and monitors, thus increasing local permeability.
Below the skin, in the subcutaneous fat, there are also discrepancies between mature and immature. In newborns, the subcutaneous fat
is rich in the saturated oils palmitic and esteric acid. These fats have higher melting point temperatures than the increasingly unsaturated
fats of adulthood; as more oleic acid becomes present, the melting point diminishes. The higher melting point means that the fat in infants
can freeze more easily: approximately 64°C vs the much lower adult melting point of 14°C. This principle is typified by "popsicle
panniculitis," a fairly common form of fat necrosis in the cheeks of infants several hours after eating popsicles or ice, and the closely
related equestrian panniculitis, seen after the cold exposure from riding horses, bicycling, or riding motorcycles.Subcutaneous fat necrosis
of the newborn, a condition frequently associated with hypothermia, trauma, or other perinatal stressors, is a panniculitis that may also be
related to the higher melting point of infant fat. Because of this limitation in infant skin, extra care must be made to avoid temperature
extremes.
Bathing an infant provides important psychological benefits between parent and child. However, oddly enough, it can also provide an
opportunity to damage the skin. There is evidence to suggest that washing the skin with a washcloth during the first 4 weeks of life is
associated with increased TEWL and decreased stratum corneum hydration compared with simply soaking in water. The consensus
appears to be that a mild liquid cleanser may actually be less drying and less irritating than water alone, and that bathing should be brief
(10 minutes or less) and no more than every other day with spot cleaning in between.
Infant and Toddler Skin: Sun Protection
PEDIATRICS . 128 , 2011,92
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Although the deleterious effects of solar ultraviolet radiation (UVR), including immunosuppression
and cutaneous tumorigenesis, are widely acknowledged, most studies to date have concentrated
on adult skin. Despite the more sensitive nature of infant and toddler skin, little is known about its
responses to UVR exposure, whether acute or long-term. Accumulating evidence suggests not
only that the skin's barrier protection remains immature throughout at least the first 2 years of life
but also that accumulation of UVR-induced changes in the skin may begin as early as the first
summer of life.
Both intense and intermittent exposure to UVR and sunburn during childhood and adolescence
increased the risks of melanoma and basal cell carcinoma later in life. The risk of developing
melanoma is particularly high in families with dysplastic nevi and/or a strong history of melanoma.
Squamous cell carcinoma seems related to UVR exposure over longer periods. Early exposure to
ultraviolet light, especially intermittent, has also been linked to an increased risk of developing
pigmented nevi, and exposure of neonates to blue light as treatment for hyperbilirubinemia
increases the risk of development of common and atypical melanocytic nevi, although not of skin
cancer. Additional effects of solar UVR exposure on adult skin include summertime
hyperpigmentation and subsequent wintertime recovery, local immunosuppression, and long-term
risks of accelerated aging
UVB, which causes acute inflammation, including sunburn, and chronic dermal matrix
degradation, has been strongly linked to basal and squamous cell carcinomas through directly
damaging DNA. UVA, the major light emitted in tanning booths and once considered relatively
innocuous, is now known to suppress cutaneous immune function and generate excess reactive
oxygen species, which indirectly damage DNA, accelerate the aging process, and facilitate UVBinduced carcinogenesis. It is also important to remember that infants are entirely dependent upon
their caregivers to practice sun protection and are generally not able to communicate the
symptoms of early sunburn
How Does Infant Skin Differ from Adult Skin?
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Photoprotection is an important function of the skin, though in the process of
preventing ultraviolet (UV) sun damage to certain structures, the skin can itself
accrue damage, increasing the chances of skin cancer. As for adults, sun protection
is important in childhood. This topic takes special importance because the damage
from UV radiation is cumulative: children spend more time doing outdoor activities,
younger skin is more susceptible to damage, and UV damage in childhood may have
particularly profound consequences later. .
Evidence for hormone disruption is another issue that is well established for
benzophenone-3, homosalate, 4-methyl-benzylidene camphor (4-MBC), octylmethoxycinnamate (OMC), and octyl-dimethyl-para-aminobenzoic acid (PABA). All
show estrogenicity, and studies document environmental persistence and widespread
presence in the population. Unfortunately, even the mineral sunscreens such as
titanium dioxide and zinc oxide are not without risk. There is evidence that the
nanoparticles present in many of these mineral sunscreens can cause cellular
damage. Although most studies have shown that there is minimal penetration into the
skin, no studies have yet tested these particles in fragile or damaged skin.
Skin diseases in infants and adults can vary as much as the difference in
fundamentals of the skin. Even disorders that may sound familiar from experience in
older patients may be distinct in infants: acne, skin infections, and nutritional
dermatoses, to highlight a few.
How Does Infant Skin Differ from Adult Skin?
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Classical teenage acne (acne vulgaris) is well known to all of us; however, there are 2 distinct forms of acne that
can affect patients in the first few years of life: neonatal acne and infantile acne. Neonatal acne is perhaps more
accurately referred to as neonatal cephalic pustulosis (NCP) and can affect up to 20% of newborns.This
papulopustular disorder lacks the comedones of true acne and may actually be related to colonization with
Malassezia yeast species on the skin. Generally benign and self-limited, treatment with topical ketoconazole may
shorten the duration of the disease
Infantile acne, on the other hand, is far more rare than neonatal acne, and generally occurs between 3 months and
1 year. Both comedones and inflammatory papules are seen in this disease, and like its teenage counterpart,
scarring may be an issue. Sometimes infantile acne will resolve by school age without specific treatment, but it
may also be a harbinger for severe forms of acne in adolescence and appears to be more common in families with
a strong family history of acne. Here the differences end: treatment can be very similar to that for teenage acne,
including a topical retinoid and topical benzoyl peroxide.
Staphylococcal scalded-skin syndrome in infants and children is caused by staphylococcal bacteria that release
exfoliative toxin and can also be seen in adults with renal failure. This suggests that it is the inability to clear the
toxin that causes the characteristic superficial bullae and widespread sloughing, with crusting and impetiginization
at the orifices. Prompt diagnosis and treatment with systemic antibiotics and skin barrier support are necessary to
minimize morbidity from this disease.
Infants are also particularly susceptible to nutritional deficiencies, and zinc deficiency may be acquired or inherited.
Acrodermatitis enteropathica (AE) is the rare, autosomal-recessive disease of impaired zinc absorption that
usually presents upon weaning from breast milk. Acrodermatitis enteropathica-like eruption can be seen in the
setting of insufficient dietary zinc, including breast milk deficiency. Symptoms of periorificial dermatitis, diarrhea,
and hair loss frequently are mild and incomplete, making this disease a challenge to diagnose at times. Once the
diagnosis is made, zinc supplementation is required, which generally results in dramatic reversal of skin lesions
within several days.
Infantile acne
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True infantile acne generally affects the cheeks, and sometimes the forehead and
chin, of children aged six months to three years. It is more common in boys and is
usually mild to moderate in severity. In most children it settles down within a few
months.
The acne may include comedones (whiteheads and blackheads), inflamed papules
and pustules, nodules and cysts. It may result in scarring.
Pityrosoprum folliculitis
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Infantile acne or 'milk spots'. Affects babies within the first few weeks of life. Increased activity of
the newborns' sebaceous glands cause inflammation and folliculitis.
Clinical features: Erythematous dome shaped papules and superficial pustules arise in crops,
commonly affecting the cheeks, nose and forehead. This rash is not itchy.
Treatment: Will resolve within weeks without treatment or may be treated with ketoconozole
shampoo (eg. Sebizole shampoo) diluted 1:5 with water, applied with a cotton bud twice a day.
Rinse off with water after 10 minutes. Or apply Hydrozole cream bd to the affected areas until the
rash has resolved.
Neonatal Milia
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Affects 40-50% of newborn babies. Few to numerous lesions.
Clinical features: Harmless cysts present as tiny pearly-white bumps just under the surface of the
skin. Often seen on the nose, but may also arise inside the mouth on the mucosa (Epstein pearls)
or palate (Bohn nodules) or more widely on scalp, face and upper trunk.
Treatment: Lesions will heal spontaneously within a few weeks of birth.
Miliaria (Heat rash)
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Arises from occlusion of the sweat ducts. In infants lesions commonly appear on the neck, groins
and armpits, but also on the face.
Clinical features: 1-3mm papules (vesicular or papular).
Treatment: Remove from heated humid environment or adjust incubator temperature. Cool
bathing or apply cool compresses. Topical steroids may be used to facilitate relief while the
condition resolves.
Erythema Toxicum Neonatorum
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A common condition affecting as many as half of all full term newborn infants. Most prominent on day 2, although
onset can be as late as two weeks of age. Often begins on the face and spreads to affect the trunk and limbs.
Palms and soles are not usually affected.
Clinical features: Erythema Toxicum is evident as various combinations of erythematous macules (flat red
patches), papules (small bumps) and pustules. The eruption typically lasts for several days however it is unusual
for an individual lesion to persist for more than a day.
Treatment: The infant is otherwise well and requires no treatment.
Staphylococcal scalded skin syndrome, (SSSS)
• Staphylococcal scalded skin syndrome, (SSSS),
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also known as Pemphigus neonatorum or Ritter's disease, or Localized bullous
impetigo is a dermatological condition caused by Staphylococcus aureus
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Acrodermatitis enteropathica
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Acrodermatitis enteropathica is an autosomal recessive metabolic affecting
the uptake of zinc, characterized by periorificial (around the natural orifices)
and acral (in the limbs) dermatitis, alopecia (loss of hair), and diarrhea.
Similar features may be present in acquired zinc deficiency. This disease
also is related to deficiency of zinc due to congenital causes.
Features of acrodermatitis enteropathica start appearing in the first few
months of life, as the infant discontinues breast milk. There
are erythematous patches and plaques of dry, scaly skin. The lesions may
appear eczematous, or may evolve further into crusted
vesicles, bullas or pustules. The lesions are frequent around the mouth
and anus, and also in hands, feet and, scalp. There may
be suppurative inflammation of the nail fold surrounding the nail plate,
known as paronychia. Alopecia (loss of hair from the scalp, eyebrows, and
eyelashes) may occur. The skin lesions may be secondarily infected
by bacteria such as Staphylococcus aureus or fungi like Candida albicans.
These skin lesions are accompanied by diarrhea.
Acrodermatitis Enteropathica
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Sharply demarcated, brightly erythematous periorificial plaque in an infant with acrodermatitis
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enteropathica
Acrodermatitis Enteropathica
Acquired acrodermatitis enteropathica
Atopic Dermatitis
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Atopic dermatitis: Infants often get atopic dermatitis on their cheeks, as did this 7month-old boy
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Atopic dermatitis:This 7-year-old girl says the thickened skin on the back of her
knees is always dry and always itches.
Atopic Dermatitis
Napkin dermatitis
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What is the cause of napkin dermatitis?
Napkin dermatitis follows damage to the normal skin barrier and is primarily a form of irritant contact dermatitis.
The US term is diaper rash. Napkin dermatitis is most often a form of contact dermatitis.
Urine and occlusion leads to overhydration¬ and skin maceration
Faecal bile salts and enzymes break down stratum corneum lipids and proteins
A mixture of urine and faeces creates ammonium hydroxide, raising pH
The wet skin is colonised by micro-organisms, particularly candida
Mechanical friction from limb movement may increase discomfort
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Other causes of napkin rashes include:
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Candida albicans
Impetigo
Infantile seborrhoeic dermatitis
Atopic eczema
Psoriasis
Miliaria
Rare disorders
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Napkin dermatitis is not due to:
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Allergy to the napkins
Toxins in the napkins
Washing powders
Dermatophyte fungal infections (tinea)
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Prescription treatments
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Use of disposable nappies
Mild topical steroid such as hydrocortisone cream, applied to inflamed skin once or twice daily for 1–2 weeks
Topical antifungal cream once or twice a day if suspicious of Candida albicans infection.
Strong steroid creams should not be applied to a baby's bottom.
Diaper dermatitis
Diaper Dermatitis
Napkin dermatitis
Diaper Dermatitis
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Diaper dermatitis is caused by overhydration of the skin, maceration, prolonged contact with urine
and feces, retained diaper soaps, and topical preparations and is a prototypical example of
irritant contact dermatitis. Signs and symptoms are restricted in most individuals to the area
covered by diapers.
. The following causes have been noted:
Overhydration of the skin
Maceration
Prolonged contact with urine and feces
Retained diaper soaps
Topical preparations
More than 3 diarrheal stools per day
Side effects of oral antibiotics
A 3-week-old female infant with diaper rash. Satellite lesions can be observed. The patient was diagnosed clinically with candidal
dermatitis and successfully treated with nystatin ointment.
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Diaper rash pathophysiology scheme
Diaper Dermatitis
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Because of the lack of contact, the fold areas are usually spared.
Chronic irritation can lead to ulcerations—this is known as Jacquet’s erosive
diaper dermatitis and likely represents the severe end of the spectrum of
irritant diaper dermatitis.
Candida Diaper Rash
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Anti-inflammatory topical steroid are useful if above measures fail. Use only low
potency steroids for short periods (no more than twice daily for 1 week). The
diaper area has very thin skin, and the use of potent topical steroids may lead to
thinning, striae, and adrenal suppression. Avoid combination preparations of
antifungal and steroids because the steroid is usually high potency and should not
be used in the diaper area.
Antibiotics may be necessary for secondary bacterial infection. Topical mupirocin
should be used over Neosporin because of neomycin’s allergic properties
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Cradle cap
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Cradle cap. This is areas of greasy, yellow, scaly patches on the scalp. In some
cases a thick scaly layer covers the whole scalp. Over time the scales may become
flaky and rub off easily. The condition is not usually itchy and, in most cases, the baby
is not aware of any problem or discomfort
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Seborrheic dermatitis
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Seborrheic dermatitis is a common, mild disease of newborns. The red, scaly rash can spread to
the forehead, behind the ears, and in the creases of the neck and armpits. The rash is not itchy
and usually does not bother babies. Occasionally babies also develop this skin disease in
the diaper area. When seborrheic dermatitis occurs in the diaper area, it is often accompanied by
a yeast infection. When yeast is present, the rash is itchy and uncomfortable. Seborrheic
dermatitis usually disappears by the end of the first year and does not reappear until puberty .
Infantile seborrhoeic eczema or psoriasis?
Bacterial Diaper Rash
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Bacterial Diaper Rash
Superficial Staphylococcal infection most common with 1-2mm fragile pustules and
honey-colored, crusted lesions. Can also cause bullous form with large, flaccid, pusfilled bullae that rupture easily and leave erosions with a collarette of scale.
Gram stain and culture of pus to confirm diagnosis
Treat with topical Mupiricin or Neosporin. Extensive infection requires oral anti-
staphylococcal coverage
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Children Are Not Little Adults
Children Are Not Little Adults
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Three factors may help explain the unique risks to children from
environmental threats.
1. Their greater environmental exposures because of differences in
childhood and adult consumption and activity patterns.
2. Key physiological differences between children and adults that increase
the dose of environmental contaminants that children receive
3. Children's Developing Bodies are More Vulnerable to Contaminants
– Individual development proceeds from the formation of sperm and egg through
fertilization, fetal development, infancy, childhood, adolescence, and adulthood.
During each stage children may have windows of extra sensitivity to
environmental agents. The resulting damage may become manifest immediately
or not until later in life.
– Vulnerability can be broken into three broad periods of development:
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Sperm and egg cell development in the parents through conception and the
subsequent two weeks . enviornmental exposures before or soon after
conception may alter genetic material passed onto the developing embryo
or may disrupt developmental control mechanisms that monitor DNA
synthesis, cell division, and cell growth
Children Are Not Little Adults
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A. Overview
Children are often more likely to be at risk from environmental hazards than adults because of:
– Unique activity patterns and behavior.
– Physiological differences.
– Windows of susceptibility during early lifestages including fetal development and puberty.
Children are also dependent upon adults to ensure that their environment is safe.
B. Unique Activity Patterns + Behavior
Children crawl and play close to the ground making them more likely to come into contact with dirt and dust, which
can include toxicants.
Children often put their hands, toys, and other items into their mouths.
C. Physiology
Children eat, breathe, and drink more relative to their body mass than adults do.
Children’s natural defenses are less developed.
– More permeable blood-brain barrier.
– Less effective filtration in nasal passages.
– Highly permeable skin.
– Lower levels of circulation of plasma proteins.
– Digestive system, metabolic pathways, renal clearances, and vital organs are still developing.
D. Windows of Susceptibility
The timing of exposure to chemicals or other insults is critical in determining the consequences to children’s
health.
Because of the differing windows of susceptibility, the same dose of a chemical during different periods of
development can have very different consequences.
For example, fetal loss or birth defects are most likely to occur as a result of exposures to chemicals during the
embryonic period, when organs are beginning to differentiate.
Even after the basic structure of an organ has been established, disruption of processes such as growth and cell
migration can have lifelong consequences on the function of key organ systems.
Due to the complexity and speed of development during the prenatal period, organ system development is
particularly susceptible to adverse effects resulting from environmental exposures
CHILDREN ARE NOT LITTLE ADULTS
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Techniques for determining adults’ preferences for various health improvements and expressing
them in monetary terms are reasonably well established, if controversial. However, these
techniques cannot be directly applied to children nor can they be adapted simply. Economists
have used two basic approaches to valuing reductions in risk to adults’ health.
1.The human capital approach looks at direct financial costs associated with illness—primarily
medical expenses and lost wages. This approach is relatively easy to implement, but provides an
incomplete measure of the value of protecting health.
2. A theoretically more satisfying measure is willingness to pay (WTP) to reduce health risks. WTP
measures are based on the trade-offs individuals make, or are willing to make, between protecting
their health and other things they need or want. Both approaches have obvious flaws when
applied to children. Human capital measures can be even more incomplete or challenging to use
because it can be more difficult to estimate the value of the time young children lose to illness
because they are not engaged in the labor market. Estimates of WTP are conventionally based on
adults’ actions or statements reflecting their judgments about the worth of protecting their own
health.
As anyone who has chased after a three-year-old running toward a busy street knows, however,
children do not have mature judgments about their own health.
Governments all over the world, including in the United States, are recognizing that specific
attention needs to be given to whether environmental law and regulation are doing a good enough
job with respect to children.
Several studies have resulted in the consistent finding that parents’ WTP to reduce children’s
health risk is two times adult WTP to reduce their own health risk.
Children are resources for the future