NEONATAL SKIN CARE AND NEONATAL SKIN DISORDERS PoHan

NEONATAL SKIN CARE AND NEONATAL SKIN DISORDERS Po-Han Huang, M. D. , F. A. A. D. Division of Dermatology Chang Gung Children Hospital-Kaohsiung, Taiwan

Neonatal skin structure • Epidermis: important barriers – Thickness: 40 -60% that of adult skin – Attenuated rete ridges: limited attachment to an immature dermis • Dermis: support and protect nerves, blood vessels – thinner – fewer and immature elastin fibers – smaller bundles of reticular dermal collagen • Subcutis: heat insulator and calories reserve Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Neonatal skin p. H • Skin p. H: – Full term newborns: p. H 6. 34 and falls to 4. 95 by 4 days – Premature: p. H 6. 0 and falls to 5. 0 by 3 weeks • Functions of the acid mantle: – Protect against bacteria – Decrease transepidermal water loss • Bathing with alkaline soap alters p. H and it takes hours to reform the acid mantle Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Premature skin structure • Stratum corneum: significant difference between a premature and term infant – Infant before 32 weeks gestation: very thin – Significant insensible transepidermal water loss(TEWL) with thermal instability, fluid and electrolyte disturbance – Increased risk of disseminated infection due to easily injured skin and diminished metabolic capacity and decreased immune responses. Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Transepidermal water loss (TEWL) • Premature: 15 times higher in 1 day old infants born at 25 weeks gestation • Very low birth weight infants: 30% of total body weight in 24 hours • Traditional resolution: fluid replacement has a lag time and may result in sodium and glucose overload Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Skin injury • Clinically occult skin injury accompanies routine care. – Skin stripping – Local application of pressure or thermal heat. – UV light burns due to white light (UVA and infrared heat included) phototherapy for jaundice. Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Percutaneous absorption • Easy administration for medication: – theophylline, diamorphine, lidocaine, and oxygen, etc. • Percutaneous poisoning: – Hexachlorophene (p. Hiso. Hex): vacuolar encephalopathy – Silver sulfadiazine (Silvadene): kernicterus and argyria – Povidine iodine (Betadine): hypothyroidism, goiter – Neomycin: neural deafness – Corticosteroids (except hydrocortisone): skin atrophy, adrenal suppression – Prilocaine (EMLA): methemoglobinemia Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Skin care practices • • Bathing Diapering Emollients Skin Antisepsis Adhesive Application and Removal Care of Cord Care of Broken Skin Control of Transepidermal Water Loss Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Murphy’s Law: Whatever can go wrong, will. Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Bathing • No antimicrobial cleansing agents for routine bathing with clearly demonstrable benefits for infants: reduced colonization for 4 hours only. • Mild cleansing products work or hurt? Little difference among them. • Burns after immersion in hot water tested only by touch. • Cloth diaper: avoid laundered with phenolic compounds (pentachlorophenol) Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Bathing • Bathing only after the temperature has established, often from 2 -4 hours later. • Leave the vernix on as long as possible. – providing added skin barrier protection: hydrophobic and bactericidal – regulating postnatal surface adhesion properties, heat flux, and surface electrical property • Robbing is avoided. • Baths should be on alternate day. Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Diapering • The first disposable diapers, Pampers, were marketed in 1963. Its absorbent core is cellulose fluff. • In the mid-1980’s, the superabsorbent core, a cross-linked sodium polyacrylate, in all disposable diapers. • Urine output monitoring by weighing diapers: – Greater evaporative loss from a regular fluff-type – Pseudoanuria: inability to feel moisture on a superabsorbent diaper Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Emollients and diaper rash products • Potential percutaneous toxicities, especially the diaper area due to occlusion. – Commercially available ingredients used with caution in the newborn: Triclosan, Propylene glycol, Benzethonium chloride, Glycerin, Ammonium lactate, and Coal tar. • Contact sensitization: thimerosal, nickel, Kathon CG, fragrances, neomycin, and wool alcohol. • The safest and best effective emollient: white petrolatum • The best initial choice for diaper dermatitis is zinc oxide ointment Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Skin antisepsis and cord care • Skin antisepsis: povidone-iodine • Cord care: 70% iospropyl alcohol pledgette with or without application of povidone-iodine • Reappraisal of the use of povidone-iodine – skin necrosis – elevation in plasma and urinary iodine, transient hypothyroxinemia, hypothyroidism and goiter • Reappraisal of the use of alcohol – skin necrosis and irritation – hypoglycemia and CNS depression Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Skin antisepsis and cord care • A safer and more effective alternative: Chlohexidine gluconate. – 0. 5% Chlohexidine gluconate is better than 10% povidone-iodine – Broad spectrum activity, even including yeast. – Strongly binding to skin – No toxic systemic effects even after massive oral ingestion – Rapid action and low potential for contact sensitivity – Alcohol can enhance percutaneous absorption of Chlohexidine gluconate Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Adhesive application and removal • Hydrogel (vigilon) or hydrocolloid ( Deo. Derm Extra Thin) is favored to replace conventional adhesive products, especially for patients with epidermolysis bullosa (EB). Cotton bandages work well, too. • Prevention of skin trauma from adhesive removal: smaller pieces of adhesive, backing the adhesive with cotton gauze, delaying removal, and reducing frequency. • Warm water is safest to facilitate removal, but not oil. Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Care of broken skin • Etiology: adhesive removal, infection, friction, pressure sores, wiping skin when diarrhea and diaper dermatitis, etc. • Care: – frequent irrigation with sterile water and covered with opsite, hydrogel, or hydrocolloid – keeping a moist surface speeds healing – Antifungal and antibacterial ointment preferred because of improved coating and healing by facilitating migration of epithelial cells Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Control of transepidermal water loss • Double walled incubators with servo controlled humidification using sterile water raises the water vapor pressure and reduces fluid loss, but the environment is also optional for contamination with pathogenic microbes. • Plastic blanket: food wraps and not tested for stability after prolonged heating but reducing TEWL by 50% • Plastic bubblewrap: acutely block heat transmission if on infrared and potential to burn contacted skin • Rigid plastic hood: not better than the former ones Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Control of transepidermal water loss • White petroleum is regarded as the gold standard. – Oils, creams, and lotions provides a much less effective moisture barrier. – Formulation requires the addition of several potentially irritating, sensitizing or toxic ingredients. – Aquaphor: TEWL after 30 minutes is 67% decrease but only 34% decrease after 6 hours. 6 hour application interval is needed. • Stable skin surface temperature, and no evidence of hyperthermia or burn following application of petrolatumbased ointment under infrared warmer. Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Proposed Recommendations for Basic Skin Care of the Premature Newborn • Use adhesive sparingly • Limit bathing • be aware of the composition and quantity of all topically applied agents • Ensure adequate intake of protein, essential fatty acid, zinc, biotin, and vitamins A, D, and B’s • Apply an ointment emollient every 6 -8 hours • Guard against excessive thermal and UV exposure • Protect sites of cutaneous injury with the appropriate occlusive dressing Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Diaper rashes update in pathomechanism • Occlusion and moisture: edema of stratum corneum • Friction: wet skin more susceptible • Urine and ammonia: ammonia DOES NOT produce primary irritation, but can be a secondary irritant when skin is injured • Feces: protease and lipase; breastfeeding babies have lower fecal p. H, lower protease and lipase activities, fewer ureasplitting bacteria (less urease) • Candida albicans: keratolytic activity, activating complement • Bacteria: colonization by S. aureus • Other risk factors: washed with detergent soaps Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Diaper rashes update in therapy • Reduce moisture and friction: frequent diaper changes (at least every 2 hours), superabsorbant diapers, no tight fitting diapers, and occlusive pants, disposable diaper with cloth-like covering • Protect diaper area: barrier ointment with diaper change • Minimize washing of diaper area: for urine, blot dry, DO NOT need wipes; for stool, avoid water, consider soap-free cleanser • Decrease skin inflammation: HC 1% ointment, No halogenated steroids, including Betamethasone and Triamcinolone. • Treat candida: satellite lesions, or if rash present for more than 3 days • Antibacterial therapy: use if crusting; topical; systemic Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Neonatal skin disorders • • • Majority are benign, limited to skin Occasional association with other abnormalities Often spontaneously resolve Treatment occasionally indicated Must consider topical therapy carefully – Increased skin permeability – Percutaneous absorption – Sensitivity – Irritation Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Milia • • Small epidermal cysts Often multiple, 1 -2 mm, white Face may be congenital In older patients, arise after trauma No treatment necessary Comedonal extraction Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Cutis mamorata • • • Reticulate bluish mottling of skin Physiologic response to chilling Disappear after rewarming No known medical significance May persist in Down’s, trisomy 18, Cornelia de Lange syndrome • DDx with Cutis mamorata telangiectatica congenita: exaggerated cutis mamorata and developmental ectasia associated with other defects ( vascular, bony, CNS) Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Acne neonatorum • • • Birth or early infancy Papules. Pustules, comedones Cheeks, chin, forehead ( chest and back spared) Infantile acne: delayed onset, more severe Etiology: hormone stimulation of sebaceous glands? Fetal testes synthesize more steroid than ovary Most cases resolve within first 2 years No treatment necessary (mild keratolytics, antibiotics) If persistent or unusually severe, sexual precocity or virilization? Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Salmon patch • • Most common vascular lesion of infancy 30 -40% of newborn Pink flat macular lesion Nape of neck, glabella, forehead, eyelids, nose “Angel kiss” or “stork bite” Pathology: distended dermal capillaries (fetal circulation) 95% fade within first year May reappear with crying or exertion Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Mongolian spots • • • Brown to gray to blue lesions Lumbosacral, buttocks, occasionally extremities Present at birth, fade over 1 -2 years Spindle melanocytes, arrested in migration Color: Tyndall effect Treatment unnecessary Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Congenital nevi • Distinct group of melanocytic lesions with predisposition to malignant melanoma • Defined as small (<1. 5 cm), medium (1. 5 -20 cm) and large or giant (>20 cm) • Incidence: Small: 1%; Large: 1 in 1, 000 -20, 000; Garment: 1 in 500, 000. (Ceballos PI, et al. NEJM 1995; 332(10): 656 -662) • Pale, tan macules or papules, may have freckling. With time, become elevated, darker, hairy. Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Congenital nevi • • Giant lesions often dermatomal, may cover entire limb or region Often satellite lesions may become verrucous, papillomatous Leptomeningeal melanocytes (neurocutaneous melanosis) When over spinal column, spinal dysraphism, cord abnormalities Risk of melanoma: Small, 2 -4 %; Medium, 3 -6%; Large, 4 -8%. Therapy: – small and medium: no consensus, most advocate excision at or around puberty when risk increases – giant: remove as early as possible; benefit, long-term prognosis unclear Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Miliaria • • Caused by sweat retention Three types: crystallina, rubra, profunda Incidence greatest in the first few months ( crystallina and rubra) Miliaria crystallina: clear, thin-walled vesicles, 1 -2 mm; superficial vesicle below stratum corneum • Miliaria rubra: tiny, pruritic papules with erythema; edema, vesiculation in epidermis near sweat duct • Differential: viral exanthem, drug eruption • Management: avoidance of excessive heat and humidity, parental education (proper clothing, temperature regulation), cool baths, air conditioning Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Sucking blistering • • 0. 5% of normal newborns Caused by vigorous sucking of part in utero Oval bullae, erosions Dorsal fingers, thumbs, wrists, lips Differential: bullous impetigo, EB, herpes Resolve rapidly without sequelae Supportive therapy Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Seborrheic dermatitis • • • Scaly eruption occuring in seborrheic areas Scalp, face, ears, presternal, intertriginous Pityrosporum ovale? Appear between 2 -10 weeks Usually clears by 8 -12 months Usually asymptomatic Warm mineral oil/ soft toothbrush Baby shampoo Low potency steroids Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.

Transient neonatal pustular melanosis • Transient neonatal pustular melanosis: the first case reported in Taiwan recently • more commonly among blacks • present at birth or during the first few days of life • Vesiculopustules resolve within 3 -5 days, then brownish crust or collarette of scale formed, and then residual hyperpigmented macules will fade by 3 -4 months of age • Forehead, chin, neck, trunk, palms, and soles • Diagnosis: smear shows PMN and negative study in cultures. • Treatment unnecessary. Pediatric Dermatology Po-Han Huang, M. D. , F. A. A. D.