Pharmacology and therapeutics

Neonatal skin care: what should we do? A four-week

follow-up randomized controlled trial at Zagazig
University Hospitals
Mohamed Amer, MD , Nagwa Diab, MD, Mohamed Soliman, MD, and Amin Amer, MD

Department of Dermatology & Venereology, Abstract

Medical School, Zagazig University, Introduction Taking care of newborn skin is necessary to avoid skin infections. The
Zagazig and Cairo, Egypt
normal daily exposure to external factors affects the skin negatively. Skin hygiene and
Correspondence
proper skin cleansing as well as protection of the infant skin barrier are essential to
Amin Amer, MD maintain barrier function and overall infant health.
Department of Dermatology & Venereology, Aim The aim of this work is to assess the neonatal skin care effectiveness in promotion of
Medical School, Zagazig University, normal skin development and protection of the optimal skin function by avoiding the
Zagazig and Cairo
different neonatal skin disorders which cause skin infection.
Egypt
Conclusion In conclusion, proper care and good hygiene of the normal mature neonatal
E-mail: [email protected]
skin are essential to maintain skin barrier function and overall health. This is achieved by
optimizing epidermal barrier integrity that includes:
doi: 10.1111/ijd.13735
• bathing and using emollient;
• preventing and managing infections and skin injury;
• minimizing transepidermal water loss (TEWL);
• minimizing heat loss and percutaneous absorption of toxins.

Baby bath products as well as baby wipes are safe to use and do not appear to affect an
infant’s skin barrier integrity. It is therefore sensible to use cleansers that have been
specially designed for baby’s skin, which are pH neutral and very mild to avoid irritant
dermatitis and allergic dermatitis.

• weaker connection between the dermis and the epider-

Introduction
mis;
Traditionally, the neonatal period has been defined as the first • thinner and less elastic skin.3
1
28 days of life.
The major functions of the human skin are: Rashes are extremely common in newborns and can be a
• maintenance of water and electrolyte homeostasis, key factor for parental concern. Most rashes are transient and
• thermoregulation, benign, but some rashes require additional work-up. Erythema
• antimicrobial defense, toxicum neonatorum, acne neonatorum, and transient neonatal
• protection from trauma, environmental toxins, and ultravi- pustular melanosis are transient vesiculopustular rashes that
olet radiation, can be diagnosed clinically based on their distinctive appear-
• synthesis of vitamin, ances. Milia and miliaria result from immaturity of skin
• immune surveillance and cosmetic function, structures.4
• sensory organ that facilitates mother–child attachment.2 Immediately after birth, the skin barrier of healthy, full-term
neonates is competent, yet skin-barrier function continues to
Skin of the newborn differs from that of an adult in several develop through at least the first year of life. Therefore, it is crit-
ways. The most important anatomical differences are: ical that infant cleansers and moisturizers be well-tolerated and
do not disrupt the stratum corneum. Infant skin is also exposed
• higher skin surface area to weight ratio (skin surface area to other factors, such as saliva, nasal secretions, urine, feces
of infant is 700 cm2/kg as compared to adult skin which (including fecal enzymes), and dirt, which can be irritants and
is 250 cm2/kg); result in disruption of the skin barrier.5 1

ª 2017 The International Society of Dermatology International Journal of Dermatology 2017

2 Pharmacology and therapeutics Neonatal skin care Amer et al.

As a result of normal daily exposure to these external factors, Mothers also agreed to avoid excessive sun exposure on their
good skin hygiene, proper skin cleansing, and protection of the infants’ arms and legs.
infant skin barrier are essential to maintenance of barrier func-
tion and overall health,6,7 Exclusion criteria
The initial bath in full-term infants can be given once the
baby’s temperature has stabilized and the infant is hemodynam- • Infants suffering from any known abnormal skin conditions
ically stable.2 (rash), hypersensitivity, or allergic reactivity to fragrances or
The aim of this work is to educate mothers for the neonatal other ingredients.
skin care effectiveness in promotion of normal skin development • Infants suffering from asthma, upper respiratory tract
and protection of the optimal skin function by avoiding the differ- infection, or other conditions that would affect the evaluation
ent neonatal skin disorders which may cause problems to of the skin care regimens.
infants. • Infants with any genetic abnormalities.
• Premature infants.

Patients and methods

Products used The products used were provided to mothers
This randomized controlled trial was carried out at the outpatient and consisted of marketed products formulated specially for
clinics of the Dermatology and Venereology Department, newborns:
Obstetric Department, and Pediatric Department, Faculty of
Medicine, Zagazig University Hospitals, in the period from April • Baby shampoo which is composed of sodium
2014 to September 2014. This study included 70 infant mother lauroamphoacetate, sodium laureth sulfate, coco glucoside,
pairs randomly assigned into two groups, A and B. polyquaternium-10, and sodium benzoate.
Group (A) included 35 neonates, 15 males and 20 females. • Baby oil is a mineral oil that contains paraffinum liquidum,
Group (B) included 35 neonates, 21 males and 14 females, and isopropyl palmitate, and parfum which are safe. It is used as
the majority of neonates were born by cesarean section (60 a moisturizer and for massage.
cesarean section and 10 normal labor); neonates were also • Baby wipes which consist of a nonwoven carrier soaked with
likely to be breastfed. an emulsion-type watery or oily lotion.
Group (A) included 35 neonates who underwent the care. • Baby cream which consists of zinc oxide and olive oil.
Group (B) included 35 neonates who did not undergo the care,
and both groups were monitored on a weekly basis for 4 weeks Skin care regimen
from the date of birth for appearance of any skin disorders.
• The caregivers (if possible) were instructed to gently dry the
All neonates were subjected to a brief medical information
baby immediately after birth and gently remove any blood or
questionnaire.
meconium and do not rub off the vernix (leave it as intact as
• Personal history includes name, age, occupation, mothers’ possible to absorb into the skin).
residence, mothers’ level of education and name, birth date, • During the 4 weeks of the study, neonates were bathed at
sex, and order of the neonates. variable frequencies by mothers mostly 1–2 times per week
• Collection of information that characterized the infants’ enteral using the shampoo as a cleanser, and sometimes the baby
nutrition (breast milk vs. infant formula), method of delivery wipes were used as an alternative to bathing.
(vaginal vs. cesarean section), and the period of gestation by • The first bath was given only when the temperature of the
weeks. newborn was stabilized, instead of considering only the
• Are the family living in the city or village? number of hours after birth, and usually during the first
week.
Mothers visual skin assessment questionnaire • Mothers were instructed to apply the oil on the skin and the
scalp 3–4 times per week and after bath time and to be
Clinical examination for skin assessment applied daily when signs of dryness (flaking/scaling) were
Inclusion criteria Male or female infants should be healthy presented.
and full-term (determined by the mothers’ obstetrician/ • Mothers were instructed to keep the umbilical cord clean and
gynecologist), as well as 1–7 days old at baseline. Mothers of dry by applying chlorhexidine in the first 10 days of life until
infant participants had to be older than 18 years of age and the cord falls and 2 days after and allowing it to be exposed
were told to refrain from using their infants’ current lotion to air as frequently as possible
products (if applicable) for the duration of study. Mothers • Mothers were instructed to use the best quality nappy
agreed not to introduce fragrances on themselves, on their available and to change soiled nappies frequently and
infant, or in their household for the duration of the study. cleanse nappy area with plain water or unperfumed, alcohol-

International Journal of Dermatology 2017 ª 2017 The International Society of Dermatology

Amer et al. Neonatal skin care Pharmacology and therapeutics 3

A comparison was done between the two groups to evaluate

neonatal skin care and possibility of avoiding different neonatal
skin disorders.
After the data collection, chi-squared tests were used for
categorical data. An ANOVA was used for comparison of
continuous data.

Results
Regarding erythema, group B has a higher erythema than group
A especially in the third and fourth weeks. There was no signifi-
cant difference between the two groups with regard to dryness
and benign transient neonatal skin dermatoses (Table 1). Group
B has higher infection than group A at the third and
fourth weeks (Table 2). As for neonatal skin diseases, there
Figure 1 Perianal dermatitis before treatment was a significant difference between the two groups in diaper
area rashes, which was the most common skin disease in neo-
nates (57.1% in neonates without care and 11.4% in neonates
with care) (Table 3). With respect to follow-up of the diaper area
rashes with treatment, there was a significant difference in
improvement with treatment of the diaper area rashes between
neonates without care and neonates with care with a P
value = 0.018 (Table 4).

Discussion
To our knowledge, this study is the first study in Egypt that
highlights the role of neonatal skin care in promotion of normal
skin development and function that was achieved by the possi-
bility of avoiding the different neonatal skin disorders. The skin
care regimen includes bathing, emollient, cord care, scalp care,
and prevention and treatment of diaper dermatitis. The care
products used are safe for neonates.
Figure 2 Perianal dermatitis after treatment
This study found that the skin condition improved with care,
free baby wipes, and expose nappy area as often as possible and this was in concordance with a study in the United States.8
and consider using a thin layer of barrier ointment or cream
with nappy change.
• Mothers were instructed to care for the neonatal intertrigo by Table 1 Erythema clinical examination
keeping it clean and dry.
• A colorful and informative booklet had also been designed for Group B Group A
the mothers, which clarify the instructions about the care of
neonatal skin and the benign transient neonatal skin disorders No % No % X2 P

for reassurance of the parents (Figs. 1 and 2). 1st week

Not present 23 65.7 24 68.6 0.06 0.79 (NS)
Skin assessment Present 12 34.3 11 31.4
Mothers visual skin assessment questionnaire This 2nd week
Not present 25 71.4 26 74.3 0.07 0.78 (NS)
questionnaire evaluated the neonatal skin for erythema and
Present 10 28.6 9 25.7
dryness (is it present or not?). 3rd week
Not present 21 60 31 88.6 7.48 0.006 (S)
Clinical examination for skin assessment It evaluated the Present 14 40 4 11.4
neonatal skin for appearance of erythema, dryness, and 4th week
Not present 26 74.3 34 97.1 7.47 0.006 (S)
infection or any skin disorders or adverse effects on weekly
Present 9 25.7 1 2.9
basis.

ª 2017 The International Society of Dermatology International Journal of Dermatology 2017

4 Pharmacology and therapeutics Neonatal skin care Amer et al.

Table 2 Infection clinical examination in concordance with a study done by Larkowski, et al.7 They
found that erythema decreased with care from 0.31  0.54 at
Group B Group A the baseline to 0.24  0.43 at weeks 4–6. This difference in
the percentage was due to general skin care in the present
No % No % X2 P
study versus assessment of the tolerance of a baby cleanser
1st week and lotion (both lightly fragranced) on healthy, full-term neo-
Not present 35 100 35 100 0 1 (NS) nates and different methods of statistical analysis in their
Present 0 0 0 0 study.
2nd week
Our skin assessment of dryness indicated that no significant
Not present 32 91.4 35 100 1.39 0.23 (NS)
differences were found between the two groups and this
Present 3 8.6 0 0
3rd week because of the high rate of moisturizer use in both groups.
Not present 28 80 34 97.1 5.01 0.025 (S) Although no significant differences were detected, we could not
Present 7 20 1 2.9 deny the role of emollient in protecting the neonatal skin as
4th week
noted by the decreased percentage of dryness in both groups.
Not present 30 85.7 35 100 5.31 0.021 (S)
This was in concordance with multiple studies.7,9–12
Present 5 14.3 0 0
Given the naturalistic setting of this study, mothers’ assess-
ments provided a real-world perspective on the effectiveness of
Table 3 Neonatal skin diseases the skin care regimen, which we believe is a unique aspect of
this study. In our study, mothers’ assessments for neonates’
Group B Group A skin indicated a significant difference between the two groups
with regard to erythema with a significant improvement in ery-
No % No % X2 P thema in group A (with care) as erythema decreased from
28.6% in the first week to 2.9% in the fourth week. Also, moth-
Diaper area rash 20 57.1 4 11.4 16.2 0.000 (HS)
Heat rash (miliaria) 2 5.7 1 2.9 0 1 (NS) ers’ assessments for neonates’ skin indicated no significant dif-
Omphalitis 2 5.7 0 0 0.51 0.47 (NS) ference between the two groups with regard to dryness. This is
Eczema 2 5.7 0 0 0.51 0.47 (NS) in concordance with our skin assessments.
Oral thrush 2 5.7 0 0 0.57 0.47 (NS) This study found that erythema toxicum neonatorum (ETN)
Others 3 8.6 0 0 1.39 0.23 (NS)
was the most transient neonatal skin disorder with a prevalence
of 22.9% in both groups, and this is in concordance with pre-
vious studies.13–15
Table 4 Follow-up of diaper rash with treatment
It was also noticed that neonatal skin care improves ETN
and decreases its recurrence, and this is in concordance with a
Group B Group A
study by Bernhofer, et al.16 They found that IL-1 receptor antag-
No % No % onist (IL-1ra) and IL-1a ratio decreases with caring for the skin
using a mild cleanser, and this ratio increases in irritant diaper
Improvement within 3–5 days 5 25 4 100
dermatitis, heat rash, and ETN, thus reduction of this ratio indi-
Improvement within 7–14 days 10 50 0 0
cates decreasing of ETN.
Improvement after >14 days 5 25 0 0
X2 = 8 As for neonatal skin diseases, our study found significant dif-
P = 0.018 ferences between the two groups when it comes to rashes in
the diaper area with high prevalence in group B. Therefore,
diaper area care is effective in preventing and decreasing
They found that the skin condition improved in full-term babies rashes in the diaper area, and this is in concordance with a
with evidence-based guidelines (AWHONN/NANN guidelines) study by Borkowski17 and different from Atherton.18
that assessed 10 aspects of neonatal skin care (assessment, Borkowski (2004) found that effective care of the nappy area
bathing, emollients, adhesives, disinfectants, control of TEWL, resulted in the maintenance of skin integrity and prevention of
prevention and treatment of skin breakdown, diaper dermatitis damage to the stratum corneum; thus, reduced the incidence of
cord care, and circumcision care). nappy rash.17
The skin assessments of erythema and infection for the two Atherton (2004) found that diaper rash occurs regularly,
groups in the present study indicated that neonatal skin care although overall incidences and severities have declined.18
has an important role in decreasing erythema and infection, The number of neonates with rashes in the diaper area in
leading to better neonatal skin. group (A) was four; all were of irritant diaper dermatitis and
It was also noticed that erythema decreased from 31.4% in improved with treatment by zinc oxide and olive oil as ointment
the first week to 2.9% in the fourth week in group A, and this or cream for 3–5 days.

International Journal of Dermatology 2017 ª 2017 The International Society of Dermatology

Amer et al. Neonatal skin care Pharmacology and therapeutics 5

Figure 3 Napkin dermatitis before treatment Figure 4 Napkin dermatitis after treatment

follow the instructions of the care. Also, we faced great chal-

The number of neonates with diaper area rashes in group B lenges to change the false habits that are related to culture and
was 20 neonates; 12 of them had irritant diaper dermatitis and beliefs (Figs. 3 and 4)
perianal dermatitis, and they were treated with zinc oxide and
olive oil as ointment or cream and sometimes needed mild corti-
Summary
costeroid topically. Candida dermatitis was observed in seven
neonates either from the start or on top of diaper dermatitis; In summary, the study proves that taking care of infant skin is
they were treated with topical antifungal for candida dermatitis very essential to infants’ overall health. Group A, neonates with
or mixed antifungal with mild corticosteroid for candida on top of care, showed significantly better results than group B, neonates
diaper dermatitis with zinc oxide and olive oil as ointment or without care, in all skin examinations except for dryness and
cream. In one neonate, the rash was due to seborrheic dermati- benign transient neonatal skin dermatoses, where there was no
tis, which was extensive and associated with candida, and was significant difference between the two groups.
treated with topical antifungal for candidiasis and then mild corti- As proven in erythema as well as in the infection examina-
costeroid topically after treatment of fungal infection. tions, group A who underwent the care was significantly better
Some of them improved within 3–5 days, and the others took than group B in the third and fourth weeks.
longer time to improve; 5 cases improved within 3–5 days of As for ETN, group A showed better result. There was a sig-
treatment, 10 cases improved within 7–14 days, and 5 cases nificant difference between the first week (25.7%) and the
took more than 14 days to improve. fourth week (0%) in group A (P value < 0.001) and nonsignifi-
The significant difference in the period of treatment was cant differences between the first week (17.1%) and the fourth
mostly due to some bad habits and mothers’ false beliefs like week (8.6%) in group B (P value 0.25).
using the baby powder that led to increased inflammation and As for neonatal skin diseases, diaper area rash is the most
delays in healing. This conclusion is in concordance with a common skin disease in neonates; group A achieved signifi-
study by Yayla and Bilge which found that powder usage is a cantly better results than group B, 57.1% in neonates without
great obstacle in avoiding diaper dermatitis. He recommended care and 11.4% in neonates with care.
that the powder usage habit has to be prevented.19 Also, there was a significant difference in improvement with
The only adverse effect of this study is a case of miliaria treatment of diaper area rash between neonates without care
using emollient, and this was because the mother turned on the and neonates with care with a P value = 0.018.
heater all night, which turns the atmosphere hot and humid, and
this conclusion is in agreement with a study by Rocha et al.,
Conclusion
which found that emollient may cause acne, folliculitis, prickly
heat, and also aggravate pruritus when used in extremely hot Proper care and good hygiene of normal mature neonatal skin
and humid areas.20 are essential to maintain skin barrier function and overall health.
The present study also had limitations; it was short in dura- This is achieved by optimizing epidermal barrier integrity, includ-
tion (≤1 month) and did not evaluate long-term efficacy of the ing bathing and using emollient, preventing and managing infec-
skin care on the neonatal health. It was also done in winter sea- tions and skin injury, and minimizing TEWL and heat loss or
son, so we found great difficulties to persuade the mothers to percutaneous absorption of toxins.

ª 2017 The International Society of Dermatology International Journal of Dermatology 2017

6 Pharmacology and therapeutics Neonatal skin care Amer et al.

The baby wash products are safe to use and do not appear knowledge and skin care practices. J Obstet Gynecol Neonatal
to affect an infant’s skin barrier integrity, and baby wipes are Nurs 2001; 30: 30–40.
9 Telofski LS, Morello AP III, Mack MC, et al. The infant skin
also safe to use. It is therefore sensible to use cleansers that
barrier: can we preserve, protect and enhance the barrier?
have been specially designed for a baby’s skin, that are pH Dermatology Research and Practice 2012; 198789: 18.
neutral and very mild to avoid irritant dermatitis and allergic der- 10 Rendell ME, Shahana F, Baig-Lewis A, et al., Do early skin care
matitis. practices alter the risk of atopic dermatitis? A case-control
Parents should be advised never to use cleansing products study. Pediatr Dermatol 2011; 28: 593–595.
11 Garcia Bartels N, Scheufele R, Prosch F, et al. Effect of
that are specifically manufactured for adults, as many of these
standardized skin care regimens on neonatal skin barrier
are not pH neutral and will not be mild enough for a sensitive function in different body areas. Pediatr Dermatol 2010; 27: 1–8.
baby’s skin. 12 Bettzuege-Pfaff BI, Melzer A. (2005): “Treating dry skin and
Similarly, choosing the right type of oil for emollients is impor- pruritus with a bath oil containing soya oil and lauromacrogols”.
tant. Mineral oil improves the skin barrier and makes it more Curr Med Res Opin 2005; 21: 1735–1739.
13 Osburn K, Schosser RH, Everett MA. Congenital pigmented and
stable and not subject to oxidation and hydrolysis.
vascular lesions in newborn infants. J Am Acad Dermatol 1987;
16: 788–792.
14 Liu C, Feng J, Qu R, et al. Epidemiologic study of the
References
predisposing factors in erythema toxicum neonatorum.
1 Ness MJ, Davis DM, Carey WA. Neonatal skin care: a concise Dermatology 2005; 210: 269–272.
15 Ekiz O, € Gu € Mollamahmutog
€l U, lu L, et al. Skin findings in
review. Int J Dermatol 2013; 52: 14–22.
2 Sarkar R, Basu S, Agrawal RK, et al. Skin care for the newborn. newborns and their relationship with maternal factors:
Indian Pediatr 2010; 47: 593–598. observational research. Ann Dermatol 2013; 25: 1–4.
3 Sarkar R. Care of the skin. In: Gupta P, ed. Essential pediatric 16 Bernhofer LP, Barkovic S, Appa Y, et al. IL-1a and IL-1ra
nursing. New Delhi: CBS Publishers and Distributors, 2007: secretion from epidermal equivalents and the prediction of the
217–226. irritation potential of mild soap and surfactant-based consumer
4 O’Connor NR, McLaughlin MR, Ham P. Newborn skin: Part I. products. Toxicol In Vitro 1999; 13: 231–239.
Common rashes. Am am Physician 2008; 77: 47–52. 17 Borkowski S. Diaper rash care and management. Pediatric Nurs
5 Catherine D, Coret CC, Michael MS, et al. Tolerance of natural 2004; 30: 467–470.
baby skin-care products on healthy, full-term infants and 18 Atherton DJ, Gennery AR, Cant AJ. The Neonate. Rook’s
toddlers, Clin Cosmet Investig Dermatol 2014; 7: 51–58. Textbook of Dermatology, 7th edn. Burns T, Breathnach S, Cox
6 Brandon DH, Coe K, Hudson-Barr D, et al. Effectiveness of no- N, Griffiths , eds. Oxford: Blackwell Publ, 2004; 14:1–14:14.86.
sting skin protectant and aquaphor on water loss and skin 19 Yayla ME, Bilge U. Diaper dermatitis coping methods in primary
integrity in premature infants. J Perinatol 2010; 30: 414–419. care, patients’ beliefs and habits. PARIPEX - Indian Journal of
7 Larkowski LE, Tiemey NK, Horowitz P. Tolerance of skin care Research 2013; 2: 8.
regimen in healthy, full-term neonates. Clin Cosmet Investig 20 Rocha N, Horta M, Selores M. Terape ^utica to
pica em
Dermatol 2013; 6: 137–144. dermatologia pedia trica. Nascer e Crescer 2004; 13: 215–225.
8 Lund C, Kuller J, Lane A, et al., Neonatal skin care: evaluation
of the AWHONN/NANN research-based practice project on

International Journal of Dermatology 2017 ª 2017 The International Society of Dermatology