Journal of Neonatology Vol. 22, No. 1, Jan. - Mar.
2008
REVIEW ARTICLE
Care of neonatal and preterm skin. How is it different?
Anu Gulati, Sushma Nangia
Division of Neonatology, Department of Pediatrics, Kalawati Saran Children’s Hospital & Lady Harding Medical College,
New Delhi - 110 001
drsnangia@yahoo.com
Abstract
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Skin is a complex structure with unusual functional
diversity. It forms a critical physical barrier that not only
protects the body but also maintains fluid homeostasis. In
addition, it regulates temperature as well as sensation1. The
skin of preterm infants is immature and ineffective as an
epidermal barrier. Poor epidermal barrier function leads to
significant disturbances in temperature regulation, water
balance and increased propensity for infections. The preterm
skin with its inherent poor microbial defense and its
denudation during care multiply the possibilities of microbial
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invasion and sepsis in this vulnerable population.
Topical agents are more rapidly absorbed into infant skin
due to deficient intercellular bridges as well as greater body
surface area to weight ratio. These inadequacies in its overall
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functioning need to be kept in mind while managing small
neonates in the high-tech neonatal intensive care units.
Introduction
Despite measurable success in decreasing childhood
mortality rates, infant mortality rates remain essentially
unchanged. Approximately 11,000 babies die each day of
prematurity and infection worldwide1,2. The survival and
long-term outcomes of these preterm infants are directly
proportional to their maturity and weight at birth. Preterm
infants account for 74% of neonatal deaths and those born
before 28 weeks of gestation account for 50% of neonatal
deaths1,2. This vulnerable population possesses an absent or
incompetent epidermal barrier1,2. Such infants have problems
with temperature control and infection and an increased
likelihood of damage from adhesives and superficial trauma.
The role of the skin in innate immunity includes serving as
both a physical barrier and as a repository of antimicrobial
proteins that permits a homeostatic balance between the
presence of commensal bacteria and the deterrence of
pathogenic microbial invasion 4,5,6 . Recent studies
demonstrate that simple skin care practices, such as topical
oil application and/or massage, significantly reduce infection
rates in preterm infants in developing countries by
mechanisms that are not completely understood3. A better
understanding of the ontogeny of the epidermal barrier is
critical to developing evidence-based guidelines for infant
and neonatal skin care practices.
5
The structure of the skin
Human skin has two distinct but interdependent
components: the epidermis and the dermis. The bulk of the
human skin is composed of the dermis and consists of
collagen and elastic fibres embedded in a hydrated matrix
of glycosaminoglycans. Blood vessels and the majority of
cutaneous nerve endings are present in the dermis. The cells
of the dermis and subcutaneous fat derive from the
embryonic mesoderm. In contrast, epidermal appendages,
such as hair follicles, sweat glands, and sebaceous glands,
as well as the interfollicular epidermis derive from embryonic
ectoderm. Intermixed is a third distinct cell type, the
Langerhans cell, which is derived from bone marrow
precursors and migrates into the primitive epidermis1.
The epidermis has marked regional variation in thickness,
colour, permeability, and surface chemical components. It
consists of a highly ordered compact layering of
keratinocytes and melanocytes. Traditionally, the epidermis
is segmented into four distinct structural and functional
compartments called the stratum genminativum (basale),
responsible for keratinocyte proliferation and epidermal
renewal, stratum spinosum, consisting of tightly packed
keratinocytes linked via desmosomal connections, the
stratum granulosum, responsible for barrier lipid synthesis
and corneocyte production via programmed cell death, and
the stratum corneum, the anucleated outermost layer, which
forms the physical interface with the environment. The
stratum corneum is markedly deficient in preterm human
infants2,12.
The physiologic development of the epidermis
The process of cutaneous morphogenesis can be divided
into embryonic and fetal periods. During the embryonic
period the skin (embryonic skin) consists of a two layered
epidermis, the basal layer (associated with the basal lamina)
and the periderm which serves as a cover and a presumptive
nutritional interface with the amniotic fluid. The basal layer
includes cells that give rise to the future definitive epidermis,
and the periderm is a transient layer that covers the embryo
and the fetus until the epidermis keratinizes at the end of the
second trimester12.
At the time of embryo to fetus transition the epidermis
begins to stratify, forming an intermediate layer of cells. Two
to three additional layers of intermediate cells are added
during the second trimester. These cells show a progressive
 Journal of Neonatology
increase in the number of keratin filaments but do not further
differentiate until the onset of keratinization in the inter-
appendageal epidermis around 22-24 weeks gestation. The
stratum corneum becomes multilayered during the third
trimester. However, it represents a less effective barrier than
adult stratum corneum1.
Preterm birth triggers immediate lipid and DNA synthesis,
with subsequent cornification of the nucleated epidermal
keratinocytes. This rapid transition in comparison to the slow
intrauterine rate of epidermal barrier maturation leads to
poor stratum corneum in these vulnerable preterm infants
even at four weeks of postnatal age.
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Multiple physiologic roles of the epidermis
post birth
Physiologic mechanisms in the epidermis that contribute
to the formation of an adaptive environmental interface
include activation of eccrine sweating, sebum production
and rapid development of an acid mantle. Physiologically,
the epidermis and its ultimate differentiation product, the
stratum corneum, remain in balance by the dual properties
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of renewability and self cleaning, which reflect the distinct
but tightly coupled process of cornefication and
desquamation.
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All these together subserve the functions of
• Barrier to water loss
• Thermoregulation
• Infection control
• Immuno-surveillance
• Acid mantle formation
• Anti-oxidant function
• UV light photo-protection
• Barrier to chemicals
• Tactile discrimination and
• Attraction to caregiver
The preterm infant is vulnerable to disruption of all these
physiologic mechanisms.
Why preterm babies need special care?
The structure and functions of the skin depends on whether
a child is born at term or prematurely. Skin care needed for
the babies is related to gestational age. Problems related to
the epidermal barrier are particularly acute in the very low-
birth weight (VLBW) population. Neonatal skin is different
from adult skin in more ways than one. It is the largest organ
of the premature infant’s body making up 13% of total body
weight, versus 3% in the adult accentuating the issues related
to large surface area and a high surface area to body weight
ratio1,2. In addition, an exponential relationship exists between
trans-epidermal water loss (TEWL) and gestational age, it
being 15 times higher in infants born at 25 weeks of gestation
than in full-term infants3,4.
Preterm infant’s skin is extremely vulnerable to detrimental
effects of the environment, as their epithelial barrier which
provides first line host defense, lacks the naturally protective
6
Vol. 22, No. 1, Jan. - Mar. 2008
cutaneous biofilm, vernix, and is developmentally immature,
easily injured and functionally compromised for several
weeks following birth20. The first week of life, when epithelial
barrier function is most highly compromised, is the neonate’s
most vulnerable period when 50-70% of fatal and life
threatening neonatal illnesses occur21.
Skin care practices affecting VLBW infants include
bathing/cleansing, thermoregulation, acid mantle formation,
blood drawing, care of central venous catheters, and use of
adhesive tapes. The scientific basis for such practices is
grounded in an understanding of the biochemistry and
development of the epidermal barrier7.
Practices to optimize the epidermal barrier
integrity
1. Prevention of skin barrier disruption: The skin barrier
disruption can occur by many caregiving activities
including blood sampling, placement of intravenous lines,
adhesive application and its removal as well as tight
tourniquet application and trans-cutaneous probe
application. The use of adhesives should be minimized.
The infant has increased evaporative losses after adhesive
tape removal. Adhesives become more aggressive over
time8. Skin stripping and tearing as well as chemical
irritation is seen with the use of bonding agents. Preventing
skin injury is a nursing art and can be achieved by limiting
the use of circumferential dressings, use of pectin barriers
or semi permeable barrier like tegaderm under adhesive
and use of hydrogel or karaya electrode leads (Fig. 1.1).
Even while fixing the endotracheal tube, umbilical
catheters and temperature probes tegaderm should be
applied before adhesives like dynaplast are applied to
secure the same. The adhesives should be removed gently
after application of cotton balls soaked with sterile water.
Adhesive tape removal is the primary risk factor for
traumatic injury to the newborn. Ulcerative erosions are
often associated with systemic bacterial or Candida sepsis,
with areas of skin breakdown as the portal of entry. Early
recognition of skin breakdown and identification of the
pathogen with a Gram stain can be essential elements in
the reduction in mortality9. After procedures like lumber
punctures tincture of benzoin should not be used.
Emollients prevent desquamation of the stratum corneum,
the outer layer of cells that form the epidermal barrier.
Aquaphor ointment can be used on an “as-needed” basis
to treat dryness and prevent cracking of skin. Prevention
of excoriation is seen with the use of Aquaphor ointment
on the groin and thighs. There may be a possible increase
in coagulase negative staph (CONS) infection in infants <
750 g with the routine topical application of Aquaphor
ointment10. Aquaphor must be applied every 6 hours to
be effective in reducing TEWL.
2. Prevention of thermal and pressure injuries: Visible
light phototherapy is an easily administered and effective
treatment for neonatal indirect hyperbilirubinemia.
Reported cutaneous side effects include transient rashes
and the uncommon bronze baby syndrome. A more
hazardous side effect is ultraviolet burn11. Premature
 Journal of Neonatology
infants, especially during the first two weeks of life, may
be significantly susceptible to UVA-Induced erythema.
Plexiglass shields when available should always be used
during visible light phototherapy. Moreover the
phototherapy units should always be placed at
recommended and safe distance. Clear transparent
dressings should be applied to high friction areas and
specialized mattresses should be utilized in critically ill
babies.
Tissue irritation and pressure necrosis of the nasal septum
related to the use of nasal continuous positive airway pressure
(NCPAP) has been discussed among nurses and other
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professionals and also described in the literature. Clinically,
there are morbidities associated with nasal skin breakdown
that include infection, scarring, reintubation, and prolonged
time of intubation (Fig. 1.2). There is no published research,
however, that evaluates the effect of specific nursing practice
on preventing or reducing breakdown due to nasal prongs.
Key elements related to NCPAP12 and skin care are:
1. Use of appropriate sized prongs to make an effective seal
for the transmission of pressure
2. Avoidance of pressure on the nares to create a seal
3. Suction and inspection of the skin every 4 hours
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4. Gentle massage of the skin with each inspection
5. Access to and use of equipment manual to understand
and utilize practices related to securing the device
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3. Use of skin disinfectants: Isopropyl alcohol’s use as a
skin disinfectant has been associated with tissue damage
in newborn infants14. Povidone iodine is more efficacious
than isopropyl alcohol13 as a disinfectant, but povidone
iodine can be absorbed systemically and alterations in
newborn thyroid function can result15. This disinfectant
can also cause skin irritation and tissue damage, as seen
in the picture below (Fig. 1.3). Efficacy of chlorhexidine
(CHG) in reducing infection has been demonstrated in
adults and newborns16,17. Skin damage specific to CHG
has not been noted clinically. Both safety and efficacy of
a product are important considerations in choosing an
antiseptic for clinical use. For neonates, isopropyl alcohol
or products containing isopropyl alcohol are not
recommended in the skin care guideline. Povidone iodine
or CHG solutions are recommended but require complete
removal after the procedure with sterile water or saline to
prevent absorption.
4. Minimizing trans-epidermal water loss: Human body
loses water to the environment through the skin and the
respiratory passage i.e. by insensible water loss (IWL g/
hr). This water loss is an important factor for water balance
and body temperature regulation. IWL consists partly of
the total cutaneous water loss (CWL g/hr) and partly of
water loss through the respiratory passages. CWL
comprises about 75% of IWL. The cutaneous evaporative
water loss is usually expressed per unit area and is then
called transepidermal water loss (TEWL; g/m2/h)18. The
stratum corneum which is the outermost 20 microns of
the skin surface, functions as the barrier between the
environment and the individual and determines the degree
of trans-epidermal water loss and heat loss. Several studies
have demonstrated that prematurity and postnatal age
are factors of major significance that determine epidermal
7
Vol. 22, No. 1, Jan. - Mar. 2008
permeability. Epidermal permeability is inversely related
to gestational maturity, the more preterm the neonate
higher is the TEWL. It is highest in the premature infant
immediately after birth. With increasing postnatal age the
epidermal barrier matures and the TEWL decreases. The
difference in cutaneous permeability between premature
infants and term infants decreases with each postnatal
day. At 2 weeks after birth, however, the epidermal barrier
of the infant with very low birth weight still has markedly
increased trans-epidermal water loss compared with
infants born at the same corrected gestational age. By
about 4 weeks of age the differences are no more
appreciable19. The various strategies utilized to improve
epithelial barrier function and thereby reduce the heat &
transepidermal water loss, conserve calories & improve
growth and possibly reduce infection have been as
follows:
1. Nursing neonates in humid conditions:
This modality was tried but went out of vogue due to
reports of increased infection and enhanced morbidity.
2. Using transparent plastic coverings on neonates and/
or their bassinets:
Thin plastic blanket may be effective in reducing
evaporative water loss by diminishing an infant’s
exposure to convective air currents while being nursed
on an open radiant warmer bed. The occlusive wrap
must be made of polyethylene rather than
polyurethane because only polyethylene transmits the
long wavelength energy of radiant heat22. A clinical
trial done using occlusive wrapping with polyethylene
at birth without drying found that it reduced postnatal
fall in temperature of very immature infants by
reducing evaporative and convective heat loss and
was more effective as compared to conventional
drying and exposure. After stratified analysis it was
seen to be more effective in 23-27 weeks of gestation.23
Another randomized trial done using a thin plastic
film made of food grade plastic to cover the bassinet
of the neonate during the first week of life reported
reduced heat loss and decreased episodes as well as
degree of hypothermia in neonates nursed under this
thin film as compared to the control group24.
3. Application of occlusive dressings:
Another strategy for minimizing TEWL is covering the
exposed surface of immature skin with semi occlusive
polyurethane dressing, tegaderm and opsite25,26. In
early studies it was found that compared to the
adjacent skin which was not dressed with artificial
polyurethane, the skin where thin semi permeable
polyurethane was adherently applied, the TEWL during
day 1-4 was reduced by 30-50% without inhibiting
natural infant skin development27.
4. Application of Topical emollients:
Topical therapy maybe an effective strategy for
enhancing epidermal barrier function and improving
neonatal outcomes in developing countries,
particularly among preterm infants weighing 1000
gm to 1500 gm whose barrier is temporarily, but
critically compromised due to immaturity and possibly
compounded by malnutrition. Topical ointment
therapy may enhance epidermal barrier function by
 Journal of Neonatology Vol. 22, No. 1, Jan. - Mar. 2008

protecting the stratum corneum, leading to improved
skin integrity, decreased trans-epidermal water losses
and less risk of nosocomial infection28. It has been
postulated that breakdown of the already
developmentally compromised epidermal barrier of
the preterm infant may further exaggerate the TEWL
and that the application of an emollient ointment may
serve as a protective barrier that enhances skin integrity
and epidermal maturation. Besides the ability of the
oils to act as a mechanical and semi-permeable barrier,
highly active lipid metabolism in the epidermis and
the presence of a fatty acid transporter on
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skin. The authors suggested that topical application
of linoleate-enriched oil such as sunflower seed oil
might enhance skin barrier function and improve
outcome in neonates with compromised barrier
function13,31. A recent randomized controlled trial
conducted in preterm VLBW babies using topical
coconut oil application twice a day for the first week
of life reduced the TEWL by as much as 46% (absolute
reduction in TEWL of 6.8 gm /m2 / hr). Such an impact
is expected to be of clinical importance, because it
could reduce initial weight loss, promote better
growth, and reduce fluid requirements32.

keratinocytes make it possible for even the immature
epidermis to metabolize lipids derived from topically
applied oils and to utilize them as nutritional building
blocks for the formation of a healthy functional
epidermal barrier29. Furthermore, a part of these
metabolized and absorbed lipids may get assimilated
and enhance growth.
A number of creams, oils and greases have been
studied for their waterproofing effect on the adult skin
and thereafter have been tried on the neonatal skin.
The creams used have been E 45 cream (a mixture of
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Choice of oil is important, however, since some oils—
e.g., those that contain essential fatty acids, particularly
linoleic acid—increase skin barrier function, whereas
others—e.g., mustard oil, which is used commonly in
traditional oil massage of newborn babies in south
Asia—could be toxic and damage the integrity of the
skin barrier.
Summary

water and paraffin used as a vehicle for other agents
in cosmetology), Oily cream BP (a mixture of water
and paraffin used as an ointment base in cosmetology),
Ung Merck Cream (a complex mixture used as an
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To summarize, Effective care of newborn skin is based on
a thorough understanding of both the physiology and the
environmental milieu of infant skin. The essentials of
newborn skin care are effective cleansing, effective

emollient and a diluent), Natuderm cream (a lipid moisturizing and the maintenance of an effective barrier
containing cream used as an emollient), and Silicone against external irritants. Baby’s protective but delicate cover
barrier cream (a silicone containing mixture used as a needs to be kept in a healthy condition and it should be
water repellant). All these have had beneficial effect disturbed as little as possible.
on the adult skin in various clinical conditions but
when used for reducing water loss they were
ineffective as a group due to the high water content
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