It has been suggested that, with the rising prevalence of atopic eczema in the UK population, information given to parents about what to be concerned about and when to seek medical advice is imperative (Cooke et al, 2018).
This article explores the evidence on general skincare from the newborn period to the treatment and management of common skin conditions, including atopic eczema and seborrheic dermatitis.
Infant skin
Skin is a dynamic organ that performs several functions (Oranges et al, 2015). The skin has three layers: the epidermis, the dermis and the hypodermis. The main function of the epidermis is to act as a barrier to prevent penetration of external irritants and to protect against water loss (Cooke, 2015a). The maturation process of the skin starts after the baby is born and continues to the end of the infant's first year (Telofski, 2012; Oranges et al, 2015). Infants have a higher skin turnover than adult (Stamatas et al, 2010).
Infant skin differs from adult skin in structure, function and composition (Telofski et al, 2012), and the infant epidermis is 20% thinner than that of adults (Stamatas et al, 2010). Babies are born covered in vernix, which acts as a natural moisturiser protecting against infection (NHS, 2021).
The top layer of a newborn's skin is very thin and easily damaged (NHS, 2021). If a baby is born past their due date their skin may be dry and cracked due to the vernix being absorbed in the womb (NHS, 2021).
Dry skin
Prevention and prompt treatment of skin problems in newborns are essential for preventing further issues (Yonezawa and Haruna, 2019). It is important to understand that dry skin in children is very common (Van Onselen, 2017) and that dry skin in the first 3–4 weeks following birth is normal and should resolve without treatment (Cooke, 2018).
Newborn babies should be bathed in plain water for the first month (NHS, 2021). If dry skin persists after 4 weeks, medical assessment should be completed (Cooke, 2018). Newborn skin is fragile and susceptible to infections, with the potential for heat loss and damage (Oranges et al, 2015). In infants with normal skin, parents should be advised to cleanse with plain water as there is a lack of evidence base on the use of creams and ointments in infants. More studies are needed to determine whether there are long-term benefits of emollients on healthy full term neonates and infants (Telofski et al, 2012).
In babies with mildly dry skin, parents should be encouraged to choose a product that will not interfere with the skin surface pH, perturb the skin barrier or cause irritation to the skin or the eyes (Blume-Peytavi et al, 2009; Telofski et al, 2012).
In a systematic review, Cooke et al (2018) found strong evidence that practitioners should avoid recommending olive and sunflower oil for the management of dry skin in healthy infants. There have been some suggestions that topical oil on babies' skin may contribute to atopic eczema; in some small studies, the use of olive and sunflower oils was found to alter the lipid structure of the skin barrier and exacerbate existing dermatitis (Danby et al, 2013; Cooke et al, 2015; Van Onselen, 2017).
There is an unfounded belief that oils are natural and safe, but health professionals should be cautious about recommending topical oils for infant dry skin as they have not been tested in clinical trials and the evidence base is mixed (Cooke, 2018). Regular application of emollients can be considered with caution in infants at high risk of atopic dermatitis (Oranges et al, 2015). However, a large UK study of 1303 exclusively breastfed infants found that regular applications of moisturisers to the skin of young infants could promote the development of food allergy through transcutaneous sensitisation.
The authors identified the need for further research to determine whether the moisturisers facilitate food and aeroallergen uptake or whether moisturisers become contaminated by the allergens in the home and on hands. It is also unknown whether the effects are limited to some moisturisers depending on ingredients. In the interim, they recommend ensuring that before moisturisers are applied, hands should be washed thoroughly and careful consideration given to the frequency of moisturiser application and the type used (Perkin et al, 2021).
‘In infants with normal skin, parents should be advised to cleanse with plain water as there is a lack of evidence base on the use of creams and ointments in infants’
A thorough assessment and consideration of the evidence should be made before recommendations are given in infants with normal skin. In the treatment of dry skin, emollients are the firstline of therapy for all dry skin conditions (Van Onselen, 2017).
‘Seborrhoeic dermatitis is a common inflammatory skin condition occurring in areas rich in sebaceous glands. In infants, the scalp is most frequently affected and this is often called ‘cradle cap’’
Emollients treat dry skin by providing a surface film of lipids that increase water to the statum coreum, soften the skin, reduce itch and maintain skin hydration (Van Onselen, 2017). Every infant and child should be treated individually and personalised plans should be implemented (Royal College of Paediatrics and Child Health, 2011). However, if the infant is diagnosed with atopic eczema, treatment should be commenced.
Atopic eczema
Atopic eczema is a chronic, inflammatory condition that affects people of all ages (National Institute for Health and Care Excellence (NICE), 2022). It can cause the skin to become itchy, dry and cracked. ‘Atopic’ means sensitivity to allergens (NHS, 2019). Atopic eczema has no single cause but is a complex condition that involves genetic, immunologic and environmental factors (NICE, 2022).
Atopic eczema occurs most frequently in childhood with 70–90% of cases occurring before the age of 5 years and affecting 10–30% of children (NICE, 2022).
Eczema can cause infection and psychological problems so prompt management and maintenance is essential (NICE, 2022). Health professionals should be also be aware that in Asian, Caribbean and black African children, atopic eczema may present differently, causing skin darkening as opposed to skin reddening, and affecting the exterior surfaces rather than the flexures (RCPCH, 2011).
Management first involves identifying and removing any triggers. A review of the diet, washing powder, soap and cleaning products should be completed and any possible triggers identified (NICE, 2022). Certain factors aggravate eczema symptoms, such as food, dust mites, pollens, soap, bubble bath, detergents, shampoos, synthetic and wool clothing, and fragrances (RCPCH, 2011).
Plain emollients should be used as those containing active ingredients may increase the risk of skin reactions. Creams and lotions can be used for red and inflamed skin, and ointments for dry skin. Several emollients may be needed for different skin in different locations on the body and with different stages of flare-up.
A pump dispenser is preferable to reduce bacterial contamination and hands should always be washed before application. Emollients should be used liberally and applied at least four times a day by smoothing into the skin along the line of the hair growth.
A range of emollients should be trialled to find the one that manages the eczema most effectively. It is important to advise that emollients containing paraffin are a fire hazard as the product can build up on clothes and bedding. Therefore, parents should be advised to wash clothes and bedding regularly at a high temperature to reduce emollient build-up and avoid smoking or naked flames near bedding and clothing (NICE, 2022).
Corticosteroids can be considered if the skin is red and inflamed. The lowest dose possible should be used for a short period of time with regular reviews, and should be applied at least 15–30 minutes after the application of emollient (NICE, 2022). For severe and persistent itch, a 1-month trial of an antihistamine can be considered (NICE, 2022).
Support and signposting should be offered to all families. Resources from the British Association of Dermatologists (www.bad.org.uk) or the National Eczema Society (https://eczema.org) can be shared to help support and inform families on management and treatment options (NICE, 2022).
‘A thorough assessment and consideration of the evidence should be made before recommendations are advised in infants with normal skin’
A referral to dermatology should be considered if (NICE, 2022):
- The diagnosis is uncertain
- Current management has not controlled the eczema satisfactorily
- Facial treatment has not responded to treatment
- Allergic dermatitis is suspected
- There is recurrent secondary infection
- The eczema is causing significant social or psychological problems.
Seborrhoeic dermatitis
Seborrhoeic dermatitis is a common inflammatory skin condition occurring in areas rich in sebaceous glands. In infants, the scalp is most frequently affected and this is often called ‘cradle cap’ (NICE, 2022a).
The exact cause is not fully understood and many factors have been associated with its development (NICE, 2022a). Infant seborrheic dermatitis usually resolves by 4 months of age, but treatment can be considered, involving softening the scales with an emollient and then gently brushing the area to loosen the scales, washing the hair with baby shampoo (NICE, 2022). If this is not effective, imidazole cream can be used. If symptoms persist longer than 4 weeks, specialist advice should be sought, and topical corticosteroids are not advised (NICE, 2022a).
Conclusion
Dry skin, atopic eczema and seborrheic dermatitis are common and it is important for health professionals in primary care settings to consider the evidence base for treatments and advice in order to support families with these conditions.