63
C HA PTER   5
Neonatal Skin Care
Peter H. Hoeger
Department of Paediatric Dermatology, Catholic Children’s Hospital Wilhelmstift, Hamburg, Germany
Introduction, 63 Skin care of the premature infant, 66
Skin care of the neonate, 63 Skin care of the term neonate and infant, 67
Abstract
Due to its structural and functional immaturity, the skin of neo-
nates is more susceptible to mechanical damage and chemical
­irritation. Neonatal skin care aims at preventing physical injury,
minimizing transepidermal water loss and avoiding infection.
The  optimal emollient for skin care remains to be determined.
Key points
• Due to its immature epidermal barrier, neonatal skin is highly
sensitive to physical and chemical damage.
• Infants are exposed to many cosmetic ingredients at an early
age.
­Introduction
Due to its structural and functional immaturity, the skin
of full‐term and preterm neonates and infants is different
from that of older children. Epidermal barrier and ther-
moregulatory mechanisms are immature; the skin is thin-
ner and more susceptible to mechanical damage and
chemical irritation; and the skin surface of neonates is
larger (in proportion to their body mass) than in adults.
As outlined in Chapter  4, these structural and develop-
mental differences are associated with decreased epider-
mal concentrations of natural moisturizing factors (NMF)
and increased transepidermal water loss (TEWL) [1,2].
As  a consequence, the skin surface pH is increased and
epidermal proteases are activated [2,3]; both factors
plus  decreased epidermal concentrations of antimicro-
bial lipids [4] facilitate bacterial colonization and trans-
cutaneous infections, particularly in preterm infants.
Furthermore, the immature epidermal barrier allows eas-
ier transcutaneous penetration of allergens and chemi-
cals. In conjunction with the larger skin surface of neonates
this transforms into an increased risk for systemic toxicity
from topically applied substances. Maturation of the bar-
rier takes at least 12 months [1]. It is therefore obvious that
the skin of neonates and young infants requires specific
care in order to avoid damage and, ideally, to compensate
for the immaturity of the epidermal barrier. The questions
if, when and how neonates should receive skin care are
Harper’s Textbook of Pediatric Dermatology, Fourth Edition. Edited by Peter Hoeger, Veronica Kinsler and Albert Yan.
© 2020 John Wiley & Sons Ltd. Published 2020 by John Wiley & Sons Ltd.
SECTION 2: SKIN DISORDERS
OF NEONATES AND INFANTS
Percutaneous absorption, 71
The benefits of emollient care need to be weighed against poten-
tial side‐effects. Anionic detergents such as sodium lauryl ­sulfate
and emollients containing emulsifiers can emulsify s­tratum
­corneum lipids, thus increasing permeability and skin dryness.
Common ­ingredients such as lanolin can cause contact a ­ llergies,
others such as parabenes or triclosan can act as endocrine
­disrupting agents.
• The rate of inadvertent percutaneous absorption of many agents
applied to the skin surface is increased in infants, but largely
unexplored for cosmetic ingredients.
• Commonly used ingredients can lead to contact sensitization.
• These aspects need to be considered for all aspects of skin care in
the neonate and young infant.
however not easily answered as there are very few rand-
omized controlled trials (RCTs) addressing these issues.
In the absence of scientific evidence, many recommenda-
tions are rather based on common sense, traditional prac-
tice or ‘experts’ opinions’, some of which are more or less
openly sponsored by the cosmetic industry.
­References
1 Nikolovski J, Stamatas GN, Kollias N et  al. Barrier function and
water‐holding and transport properties of infant stratum corneum
are different from adult and continue to develop through the first
year of life. J Invest Dermatol 2008;128:1728–36.
2 Chittock J, Cooke A, Lavender T et  al. Development of stratum cor-
neum chymotrypsin‐likeprotease activity and natural moisturizing
factors from birth to 4 weeks of age compared with adults. Br J
Dermatol 2016;175:713–20.
3 Hachem JP, Man MQ, Crumrine D et  al. Sustained serine proteases
activity by prolonged increase in pH leads to degradation of lipid pro-
cessing enzymes and profound alterations of barrier function and stra-
tum corneum integrity. J Invest Dermatol 2005;125:510–20.
4 Drake DR, Brogden KA, Dawson DV et al. Thematic review series: skin
lipids. Antimicrobial lipids at the skin surface. J Lipid Res 2008;49:
4–11.
­Skin care of the neonate
Aims of neonatal skin care
Neonatal skin care aims at:
• minimizing transepidermal water loss
• prevention of physical injury and
• avoiding infections.
 64 Section 2  Skin Disorders of the Neonate and Young Infant
Environmental factors affecting epidermal
integrity
The abrupt switch from 100% humidity within the
­amniotic fluid to the relatively dry ambient atmosphere
represents a maximal challenge to the adaptability of
the  neonatal skin. Various environmental factors can
SECTION 2: SKIN DISORDERS
OF NEONATES AND INFANTS
adversely affect the epidermal integrity and should be
avoided wherever possible (Table 5.1).
Soap and anionic detergents such as sodium lauryl sul-
fate (SLS) lead to an immediate increase of the skin sur-
face pH which in turn activates proteases capable of
disturbing the epidermal barrier. ‘Hard’ tap water which
contains high levels of free calcium is prevalent in many
areas. In these areas, the incidence of atopic dermatitis
(AD) is increased [1]. Hard water can induce skin irrita-
tion [2], particularly so because it requires increased use
of soap. High levels of free calcium have been shown to
inhibit skin barrier repair in vitro [3].
Skin irritation can likewise be induced by too‐frequent
washing, synthetic or inflexible garments causing abra-
sions, or the removal of adhesives [4].
It is well known that disruption of the normal skin
microbiome by antibiotic treatment during the first weeks
of life increases the risk to develop AD [5]. Recent evi-
dence using whole‐metagenome sequencing [6] suggests
that skin bacteria can influence the skin surface microen-
vironment, for instance by production of excessive
amounts of ammonia which adds to the increased skin
surface pH in children with AD.
Skin care immediately after birth
and in the first 2–3 days
Immediately after delivery, the neonate should be
wrapped in a towel and gently rubbed. The baby should
be kept in a room of at least 25–28 °C ambient temperature
and no draught. Any remaining vernix should be left in
place and allowed to dry and peel off naturally [7–9].
Owing to its antimicrobial property and its capacity to
diminish TEWL, vernix would in fact be an ideal emol-
lient for the neonate [10], and there is some evidence that
retention of vernix is associated with better skin hydra-
tion and lower skin surface pH as compared to newborns
whose vernix was removed immediately after birth [10].
However, in case of maternal human immunodeficiency
virus (HIV) or hepatitis B infection, early removal is
advisable due to the risk of transmission of infectious
agents via maternal blood [7].
Table 5.1  Environmental factors exerting negative effects on the epider-
mal barrier
Factor Effect on epidermal barrier
Hard water Hydration of SC↓, skin barrier repair↓
Detergents Skin surface pH↑, activation of proteases
Too‐frequent washing Hydration of SC↓, skin dryness↑
Adhesive plasters Destruction of corneal layer
Synthetic garments Skin irritation
Altered skin flora Formation of ammonia, skin surface pH↑
↑, increase; ↓, decrease; SC stratum corneum.
As bathing can lead to neonatal hypothermia (<36.5 °C),
which in itself carries the risk of intraventricular haemor-
rhage, the first bath should be delayed until the neonate’s
vital signs and body temperature have remained stable
for at least 4–6 hours [7,11,12]. For rewarming after
the  first bath, close skin‐to‐skin contact (under protec-
tive covering) is preferred by most mothers and has been
shown to be safe and effective [13]. In resource‐poor
countries neonatal mortality can be reduced significantly
by postponing the first bath for 72 hours post partum [14].
Blood and meconium should however be gently removed
after birth.
Washing and bathing
Immersion (tub) bathing is not only a means of cleansing,
but also a moment of close tactile interaction between
baby and parent(s). In an RCT comparing sponge and tub
immersion bathing in a cohort of late preterm infants, tub
bathing was shown to significantly improve thermoregu-
lation [15]. The water should cover the infant’s entire
body in order to decrease evaporative heat loss. The opti-
mal water temperature is 37–38 °C. Water temperature
should always be accurately measured before immersion
as tests just by touch have proved inaccurate to avoid
scalds. Since hyperhydration of the epidermis would ren-
der the skin more fragile, the duration of the bath should
be limited to 5–10 minutes every other day [9,16].
Immediately after bathing, the infant’s skin should be
gently towelled and a head covering applied [7]. There is
no evidence that delaying the first bath until the umbilical
cord has separated prevents umbilical cord infection
[8,9,17].
Surfactants in skin cleansers are tensioactive agents
capable of removing fatty substances from the skin sur-
face by emulsifying them into fine droplets, which can
then be rinsed away. Anionic detergents contain mole-
cules with a negatively charged hydrophilic end (e.g.
SLS). They create a foaming effect which is associated
with a cleansing action on the stratum corneum. Cationic
detergents such as quaternary ammonium salts contain
molecules with a positively charged end. Skin cleansing
with soaps leads to alkalization of the skin surface and
can cause irritation [17,18].
Surfactants can emulsify stratum corneum lipids, thus
increasing permeability and dryness of the skin surface
[19]. Detergents should therefore be used cautiously in
neonates, and the skin should be rinsed with water fol-
lowing their use. Although frequently recommended by
various sponsored panels, the evidence in favour of the
use of liquid (or gel) cleansers with or without emollient
is inconclusive. A comparative study in neonates indi-
cated that liquid cleansers plus emollients might lead to
increased TEWL as compared to rinsing with water alone
[20]; opposite results were found in another study [21]. It
is strongly advisable to use only mild, non‐irritating liq-
uid cleansers able to maintain the normal surface pH [17];
in order to minimize their irritation potential, cleansers
should be fragrance‐free and dye‐free and contain the
least possible concentration of preservatives [8]. The same
cleansers can be used for the scalp and hair. Alternatively,

shampoos containing very mild surfactant complexes
and buffers in order to achieve a pH and saline concentra-
tion similar to those of tears have been specifically
designed for infant care [16,22].
Umbilical cord care
The umbilical cord stump dries out and falls off between
5 and 10 days after birth. In countries with poor hygienic
standards, the cord stump represents an important focus
for neonatal infection and mortality. Umbilical cord care
varies widely around the world [23–27]. General recom-
mendations issued by the WHO in 2004 [23] include:
• proper hand hygiene
• cutting the cord with a sterile instrument
• washing the cord stump with clean water or soap.
Several agents formerly recommended for cord care
(isopropyl alcohol, hexachlorophene, neomycin) can have
serious adverse effects and should be avoided [9]. Alcohol
or topical antiseptics delay cord separation by 2 days
[23,24]. Meta‐analyses of controlled studies indicate that
the application of 4% chlorhexidine solution to the umbil-
ical stump is non‐hazardous and can reduce the risk of
omphalitis by up to 50% and of neonatal mortality by 12%
[25–27]. However, in a large randomized study from
France with 8698 participants published in 2017, dry care
of the cord proved non‐inferior to the use of antiseptics
[28]. Both approaches may have their justification; how-
ever, antiseptic prophylaxis may be preferable for deliver-
ies outside a hospital setting and in resource‐limited
populations [29].
There is currently no good evidence favouring full‐
body skin cleansing with chlorhexidine as a prophylactic
skin disinfectant in neonates [26]. The same applies to
maternal vaginal chlorhexidine washes compared to
usual care [26]. Underdeveloped countries with poor
hygienic conditions might nevertheless benefit from these
approaches to reduce neonatal mortality [9]. All antisep-
tic  solutions required for sterile procedures should be
applied only to the immediate skin area and in very small
amounts. They should be removed with water‐soaked
gauze after the procedure to prevent unnecessary absorp-
tion due to prolonged exposure in order to avoid serious
complications [30]. In neonates, alcohol used as a topical
antiseptic is nearly completely absorbed percutaneously
with a potential for systemic toxicity. It is also drying and
painful to abraded skin and can cause skin necrosis [31].
Its use should be completely abandoned in this age group.
Napkin/diaper care
Since permanently moist skin leads to maceration, and
macerated skin is more susceptible to irritation and injury,
napkins should be changed frequently, i.e. every 3–4
hours, at least after each feed. Superabsorbent napkins
are clearly superior to cloth napkins with respect to sur-
face dryness and prevention of napkin dermatitis [32,33]
(Chapter  20). Although water and a wash cloth are the
traditional standard of care for rinsing the napkin area
[8,9], disposable infant wipes have become a popular
alternative. Comparative studies suggest that they may
be equally or even better tolerated, particularly those able
Chapter 5  Neonatal Skin Care 65
Box 5.1  List of common potential allergens in baby wipes causing
allergic contact dermatitis [36,37]
• Botanical extracts, including members of the Compositae family
• α‐tocopherol
• Fragrances
SECTION 2: SKIN DISORDERS
OF NEONATES AND INFANTS
• Propylene glycol
• Parabens
• Iodopropynyl butylcarbamate
• Lanolin
• Methylchloroisothiazolinone/methylisothiazolinone
• Formaldehyde releaser
to maintain an acidic skin surface pH [34]. This is in
accordance with the results of a prospective study show-
ing that a higher skin pH in neonates is a predisposing
factor for napkin dermatitis [35]. However, preservatives
and fragrances in baby wipes can lead to allergic contact
sensitization which is an underrecognized cause of per-
ineal dermatitis [36,37] (Box 5.1).
­References
1 Ewence A, Rumsby P, Rockett L et al. A review of skin irritation and
tap water quality. Swindon: WRc. Drinking Water Inspectorate Ref.
DWI8375, 2011:1–149.
2 Warren R, Ertel KD, Bartolo RG et  al. The influence of hard water
(calcium) and surfactants on irritant contact dermatitis.Contact
Dermatitis 1996;35:337–43.
3 Lee SH, Elias PM, Proksch E et al. Calcium and potassium are impor-
tant regulators of barrier homeostasis in murine epidermis. J Clin
Invest 1992;89:530–8.
4 Lund CH, Nonato LB, Kuller JM et al. Disruption of barrier function
in neonatal skin associated with adhesive removal. J Pediatr 1997;131:
367–72.
5 Tsakok T, McKeever TM, Yeo L, Flohr C. Does early life exposure to
antibiotics increase the risk of eczema? A systematic review. Br J
Dermatol 2013;169:983–91.
6 Chng KR, Tay ASL, Li C et al. Whole metagenome profiling reveals
skin microbiome‐dependent susceptibility to atopic dermatitis flare.
Nat Microbiol 2016;1:1–10.
7 Lund CH, Osborne JW, Kuller J et al. Neonatal skin care: clinical out-
come of the AWHONN/NANN evidence‐based clinical practice
guideline. J Obstet Gynecol Neonatal Nurs 2001;30:41–51.
8 Dyer JA. Newborn skin care. Semin Perinatol 2013;37:3–7.
9 Ness MJ, Davis DMR, Carey WA. Neonatal skin care: A concise
review. Int J Dermatol 2013;52:14–22.
10 Visscher MO, Barai N, LaRuffa AA et al. Epidermal barrier treatments
based on vernix caseosa. Skin Pharmacol Physiol 2011;24:322–9.
11 Blume‐Peytavi U, Lavender T, Jenerowicz D et al. Recommendations
from a European Roundtable Meeting on Best Practice Healthy Infant
Skin Care. Pediatr Dermatol 2016;33:311–21.
12 WHO. Pregnancy, Childbirth, Postpartum and Newborn Care: A
guide for essential practice, 3rd edn. Geneva: WHO, 2015.
13 George S, Phillips K, Mallory S et al. A pragmatic descriptive study of
rewarming the newborn after the first bath. J Obstet Gynecol Neonatal
Nurs 2015;44:203–9.
14 Akter T, Dawson A, Sibbritt D. What impact do essential newborn
care practices have on neonatal mortality in low and lower‐middle
income countries? Evidence from Bangladesh. J Perinatol 2016;36:
225–30.
15 Loring C, Gregory K, Gargan B et  al. Tub bathing improves ther-
moregulation of the late preterm infant. J Obstet Gynecol Neonatal
Nurs 2012;41:171–9.
16 Gelmetti C. Skin cleansing in children. J Eur Acad Dermatol Venereol
2001;15:12–15.
17 Blume‐Peytavi U, Cork MJ, Faergemann J et al. Bathing and cleansing
in newborns from day 1 to first year of life: recommendations from a
European round table meeting. J Eur Acad Dermatol Venereol
2009;23:751–9.
 66 Section 2  Skin Disorders of the Neonate and Young Infant
18 Visscher MO, Adam R, Brink S. Newborn infant skin: Physiology,
development and care. Clin Dermatol 2015;33:271–80.
19 Lodén M, Buraczewska I, Edlund F. The irritation potential and reser-
voir effect of mild soaps. Contact Dermatitis 2003;49:91–6.
20 Roberta R, Patrizi A, Cocchi G et al. Comparison of two different neo-
natal skin care practices and their influence on transepidermal water
loss in healthy newborns within first 10 days of life. Minerva Pediatr
2014;66:369–74.
SECTION 2: SKIN DISORDERS
OF NEONATES AND INFANTS
21 Garcia Bartels N, Scheufele R, Prosch F et al. Effect of standardized
skin care regimens on neonatal skin barrier function in different body
areas. Pediatr Dermatol 2010;27:1–8.
22 Walters RM, Fevola MJ, LiBrizzi JJ et al. Designing cleansers for the
unique needs of baby skin. Cosm Toil 2008;123:53–60.
23 Zupan J, Garner P, Omari AA. Topical umbilical cord care at birth.
Cochrane Database Syst Rev 2004;CD001057.
24 Ahn Y, Sohn M, Jun Y et  al. Two methods of cord care in high‐risk
newborns: their effects on hydration, temperature, pH, and floras of
the cord area. J Child Health Care 2015;19:118–29.
25 Mullany LC, Shah R, El Arifeen S et al. Chlorhexidine cleansing of
the umbilical cord and separation time: a cluster‐randomized trial.
Pediatrics 2013;131:708–15.
26 Sinha A, Sazawal S, Pradhan A et  al. Chlorhexidine skin or cord
care for prevention of mortality and infections in neonates.
Cochrane Database Syst Rev 2015;(3):CD007835.
27 Karumbi J, Mulaku M, Aluvaala J et al. Topical umbilical cord care for
prevention of infection and neonatal mortality. Pediatr Infect Dis J
2013;32:78–83.
28 Gras‐Le Guen C, Caille A, Launay E et al. Dry care versus antisep-
tics for umbilical cord care: A cluster randomized trial. Pediatrics
2017;139:e20161857.
29 Stewart D, Benitz W. Umbilical cord care in the newborn infant.
Pediatrics 2016;138:e20162149.
30 Upadhyayula S, Kambalapalli M, Harrison CJ. Safety of anti‐infective
agents for skin preparation in premature infants. Arch Dis Child
2007;92:646–7.
31 Harpin VA, Rutter N. Percutaneous alcohol absorption and skin
necrosis in a premature infant. Arch Dis Child 1982;57:477–9.
32 Heimall LM, Storey B, Stellar JJ, Davis KF. Beginning at the bottom:
evidence‐based care of diaper dermatitis. MCN Am J Matern Child
Nurs 2012;37:10–16.
33 Tüzün Y, Wolf R, Bağlam S, Engin B. Diaper (napkin) dermatitis: A
fold (intertriginous) dermatosis. Clin Dermatol 2015;33:477–82.
34 Visscher M, Odio M, Taylor T et  al. Skin care in the NICU patient:
effects of wipes versus cloth and water on stratum corneum integrity.
Neonatology 2009;96:226–34.
35 Yonezawa K, Haruna M, Shiraishi M et al. Relationship between skin
barrier function in early neonates and diaper dermatitis during the
first month of life: a prospective observational study. Pediatr Dermatol
2014;31:692–7.
36 Yu J, Treat J, Chaney K, Brod B. Potential allergens in disposable
diaper wipes, topical diaper preparations, and disposable dia-
pers:  under‐recognized etiology of pediatric perineal dermatitis.
Dermatitis 2016;27:110–18.
37 Chang MW, Nakrani W. Six children with allergic contact dermatitis
to methylisothiazolinone in wet wipes (baby wipes). Pediatrics 2014;
133:e434–8.
­Skin care for the premature infant
As outlined in Chapter 4, the thickness of the epidermis
correlates inversely with gestational age. In a 25‐week‐
old premature baby, it is only 25 μm instead of 50 μm in a
neonate at term. The skin of premature infants is thus
even more susceptible to trauma, TEWL and transepider-
mal intoxication than that of a mature neonate.
Control of transepidermal water loss
In premature infants younger than 30 weeks of gesta-
tion, transepidermal and evaporative water loss is exces-
sive and life‐threatening. Immediately after birth, babies
are wrapped in polyurethane foil [1] and then placed
in  a humidification incubator with an initial ambient
humidity of ≥80%. Ambient humidity is usually reduced
stepwise after a week because of concerns about an
increased risk of infection [2]. Conventional phototherapy
can increase TEWL, while modern LED phototherapy
units do not [3].
Various emollients have been shown to improve the
immature epidermal barrier function in premature
infants. Since the first randomized controlled study in
60  premature infants (<33 weeks of gestation) demon-
strated decreased TEWL, improved skin scores and
decreased colonization and infection rates in those treated
with a preservative‐free petrolatum ointment versus an
untreated control group [4], about 20 similar studies with
various emollients (mineral oil, lanolin cream, oils from
sunflower seed, olive, almond, vegetable or coconut) and
involving a total of >3000 infants have confirmed the orig-
inal findings [e.g. 5–9]. There are however concerns about
an increased risk of coagulase‐negative staphylococcal
infection, nosocomial infection and systemic candidiasis
in premature infants treated with topical emollients
[10,11]. A meta‐analysis of 18 studies published between
1993 and 2015 revealed no benefit in terms of significant
reduction of mortality in the emollient‐treated groups of
preterm infants [12]. This was probably due to methodo-
logical weakness of many studies, specifically uncertainty
about adequate allocation concealment methods in many
and lack of blinding in all of the trials [12].
Therefore, preventive application of ointments to
improve the immature epidermal barrier cannot be rec-
ommended at present. However, this simple and low‐
cost approach to reduce infectious complications and
mortality of premature infants has great potential, par-
ticularly for low‐income countries, and deserves further
well‐designed RCTs.
Avoidance of mechanical damage
Patients undergoing neonatal intensive care are exposed to
many diagnostic and therapeutic procedures. Neonates are
particularly susceptible to iatrogenic injury, the incidence
of which was calculated in a prospective study at 25.6 per
1000 patient days [13]. Among 267 iatrogenic events
observed, cutaneous injuries were the most frequent
(35.2%), but they were mild in 95% [13]. In a more detailed
analysis in 113 premature infants <33 weeks of gestation,
16.8% of all infants were affected by iatrogenic cutaneous
injuries [14]. These were mainly induced by ventilation
equipment, intravenous catheters, electrodes, dressings,
disinfectants and pressure sores. The main risk factors
were low birthweight and duration of ventilation [14].
Implementation of a systematic quality improvement
approach can lead to a significant reduction in device‐
related pressure ulcers on the NICU [15]. This approach
includes preventive skin care, early detection of immi-
nent damage through systematic assessment of the skin,
and identification of strategies to mitigate device‐related
injury to further reduce ulcer rates [15]. Nasal continuous
positive airway pressure frequently (20–60%) leads to
nasal injury and trauma secondary to tight‐fitting nasal
interfaces [16]. Nasal injury can be reduced using rotating
mask/prong nasal interfaces [17].

Table 5.2  Recommendations for skin care in premature infants
Problem Recommendation
Bathing • No full‐immersion bathing until ≥32 weeks of
gestation and stable body temperature
• No cleansing agent in the first 2 weeks
• Surface cleansing with a cotton cloth twice a week
Adhesives • Avoid adhesives wherever possible
• Place protective barrier (pectin hydrocolloid) between
skin and sites of frequent taping (e.g. nose for
nasogastric tubes, continuous positive airway pressure)
• Use silicone adhesives wherever possible
• Use nonadhesive probes
Topical agents • Be aware of percutaneous absorption
• Never use alcohol or alcoholic solutions
• Never use triclosan, hexachlorophene and other
potentially toxic agents (see Table 5.4)
Emollients • Consider preventive/protective skin care with
emollients when humidified incubators for premature
infants are not available
Phototherapy • Use LED phototherapy only
Adhesive tapes should be used only sparingly. Removal
requires a special technique with one hand holding the
underlying skin while the other peels off the adhesive.
The application of a hydrocolloid (pectin) barrier between
the adhesive surface of a temperature probe and the neo-
nate’s skin or under tape minimizes the trauma of strip-
ping when the probe is removed [18,19]. The pectin‐based
barrier under tape held probes and appliances safely for
an average of 5–6 days, and the skin condition remained
normal in 97% after barrier removal [18].
Use of soft silicone adhesives was shown to reduce pain
severity scores during dressing changes and was atrau-
matic in >99% [20]. For full‐thickness and exudative
wounds, polyurethane foam may likewise be suitable as
an atraumatic wound dressing. Silver alginate, however,
is not advisable in premature infants because it can lead
to systemic absorption of silver [21].
Pulse oximetry has largely replaced transcutaneous
oxygen monitoring. If transcutaneous oxygen monitors
are still required, electrodes should be adjusted to the
lowest effective temperature; in order to prevent skin burns,
electrode positions should be changed every 4  hours.
An ideal goal for the (near) future is the continuous moni-
toring of vital signs (heart and respiratory rate, oxygen
saturation) in preterm infants with non‐contact methods
such as a digital video camera [22].
Table 5.2 summarizes basic recommendations for skin
care in premature infants.
­References
1 Bhandari V, Brodsky N, Porat R. Improved outcome of extremely low
birth weight infants with Tegaderm application to skin. J Perinatol
2005;25:276–81.
2 Lund CH, Osborne JW, Kuller J et al. Neonatal skin care: clinical out-
come of the AWHONN/NANN evidence‐based clinical practice
guideline. J Obstet Gynecol Neonatal Nurs 2001;30:41–51.
3 Bertini G, Perugi S, Elia S et al. Transepidermal water loss and cerebral
hemodynamics in preterm infants: conventional versus LED photo-
therapy. Eur J Pediatr 2008;167:37–42.
Chapter 5  Neonatal Skin Care 67
4 Nopper AJ, Horii KA, Soodeo‐Drost S et al. Topical ointment therapy
benefits premature infants. J Pediatr 1996;128:660–9.
5 Darmstadt GL, Badrawi N, Law PA et al. Topically applied sunflower
seed oil prevents invasive bacterial infections in preterm infants in
Egypt: a randomized, controlled clinical trial. Pediatr Infect Dis J
2004;23:719–25.
6 Darmstadt GL, Ahmed S, Ahmed NU, Saha SK. Mechanism for pre-
vention of infection in preterm neonates by topical emollients. A ran-
SECTION 2: SKIN DISORDERS
OF NEONATES AND INFANTS
domized, controlled clinical trial. Pediatr Infect Dis J 2014;33:1124–7.
7 Erdemir A, Kahramaner Z, Yuksel Y et al. The effect of topical oint-
ment on neonatal sepsis in preterm infants. J Matern Fetal Neonatal
Med 2015;28:33–6.
8 Salam RA, Darmstadt GL, Bhutta ZA. Effect of emollient therapy on
clinical outcomes in preterm neonates in Pakistan: a randomized con-
trolled trial. Arch Dis Child Fetal Neonatal Ed 2015;100:F210–15.
9 Nangia S, Paul VK, Deorari AK et al. Topical oil application and trans‐
epidermal water loss in preterm very low birth weight infants—a ran-
domized trial. J Trop Pediatr 2015;61:414–20.
10 Conner JM, Soll RF, Edwards WH. Topical ointment for preventing
infection in preterm infants. Cochrane Database Syst Rev 2004;(1):
CD001150.
11 Campbell JR, Zaccaria E, Baker CJ. Systemic candidiasis in extremely
low birth weight infants receiving topical petrolatum ointment for
skin care: A case‐control study. Pediatrics 2000;105:1041–5.
12 Cleminson J, McGuire W. Topical emollient for preventing infection
in preterm infants. Cochrane Database Syst Rev 2016;(1):CD001150.
13 Ligi I, Arnaud F, Jouve E et al. Iatrogenic events in admitted neonates:
a prospective cohort study. Lancet 2008;371:404–10.
14 Roche‐Kubler B, Puzenat E, Mariet AS et  al. Lésions cutanées
iatrogènes: étude prospective chez les prématurés de moins de 33
semaines de l´hôpital universitaire de Besançon. Ann Dermatol
Venereol 2015;142:3–9.
15 Visscher M, King A, Nie AM et al. A quality‐improvement collabora-
tive project to reduce pressure ulcers in PICUs. Pediatrics 2013;
131:e1950–60.
16 Newnam KM, McGrath JM, Estes T et  al. An integrative review of
skin breakdown in the preterm infant associated with nasal continu-
ous positive airway pressure. J Obstet Gynecol Neonatal Nurs
2013;42:508–16.
17 Newnam KM, McGrath JM, Salyer J et al. A comparative effectiveness
study of continuous positive airway pressure‐related skin break-
down when using different nasal interfaces in the extremely low birth
weight neonate. Appl Nurs Res 2015;28:36–41.
18 Lund C, Kuller JM, Tobin C et al. Evaluation of a pectin‐based barrier
under tape to protect neonatal skin. J Obstet Gynecol Neonatal Nurs
1986;15:39–44.
19 OʼNeil A, Schumacher B. Application of a pectin barrier for medical
adhesive skin injury (epidermal stripping) in a premature infant.
J Wound Ostomy Continence Nurs 2014;41:219–21.
20 Morris C, Emsley P, Marland E et al. Use of wound dressings with soft
silicone adhesive technology. Paediatr Nurs 2009;21:38–43.
21 Khattak AZ, Ross R, Ngo T, Shoemaker CT. A randomized controlled
evaluation of absorption of silver with the use of silver alginate
(Algidex) patches in very low birth weight (VLBW) infants with cen-
tral lines. J Perinatol 2010;30:337–42.
22 Villarroel M, Guazzi A, Jorge J et al. Continuous non‐contact vital sign
monitoring in neonatal intensive care units. Healthc Technol Lett
2014;1:87–91.
­ kin care of the term neonate
S
and infant
Infants and young children have become a major target of
the cosmetics industry. The use of cosmetic products has
increased significantly in this age group over the past
years [1–3]. Regular use of ‘leave‐on’ products such as
facial cream and body lotion is very common in children
from 0 to 4 years [1,3]. The newborn infant is exposed to
an average of 8 ± 3 different skin care products containing
48 ± 18 different environmental chemicals. On average,
infants are bathed four times per week and shampooed
three times [4]. Many cosmetic products carry a risk of
 68 Section 2  Skin Disorders of the Neonate and Young Infant
percutaneous absorption, irritation or sensitization, and
the mere fact that they are advertised for children does
not necessarily imply that they are free of these risks [1–4].
Baby powder containing talcum or corn starch was part of
the traditional care of infants. However, it neither pos-
sesses moisturizing properties nor is it suitable for the
SECTION 2: SKIN DISORDERS
OF NEONATES AND INFANTS
treatment of oozing umbilical stump infections. Powders
should be completely abolished from infant care because
of the risk of accidental aspiration with potentially life‐
threatening respiratory disease [5,6].
Emollients
Dry skin is a common phenomenon in term and post‐
term neonates. The instantaneous transition from 100%
humidity in utero to a comparatively dry ambient atmos-
phere is frequently followed by a period of transitory
postnatal desquamation (Fig. 5.1) which can be quite pro-
nounced and is sometimes mistaken for the manifestation
of a keratinization disorder. As outlined previously,
immaturity of the epidermal barrier leads to increased
(a)
(b)
Fig. 5.1  Postnatal desquamation in 2‐ to 8‐day‐old neonates. (a) Abdomen, (b) upper arm, (c) foot.
TEWL, and hence increased dryness. Maturation of the
epidermal barrier extends throughout the first year of life
and beyond [7]. The extent of skin dryness varies widely
between neonates; if marked and persistent it can be an
early sign of dominantly inherited filaggrin deficiency.
Emollients are cosmetic products intended to make the
skin softer (Latin: mollis) since sufficient hydration is
essential for softness and flexibility of the skin. Some work
by reducing dehydration through an occlusive effect and
create a film, thus decreasing imperceptible water loss.
The most occlusive emollients are derivatives of mineral
oil (Vaseline, liquid paraffin) or those containing waxes
(mainly beeswax). More physiological lipid film compo-
nents are lanolin, plant oils (evening primrose, sunflower
seed, jojoba, wheat germ, avocado and others) and cera-
mides. Fatty, cetyl or stearyl alcohols are frequently required
due to their emulsifying capacity. In addition to lipids,
many emollients contain humectants (mainly glycerol,
urea). In a direct comparison, emollients containing humec-
tants exhibit a greater and more sustained improvement of
(c)

Table 5.3  Potentially irritant or hazardous components of emollient
creams
Component Hazard
Detergents (e.g. SLS) Damage of epidermal barrier, TEWL↑
Emulsifiers Emulsification of endogenous epidermal
lipids, TEWL↑
Lanolin Contact allergy; low‐level contamination with
organophosphates from pesticides
Mineral oils (petrolatum, Accumulation of mineral oil saturated and
paraffin) aromatic hydrocarbons in fatty tissue
Olive oil Damage of epidermal barrier, TEWL↑
Polyethylene glycols (PEG) Percutaneous absorption in burns patients,
serum osmolarity ↑, high calcium gap,
imminent renal failure
Propylene glycol Serum hyperosmolarity after excessive use in
burns patients or patients with toxic
epidermal necrolysis
Urea Skin irritation in children <2 years (‘stinging
effect’)
↑, increase; SLS, sodium lauryl sulfate; TEWL, transepidermal water loss.
the epidermal barrier function [8]. However, all emollients
currently available have only transient effects and need to
be applied repeatedly over the day [8].
Emollients are generally perceived as ‘inert’, and poten-
tial side‐effects are neither expected nor systematically
investigated. However, several reports highlight negative
effects of commercially available skin care products on
the epidermal barrier [9–11]. Potential hazards of emol-
lients (Table 5.3) should therefore be borne in mind, par-
ticularly in infants and young children:
• Mineral oils (petrolatum, paraffin) contain variable
amounts of mineral oil saturated hydrocarbons and
mineral oil aromatic hydrocarbons, some of which are
strongly accumulated in fatty tissue and can lead to
granuloma formation [12,13]. Mineral oil hydrocarbons
are considered the greatest contaminant of the human
body, amounting to approximately 1 g per person.
Routes of contamination include inhalation, food
intake (e.g. breast milk [12], baby food contaminated by
packaging [14]), and dermal absorption from moistur-
izers or lipsticks.
• Lanolin: Lanolin is a component of many ‘natural’ skin
care products. With a prevalence of up to 3.8% [15], it is
also one of the most common contact allergens.
Children with AD are particularly prone to develop
contact allergy to skin care components, most com-
monly to cocamidopropyl betaine, lanolin, tixocortol
pivalate and parthenolide [16]. Since lanolin is derived
from sheep wool, low‐level contamination of lanolin
wool grease with organophosphates such as diazinon
derived from insecticides is still detectable with highly
sensitive methods [17,18].
• Sodium lauryl sulfate (SLS): Detergents such as SLS are
known to exert negative effects on the intactness of the
epidermal barrier. A widely used emollient, aqueous
cream BP, was found to increase TEWL in volunteers
prone to AD; this effect was attributed to the presence
of 1% SLS in the emollient [10].
Chapter 5  Neonatal Skin Care 69
• Vegetable oils: Vegetable oils share the benefit of being
‘natural’ and are commonly used in baby skin care.
However, owing to different ratios of saturated/unsat-
urated fatty acids, the physicochemical properties of
vegetable oils on the skin surface are quite different.
Olive oil, with a high percentage of saturated fatty
SECTION 2: SKIN DISORDERS
OF NEONATES AND INFANTS
acids, is prone to oxidation on the skin surface, which
leads to increased formation of reactive oxygen radi-
cals. As a consequence, and in contrast to sunflower
seed oil, olive oil was found to damage the epidermal
barrier and cause skin irritation and exacerbation of
AD [11]. However, in an RCT in 115 healthy, full‐term
neonates, both olive and sunflower seed oil treated
infants had significantly improved hydration but sig-
nificantly less improvement in lipid lamellae structure
compared to the no oil group. There were no significant
differences in TEWL, pH or erythema/skin scores
between treated and untreated neonates [19].
• Emulsifiers: Emulsifiers are required to link the lipo-
philic and hydrophilic components in creams. They
permeate through the stratum corneum into deeper
layers of the epidermis where they can interact with
epidermal lipids [20]. Long‐term use of creams con-
taining high concentrations of emulsifiers can lead to
irritational dermatitis and paradoxically increase skin
dryness [20,21].
• Polyethylene glycols (PEG) are widely used in cosmetic
applications because of their emulsifying and viscous
properties and low toxicity. In patients with wide-
spread burns, however, percutaneous absorption of
ethylene glycol after topical treatment with a PEG‐
based burn cream was described, leading to increased
serum osmolalities and a high ‘calcium gap’, i.e.
increased serum calcium with a concomitant decrease
in the ionized calcium likely attributable to binding of
calcium by dicarboxylic acid metabolites of PEG [22].
All three patients died in acute renal failure. Similar
findings were obtained in rabbits treated with PEG.
Caution is advised with PEG‐containing emollients not
only in burn patients but also in children with wide-
spread barrier defects, e.g. premature babies and epi-
dermolysis bullosa patients. Hyperosmolarity was
likewise observed after excessive topical use of PEG in
burns or toxic epidermal necrolysis patients [23].
• Urea: Emollients containing urea frequently cause skin
irritation In infants described as a ‘stinging effect’.
Glycerol (5–20%) is well tolerated and therefore the
preferred moisturizer up to the age of 2 years.
There are very few RCTs dealing with regular skin care in
neonates [24], and virtually all were sponsored by pro-
ducers of baby skin care products. In a small RCT with 64
neonates assigned to different skin care modalities and
followed up for 2 months, babies who were bathed twice
a week with a wash gel followed by application of a skin
care cream were found to have lower TEWL than those
bathed in water alone; not surprisingly, cream application
was associated with higher stratum corneum hydration
[25]. The significance of these findings is limited by the
small group of infants studied and the short period of
follow‐up.
 70 Section 2  Skin Disorders of the Neonate and Young Infant
Emollients for primary prevention
of atopic dermatitis
Although AD rarely manifests before the age of 3–4
months, recent evidence suggests that asymptomatic neo-
nates who later develop AD have an elevated TEWL as
early as 2 days and 2 months of life [26]. In filaggrin‐defi-
SECTION 2: SKIN DISORDERS
OF NEONATES AND INFANTS
cient infants, early transcutaneous sensitization to food
allergens is a common phenomenon [27]. Correspondingly,
early elevation of TEWL also correlates with the presence
of food sensitization/food allergy at the age of 2 years
[28]. It would therefore make perfect sense to prevent AD
and food allergy by improving the defective skin barrier
in presymptomatic neonates immediately after birth. The
effectiveness of a preventive barrier therapy in neonates
at high risk of developing AD – as deduced from the fam-
ily history – was studied in two RCTs from Japan [29] and
the UK [30], with 118 and 108 healthy neonates, respec-
tively, who were randomized to either receive daily emol-
lient care for 6 months, or not. The primary endpoint was
the cumulative incidence of AD at week 32 and 24, respec-
tively. This was 32% less in the treated group (P = 0.12) in
the first [29], and 50% less (OR 0.50, CI 0.28–0.9, P = 0.17)
in the second [30] study. No effect on food sensitization
could be demonstrated.
The results of these pilot studies have been received
with enthusiasm. However, many questions still need to
be answered before preventive barrier therapy can and
should be recommended for all newborns at risk:
• Type of emollient: Different emollients have been used in
the studies mentioned. With respect to potential haz-
ards associated with the long‐term use of emollients as
outlined previously, the risks of unnecessarily exposing
many asymptomatic neonates to agents that can be sen-
sitizing, accumulate or induce paradoxical skin dry-
ness must be weighed up against noticeable long‐term
benefits which still need to be demonstrated.
• Definition of risk group: It is obvious that the more spe-
cifically risk group(s) can be defined, the more effective
(and justifiable) are the preventive measures. Based on
recent studies [26,28], it is likely that early assessment
of TEWL in addition to a positive family history would
significantly enhance the predictive power and thus
limit the number needed to treat (number of neonates
needed to receive preventive barrier therapy in order to
reduce the incidence of AD and food allergy).
• Duration of protective effects: It is unclear at present
whether preventive barrier therapy indeed reduces the
manifestation rate of AD or just postpones it to a later
stage.
­References
1 Gomez‐Berrada MP, Gautier F, Parent‐Massin D, Ferret PJ.
Retrospective exposure data for baby and children care products: an
analysis of 48 clinical studies. Food Chem Toxicol 2013;57:185–94.
2 Ficheux AS, Dornic N, Bernard A et  al. Probabilistic assessment of
exposure to cosmetic products by French children aged 0‐3 years. Food
Chem Toxicol 2016;94:85–92.
3 Manová E, von Goetz N, Keller C et al. Use patterns of leave‐on per-
sonal care products among Swiss‐German children, adolescents and
adults. Int J Environm Res Publ Health 2013;10:2778–98.
4 Cetta F, Lambert GH, Ros SP. Newborn chemical exposure from over‐
the‐counter skin care products. Clin Pediatr (Phila) 1991;30:286–9.
5 Silver P, Sagy M, Rubin L. Respiratory failure from corn starch aspi-
ration: a hazard of diaper changing. Pediatr Emerg Care 1996;12:
108–10.
6 Matina F, Collura M, Maggio MC et al. Inhaled surfactant in the treat-
ment of accidental talc powder inhalation: a new case report. Ital J
Pediatr 2011;37:47.
7 Nikolovski J, Stamatas GN, Kollias N et  al. Barrier function and
water‐holding and transport properties of infant stratum corneum
are different from adult and continue to develop through the first
year of life. J Invest Dermatol 2008;128:1728–36.
8 Danby SG, Chalmers J, Brown K et  al. A functional mechanistic
study of the effect of emollients on the structure and function of the
skin barrier. Br J Dermatol 2016;175:1011–19.
9 Man MQ, Sun R, Man G et al. Commonly employed african neonatal
skin care products compromise epidermal function in mice. Pediatr
Dermatol 2016;33:493–500.
10 Danby SG, Al‐Enezi T, Sultan A et al. The effect of aqueous cream BP
on the skin barrier in volunteers with a previous history of atopic der-
matitis. Br J Dermatol 2011;165:329–34.
11 Danby SG, Al‐Enezi T, Sultan A et al. Effect of olive and sunflower
seed oil on the adult skin barrier: implications for neonatal skin
care. Pediatr Dermatol 2013;30:42–50.
12 Concin N, Hofstetter G, Plattner B et al. Evidence for cosmetics as a
source of mineral oil contamination in women. J Womens Health
(Larchmt) 2011;20:1713–19.
13 Niederer M, Stebler T, Grob K. Mineral oil and synthetic hydrocar-
bons in cosmetic lip products. Int J Cosmet Sci 2016;38:194–200.
14 Mondello L, Zoccali M, Purcaro G et al. Determination of saturated‐
hydrocarbon contamination in baby foods by using on‐line liquid‐gas
chromatography and off‐line liquid chromatography‐comprehensive
gas chromatography combined with mass spectrometry. J Chromatogr
A 2012;1259:221–6.
15 Miest RY, Yiannias JA, Chang YH, Singh N. Diagnosis and preva-
lence of lanolin allergy. Dermatitis 2013;24:119–23.
16 Jacob SE, McGowan M, Silverberg NB et  al. Pediatric Contact
Dermatitis Registry Data on Contact Allergy in Children With Atopic
Dermatitis. JAMA Dermatol 2017;153:765–70.
17 Copeland CA, Raebel MA, Wagner SL. Pesticide residue in lanolin.
JAMA 1989;261:242.
18 Wester RC, Sedik L, Melendres J et  al. Percutaneous absorption of
diazinon in humans. Food Chem Toxicol 1993;31:569–72.
19 Cooke A, Cork MJ, Victor S et al. Olive oil, sunflower oil or no oil for
baby dry skin or massage: a pilot, assessor‐blinded, randomized con-
trolled trial (the Oil in Baby SkincaRE [OBSeRvE] Study). Acta Derm
Venereol 2016;96:323–30
20 Wohlrab J, Klapperstück T, Reinhardt HW, Albrecht M. Interaction of
epicutaneously applied lipids with stratum corneum depends on the
presence of either emulsifiers or hydrogentated phosphatidylcholine.
Skin Pharmacol Physiol 2010;23:298–305.
21 Wolf G, Höger PH. [Hypoallergenic and non‐toxic emollient therapies
for children.] J Dtsch Dermatol Ges 2009;7:50–60.
22 Bruns DE, Herold DA, Rodeheaver GT, Edlich RF. Polyethylene gly-
col intoxication in burn patients. Burns 1982;9:49–52.
23 European Medicines Agency (EMA). Propylene glycol in medicinal
products for children. Assessment report EMA/175205/2014. London:
EMA, 2014.
24 Irvin EJ, Miller HD. Emollient use in the term newborn: a literature
review. Neonatal Network 2015;34:227–30.
25 Garcia Bartels N, Scheufele R, Prosch F et al. Effect of standardized
skin care regimens on neonatal skin barrier function in different body
areas. Pediatr Dermatol 2010;27:1–8.
26 Kelleher M, Dunn‐Galvin A, Hourihane JO et al. Skin barrier dys-
function measured by transepidermal water loss at 2 days and 2
months predates and predicts atopic dermatitis at 1 year. J Allergy
Clin Immunol 2015;135:930–5.
27 Brown SJ, Asai Y, Cordell HJ et  al. Loss‐of‐function variants in the
filaggrin gene are a significant risk factor for peanut allergy. J Allergy
Clin Immunol 2011;127:661–7.
28 Kelleher MM, Dunn‐Galvin A, Gray C et al. Skin barrier impairment
at birth predicts food allergy at 2 years of age. J Allergy Clin Immunol
2016;137:1111–16.
29 Horimukai K, Morita K, Narita M et al. Application of moisturizer to
neonates prevents development of atopic dermatitis. J Allergy Clin
Immunol 2014;134:824–830.
30 Simpson EL, Chalmers JR, Hanifin JM et al. Emollient enhancement of
the skin barrier from birth offers effective atopic dermatitis preven-
tion. J Allergy Clin Immunol 2014;134:818–23.
 Chapter 5  Neonatal Skin Care 71

­Percutaneous absorption the endocrine disrupting actions of triclosan, parabenes

Immaturity of the epidermal barrier in infants is not only
associated with increased TEWL and skin dryness but
also brings an increased risk of percutaneous resorption
of toxic substances applied to the skin surface. Skin per-
meability is inversely proportional to gestational age [1].
and several chemical ultraviolet (UV) filters [3–6] which
have been shown to exert mainly oestrogenic activity in
vitro. Early (or even prenatal) exposure to triclosan, para-
benes, phthalates and other chemical compounds can
contribute to premature puberty [7]. In addition to avoid-

SECTION 2: SKIN DISORDERS

Even in the term infant, transcutaneous absorption is
more readily achieved because the body surface area to
weight ratio is two‐ to threefold higher than in older chil-
dren and adults [2]. Low‐molecular‐weight chemicals
(<800 Da) penetrate more easily. Topical antiseptics (hexa-
chlorophene, iodine) and antibiotics (particularly neomy-
cin, which is highly ototoxic), alcohol dressings, salicylates,
urea and others have all been associated with neonatal
toxicity caused by transcutaneous resorption, particularly
in the preterm infant [1]. The likelihood of percutaneous
absorption is higher in areas with high numbers of seba-
ceous glands per cm2 (head, napkin area) and in intertrigi-
nous areas due to the occlusive effect. The vehicle also
affects percutaneous absorption. Lipophilic agents can
penetrate the lipid bilayer better than water‐soluble com-
pounds. Their occlusive effects lead to enhancement of
epidermal hydration which in turn widens the intracellu-
lar bonds and facilitates absorption. The risk of toxicity is
further compounded by immature metabolic mechanisms
of detoxification. Table 5.4 summarizes potential hazards
of common topically applied drugs. Of particular note are
OF NEONATES AND INFANTS
ance of high‐level UV exposure and appropriate clothing,
UV protection in young children should preferably be
based on mineral agents such as micro‐ (not nano‐) molec-
ular titanium dioxide and zinc dioxide.
­References
1 Barker N, Hadgraft J, Rutter N. Skin permeability in the newborn.
J Invest Dermatol 1987;88:409–11.
2 Rutter N. Percutaneous drug absorption in the newborn: hazards and
uses. Clin Perinatol 1987;14:911–30.
3 Diamanti‐Kandarakis E, Bourguignon JP, Giudice LC et  al.
Endocrine‐disrupting chemicals: an Endocrine Society scientific
statement. Endocr Rev 2009;30:293–342.
4 Schlumpf M, Cotton B, Conscience M et al. In vitro and in vivo estro-
genicity of UV screens. Environ Health Perspect 2001;109:239–44.
5 Ozáez I, Martínez‐Guitarte JL, Morcillo G. Effects of in vivo exposure
to UV filters (4‐MBC, OMC, BP‐3, 4‐HB, OC, OD‐PABA) on endocrine
signaling genes in the insect Chironomus riparius. Sci Total Environ
2013;456‐457:120–6.
6 Schreurs RH, Sonneveld E, Jansen JH et  al. Interaction of polycyclic
musks and UV filters with the estrogen receptor (ER), androgen recep-
tor (AR), and progesterone receptor (PR) in reporter gene bioassays.
Toxicol Sci 2005;83:264–72.
7 Harley KG, Berger KP, Kogul K et al. Association of phthalates, para-
bens and phenols found in personal care products with pubertal tim-
ing in girls and boys. Human Reproduction 2019;34:109–17.

Table 5.4  Potential hazards of percutaneously absorbed agents

Compound Function Toxicity

Alcohols Topical antiseptic Cerebral and hepatic damage, cutaneous haemorrhagic necrosis
Benzocaine Topical anaesthetic Methaemoglobinaemia
Calcipotriol Topical vitamin D3 analogue Hypercalcaemia
Clioquinol Topical antiseptic Neurotoxicity (subacute myelo‐ophthalmoneuritis, SMON)
Diphenhydramine Topical antipruritic Sedation, central anticholinergic syndrome
EMLA Topical anaesthetic mixture Methaemoglobinaemia
Gentamicin Topical antibiotic Neuro‐, oto‐, nephrotoxic
Lindane Topical scabicide Neurotoxic
Neomycin Topical antibiotic Neuro‐, oto‐, nephrotoxic
Contact allergen
N,N‐dimethyl‐m‐toluamide (DEET) Insect repellant Neurotoxicity
Parabene Preservative Endocrine disrupting agent
Phenolic compounds (pentachlorophenol, Topical antiseptic Neurotoxicity, tachycardia, metabolic acidosis,
hexachlorophene, resorcinol) methaemoglobinaemia, death
Povidone–iodine Antiseptic Hypothyroidism
Prilocaine Topical anaesthetic Methaemoglobinaemia
Salicylic acid Keratolytic Metabolic acidosis, seizures
Silver sulfadiazine Topical antibiotic Kernicterus, agranulocytosis, argyria
TCS (potent) Anti‐inflammatory Adrenal suppression, Cushing’s syndrome, skin atrophy, acne
Triclosan Antiseptic Endocrine disrupting agent
UV filtersa UV protection Endocrine disrupting agents

TCS, topical corticosteroid.

a
 UV filters with potential oestrogenic side‐effects: benzophenone‐3, ethylhexyl‐methoxy‐cinnamate (EHMC), octocrylene.