Three “hot topics” in pediatric dermatology have received
significant attention in the past year. These include: 1) advanced knowledge
regarding optimal skin care practices for infants; 2) the utilization of
probiotics, wet wrap therapy and skin infections in atopic patients; and 3) the
beneficial effects of topical and systemic beta-blocker therapy for infantile
Sheila Fallon Friedlander
Skin care practices in infants
The pediatric and dermatologic communities have not yet reached
consensus on appropriate cleansing practices for infants. A recent review by
Blume-Peytavi and colleagues in a 2012 study in Pediatric Dermatology
provided an extensive analysis of 14 studies of moderate to high levels of
evidence pertaining to skin development and cleansing practices for babies.
Infant skin has thinner layers and smaller cells than adult skin. Barrier
function differs at different sites. Some areas, such as the forehead, upper
leg and abdomen, possess adult transepidermal water loss (TEWL) values as early
as day 2, whereas forearm skin does not reach adult levels even at 1 year of
Neonates have a higher surface pH, which decreases to adult levels by
day 28. Sebum levels initially increase up to day 7 of life, then decline to
low levels by 6 months of age. These findings support the belief that neonatal
skin undergoes maturational changes and differ at different body sites.
Cleansing and care practices should optimally take these differences into
There have been at least six large, well-designed studies that concluded
that bathing routines are not detrimental for infants and are not superior to
sponge bathing. Four studies instituted bathing before the cord fell off, and
based on these studies, it was concluded that bathing at appropriate
temperatures made babies more comfortable and resulted in decreased heat loss.
A bathing routine did not adversely affect the skin barrier.
Six articles addressed the effects of washing agents on neonatal skin
function and found that the use of syndets (pH 5.5) led to a faster
approximation (lower pH) of infant skin to adult acidity. Mild cleansers do not
compromise the acid mantle function of the skin, but use of alkaline soaps
increased surface pH. The use of synthetic detergents daily did not appear to
have negative effects on normal infantile skin.
Regarding bacterial characteristics of infantile skin, it was found that
bacterial colonization occurs in the first 2 to 3 days of life in almost all
infants. The type and numbers of microbial flora do not vary with the use of
conventional soap, detergent bath or plain water. Bacterial and candidal
colonization were not affected by skin care regimens, the use of wash gels or
creams. Bathing immediately after birth did not appear to affect cord healing
based on results of a study that compared washing and immersion bathing.
In summary, these studies confirmed that the structure, function and
composition of infant skin varies from that of adults and continues to undergo
maturational processes throughout the first year of life. Twice weekly bathing,
initiated after the umbilical cord has fallen off, has no deleterious effects
as measured by TEWL, skin surface pH and sebum production.
Bathing seems superior to washing. There is also evidence that bathing
immediately after birth is safe for full-term infants. Skin surface pH at birth
is higher (6.2 to 7.5), but decreases to adult levels (5.4 to 5.9) in the
subsequent few weeks. Cleansing with mild liquid baby cleansers or syndets is
comparable and may even be superior to the use of plain water alone.
Advances in atopic dermatitis
Probiotics: The latest news regarding atopic dermatitis
prevention is promising regarding the use of probiotics to decrease incidence
in infants. In 2008, Wickens and colleagues in the Journal of Allergy and
Clinical Immunology published the results of a double blind, randomized,
placebo-controlled trial that demonstrated a 48% reduction in eczema in those
children who received HN001 Lactobacillus rhamnosus probiotics in the
first 2 years of life. In contrast, HN019 Bifidobacterium strains showed
no protective effect over placebo. Wickens’ most recent study in
Clinical & Experimental Allergy followed pregnant women who were at
high risk to deliver atopic children. These women received probiotics (HN001 or
HN019) or placebo starting at 35 weeks, and their infants the same for the
first 2 years of life. These children were followed to age 4 years. The
cumulative rates of incident eczema at 4 years were 32.7% for the
Lactobacillus group, 40.3% for the Bifidobacterium group, and
49.3% for the placebo group. The HR for HN001 was 0.57 (95% CI, 0.18-0.83).
This second study showed that the Lactobacillus probiotic
supplementation may have an enduring effect in decreasing the risk for eczema
in supplemented children.
Wet wraps: Children with severe atopic dermatitis can prove a
therapeutic challenge. The use of systemic treatments such as cyclosporine,
azathioprine and methotrexate are sometimes required but avoided when possible
due to their adverse risk profiles. Wet wrap treatment (WWT) has been utilized
as a means to improve topical therapy efficacy and avoid riskier systemic agent
when children fail traditional topical therapy. The treatment entails the
application of a double layer of gauze, tubular bandages or even cotton
pajamas, in which medication is applied to affected skin. A wet layer of
material is then applied to the site, followed by a dry second layer.
Devillers and colleagues in Pediatric Dermatology recently
published a practical guideline for the use of this treatment. They caution
that this should not be used in children aged younger than 6 months because of
concern for systemic absorption. They recommend application of topical steroids
only once a day under the layers, and rewetting of the first layer every 2 to 3
hours during the day. Such treatments can be left on the skin for up to 24
hours. Treatments should not be utilized daily for more than 14 days; however,
“plain Vaseline or emollient” therapy can be substituted for longer
durations. Risk of such therapy includes discomfort, chills and folliculitis of
an occlusive or infectious nature. Temporary systemic corticosteroid effect is
also possible. In appropriate situations, such therapy can eliminate the need
for riskier systemic therapies.
CA-MRSA infections in atopics
Community-associated methicillin-resistant staph infections are a
growing concern, as the incidence continues to rise across the nation. Matiz
and colleagues investigated the incidence in atopic dermatitis patients and
found that it was less common than in non-atopic patients suffering from
cutaneous staphylococcal infections. Eleven of 78 isolates (14%) from children
with atopic dermatitis were resistant vs. 658 of 1,482 isolates (44%) from the
general population. No clindamycin-inducible resistance was found in the atopic
group, whereas 1.9% of the general population isolates displayed inducible
resistance, according to the findings reported in Pediatric Dermatology.
Studies from both Philadelphia and Chicago have confirmed these findings, and
it therefore appears that community-associated methicillin resistance may be
less of an issue for cutaneous skin infections in atopics. Cephalosporins,
thus, can serve as first-line therapy for otherwise healthy children with
atopic dermatitis and uncomplicated skin infections in many communities.
Propranolol as first-line therapy for symptomatic infantile
hemangiomas: In 2008, Léauté-Labrèze and colleagues
published in the New England Journal of Medicine their experiences with
propranolol for the treatment of large facial infantile hemangiomas. In the
past 3 years, more than 100 publications have documented the effectiveness of
this non-selective beta-blocker in the treatment of hemangiomas, which pose a
functional or significant cosmetic risk to children.
The drug is quite effective, but adverse effects that include
hypoglycemia, sleep disturbance, low blood pressure and wheezing can occur.
Most practitioners utilize 2 mg/kg, divided twice or three times a day, with
careful attention to blood pressure and glucose intake. Very young infants are
usually hospitalized for initiation of therapy, and some practitioners prefer
to admit all patients for initial treatment. Most patients require prolonged
therapy, and early cessation often leads to recurrence. Approximately 20% of
lesions can recur after discontinuation of therapy, even when therapy exceeds 6
to 8 months, according to a study by Bagazgoitia in Pediatric
Dermatology. In the past year, further evidence has confirmed the utility
and relative safety of this treatment. Hogeling and colleagues conducted a
prospective study documenting the efficacy of propranolol vs. placebo for
infantile hemangiomas, which was published in Pediatrics. Subsequently,
Bertrand and colleagues in Pediatric Dermatology noted the superiority
of propranolol over systemic corticosteroids for the treatment of these
Given the small but real risk of adverse effects of this beta-blocker,
investigators have tested the efficacy of a topical beta-blocker, timolol, in
the treatment of superficial infantile hemangiomas. Pope and colleagues
performed a retrospective, multicenter, cohort study utilizing timolol
gel-forming solution and found that all but one of 73 patients improved after
treatment with either 0.5% or 0.1% twice daily without occlusion. This
treatment is an option for patients with superficial lesions, according to the
study in Pediatric Dermatology.
In summary, propranolol is now considered “first-line” therapy
for significant problematic infantile hemangiomas. A dosage of 2 mg/kg divided
twice or three times daily is administered and prolonged therapy is required.
Very young infants are better treated initially in hospital, and all children
must be monitored for blood pressure changes early in the course of therapy.
Families must be warned about possible risks and rebound. Infants with
superficial lesions may benefit from topical timolol therapy, administered
twice daily to the lesion.
- Bagazgoitia L. Pediatr Dermatol. 2011;28:658-662.
- Bertrand J. Pediatr Dermatol. 2011;28:649-654.
- Blume-Peytavi U.Pediatr Dermatol. 2012;29:1-14.
- Chakkittakandiyil A. Pediatr Dermatol. 2012; 29;28-31.
- Devillers AC. Pediatr Dermatol. 2012;29:24-27.
- Hogeling M. Pediatrics. 2011;128:e259-266.
- Léauté-Labrèze C. N Engl J Med.
- Matiz C. Pediatr Dermatol. 2011;28:6-11.
- Wickens K. Clin Exp Allergy.
- Wickens K. J Allergy Clin Immunol. 2008;122:788-794.
Sheila Fallon Friedlander, MD, is co-director of the Vascular Lesion
and Birthmark Center at Rady Children’s Hospital and Professor of Clinical
Pediatrics and Medicine at the University of California at San Diego. Dr.
Friedlander is also a member of the Infectious Diseases in Children Editorial
Board. Disclosure: Dr. Friedlander reports no relevant financial disclosures.