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Definition of Terms
Common newborn rashes
Preservation of skin integrity, reduction of risk factors and neonate skin care education for parents are key nursing priorities in the care of the term and preterm neonate.
The skin contains three separate layers. The uppermost layer is the stratum corneum. This provides the barrier function of the skin and has 10-20 layers in adults and term neonates. It protects against toxins, irritants, allergens and pathogens, retains heat and water as well as maintaining a normal microbiome. During the first year of life the stratum corneum is not fully mature and is approximately 30% thinner than that of adult skin. Directly under the stratum corneum is the basal layer of the epidermis and then the dermis which are also thinner and underdeveloped in neonates compared to adults. In preterm neonates the stratum corneum has only 2-3 layers. This deficiency and immaturity of the stratum corneum results in increased fluid and heat loss leading to electrolyte imbalance, reduced thermoregulation and increased infection risk.
Understanding the physiological and anatomical skin differences of preterm and term neonate skin is important in aiding thorough assessment and appropriate management of the skin.
key differences in neonate skin for further information on the structure and function of neonate skin.
guideline provides recommendations for the skin care of neonates (birth to 28
days of age) of all gestational ages. Additional considerations for preterm
neonates and product suggestions are identified in the boxes below each
To maintain skin integrity and minimise heat loss in the neonate requiring hospitialisation. This is achieved by understanding the key differences of preterm and term neonate skin enabling appropriate assessment and management of our neonatal population using evidence based practice.
Assessment of neonate skin should be undertaken daily, or more frequently as clinically indicated. Neonates at increased risk of systemic infection and longer hospital stays will be identified promptly. The Neonatal Skin Condition Score (NSCS) may be used to measure skin condition objectively.
1 = Normal, no signs of dry skin
2 = Dry skin with visible scaling
3 = Very dry skin with cracking and/or fissures present
1 = No evidence of erythema
2 = Visible erythema (
<50% body surface)
3 = Visible erythema (>50% body surface)*
1 = None evident
2 = Small and/or localized areas
3 = Extensive
The perineal environment is prone to changes in the skin barrier causing skin irritation. Increased moisture, prolonged contact with irritants, and an alkaline skin surface may contribute to skin breakdown.
Implement safety principles when bathing neonates
First Bath (applies to all neonates, additional considerations for preterm neonates given below)
Preterm Infant Considerations
- Consider weight, gestational age and severity of illness when bathing preterm neonates
- For neonates less than 32 weeks gestation, consider the use or warm water only bathing during the first week of life due to skin irritation and risk with cleansers. Avoid rubbing.
- For neonates more than 32 week’s gestation, pH neutral or slightly acidic cleansers may be utilised. Neonates may be bathed every 2-3 days
- Use warm sterile water when areas of skin breakdown are evident
- If skin is dry, flaking or cracked after the bath, an emollient may be applied to the skin
Cleansing: QV Wash™, QV Gentle Cleanser™, Hamilton Skin Therapy Gentle ash™, Cetaphil Gentle Cleanser™, Avene Trixera Cleansing Gel™, Kenkay Body Wash™, Mustela Stelatopia Cream Cleanser™, CeraVe Hydrating Wash™, Dermeze Soap Free Wash™, Laroache Posay Lipikar
Emollients: As per Emollient box below
A number of measures can be undertaken to ensure a reduced incidence of skin trauma with the use of adhesives in NICU
Current best practice exists for the taping of venous and arterial lines, however the following are general considerations.
Preterm Neonate Considerations
Tegaderm and Leukoplast tapes are to be avoided in neonates less than 27 weeks (at minimum all leukoplast is to be ‘double backed’ or dabbed with cotton wool to reduce adherence to surface area.
Dressings: Comfeel, Duoderm, Transparent adhesive dressings (Tegaderm™), Hydrocolloids, Gel electrodes, Silicone based tapes (Siltape™, Mepitac™, 3M Kind Removal Silicone Tape™)
Very little data is available on what disinfectants are best suited to the neonate skin, in particular preterm neonate skin.
Preterm Neonate Considerations
Chlorhexidine Gluconate aqueous solutions (0.1% Chlorhexidine Gluconate) are preferred in the preterm infant. The surrounding area should be cleansed thoroughly with a moistened gauze square after use. A number of studies have shown chemical burns in preterm infants where Povidone-Iodine and Isopropyl Alcohol were used, this should therefore be avoided.
Disinfectants: 0.1% Chlorhexidine Gluconate, 0.5% Chlorhexidine in 70% isopropyl alcohol
Emollients restore lipid levels, improve hydration, preserve natural moisturising factors and offer significant buffering capacity to normalise skin pH and maintain skin microbiome.
Preterm Neonate ConsiderationsSome evidence states that prophylactic emollient use in preterm neonates weighing 750 grams or less is associated with an increased risk of infection. Emollient use in this population should be weighed against the risk of infection and be in consultation with the Neonatologist.
Product ExampleEmollients: QV Cream™, Cetaphil Cream™, CeraVe cream™ Kenkay Extra Relief Cream™, Mustela Stelatopia Moisturising Cream™, La Roache Posay Lipikar Baume AP™, Bioderma Atoderm Crème™, Dermeze Treatment Cream™, Hamilton Skin Therapy Cream™, Avene Xeracalm™
A common condition affecting as many as half of all full term neonate neonates. Most prominent on day 2, although onset can be as late as two weeks of age. Often begins on the face and spreads to affect the trunk and limbs. Palms and soles are not usually affected.
Clinical features: Erythema Toxicum is evident as various combinations of erythematous macules (flat red patches), papules (small bumps) and pustules. The eruption typically lasts for several days however it is unusual for an individual lesion to persist for more than a day.
Treatment: The neonate is otherwise well and requires no treatment.
Figure 1. Erythema Toxicum Neonatorum (
Affects 40-50% of newborn babies. Few to numerous lesions.
Clinical features: Harmless cysts present as tiny pearly-white bumps just under the surface of the skin. Often seen on the nose, but may also arise inside the mouth on the mucosa (Epstein pearls) or palate (Bohn nodules) or more widely on scalp, face and upper trunk.
Treatment: Lesions will heal spontaneously within a few weeks of birth.
Figure 2. Neonatal Milia (
Arises from occlusion of the sweat ducts. In neonates, lesions commonly appear on the neck, groins and armpits, but also on the face.
Clinical features: 1-3mm papules (vesicular or papular).
Treatment: Remove from heated humid environment or adjust incubator temperature. Cool bathing or apply cool compresses. Topical steroids may be used to facilitate relief while the condition resolves.
Figure 3 & 4 Miliaria (
Neonatalacne or 'milk spots'. Affects babies within the first few weeks of life. Increased activity of the neonates' sebaceous glands cause inflammation and folliculitis.
Clinical features: Erythematous dome shaped papules and superficial pustules arise in crops, commonly affecting the cheeks, nose and forehead. This rash is not itchy.
Treatment: Will resolve within weeks without treatment or may be treated with ketoconazole shampoo (i.e. Sebizole shampoo) diluted 1:5 with water. Apply with a cotton bud twice a day. Rinse off with water after 10 minutes. Or apply Hydrozole cream bd to the affected areas until the rash has resolved.
Figure 5 & 6 Pityrosoprum Folliculitus (Images courtesy of of Dr David Orchard, Dermatologist RCH)
Evidence table for the
Neonatal and Infant Skincare guideline can be viewed here.
Please remember to read the
The development of this nursing guideline was coordinated by Robyn Kennedy, Nurse Practitioner, Dermatology and Alanah-Rae Crowle, Associate Nurse Unit Manager/CNS, Neonatal Intensive Care and and approved by the Nursing Clinical Effectiveness Committee. Updated May 2020.