Skin cleansing in children

12

© 2001 European Academy of Dermatology and Venereology

OR I G I N AL AR T I C LE

JEADV

(2001)

15 (Suppl. 1)

, 12–15

Blackwell Science, Ltd

Skin cleansing in children

C GELMETTI

Department of Paediatric Dermatology, IRCCS. ‘Ospedale Maggiore di Milano’, Via Pace, 9, 20122, Milano, Italy. tel. +39 02 5516180;

fax +39 02 5468007; E-mail: [email protected]

ABSTRACT

The problems of skin cleansing in infants have been re-evaluated in recent years on the basis of currentunderstanding of cosmetology and skin physiology. The anatomical and functional peculiarities of infant’sskin have been elucidated and, although it is known that the barrier function is established at birth in normalbabies, it remains the case that children’s skin is more delicate and therefore more prone to irritant and aller-gic contact dermatitis. These factors determine the choice of cleansing agents during infancy. The productsavailable on the market differ markedly. Indeed detergents, bath oils, bath powders, due to their distinctiveproperties, have different indications and different benefits. The method of cleansing the skin, i.e. bathingor showering, is also important. The frequency of cleansing should take into account the age and the degreeof exposure to pollutants. For special purposes, e.g. impetiginized dermatoses, antiseptics such as potassiumpermanganate or chlorhexidine can be added to the water in appropriate concentrations. The ideal paedi-atric detergent should be very mild to avoid irritant dermatitis, and very simple to avoid allergic dermatitis.

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bath, hygiene, detergents, newborn, infant

Introduction

Hygiene is defined as the science of health and of its

preservation. Consequently, skin hygiene is not simply the

science of cleaning it, but the art of preservation of its health in

a broader sense. This can be obtained both by avoiding the

contact with and by protecting the surface from contact with

micro-organisms and noxious substances.

Cleansing is of overriding importance in skin hygiene. But, as

that the final goal of hygiene is the preservation of skin health,

a fine balance is necessary between cleansing of the skin and

the preservation of its homeostatic properties. In other words,

the most effective detergent could be hazardous because an

excessive removal of lipids from the stratum corneum would

eliminate those essential to the surface ecosystem.

When considering the problem of cleansing we should con-

sider some of the distinctive properties of the infant’s skin. A

full-term baby presents membrane characteristics similar to

that of an adult, but the stratum corneum is thinner. The pro-

tective lipid film, which at birth shows a marked similarity to

that of the adult, changes after a few weeks. The secretion of

sebum, rich in waxes, diminishes, to be replaced by lipids of

cellular origin, such as membrane cholesterol. At puberty, the

secretion of sebum re-starts and leads to more efficient skin

surface protection.

The ratio of skin surface to body weight is highest at birth and

tends to decline progressively during infancy. Therefore,

whereas the proportion of an applied substance absorbed

through the skin is equal, in the infant the total amount

absorbed per kilogram body weight will be higher than in the

adult. Finally, it must be kept in mind that in the infant, because

of immature motor co-ordination, the cardinal symptom of

intolerance to detergents, itchiness, may instead be manifest by

general restlessness, irritability and difficulty in sleeping, and its

significance may therefore be overlooked.

Cleansing products

Washing the skin with water alone does not remove all of the

impurities on the surface. This is because some of those

substances are not water-soluble but fat-soluble, and there-

fore require the use of products capable of emulsifying them

into fine droplets that can then be removed by water. These

products, known as surfactants or detergents, act by suppress-

ing the surface tension that allows fatty products to remain

on the skin surface. The greater the suppression of surface

tension, however, the greater is the risk of coincidental damage

to the skin.

Detergents are classified as ionic or non-ionic. Anionic prod-

ucts possess molecules with a negatively charged hydrophilic

JDV003.fm Page 12 Friday, August 31, 2001 1:29 PM


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JEADV

(2001)

15 (Suppl. 1)

, 12–15

terminal (e.g. lauryl sulphate), and produce high foaming

activity. Cationic products possess molecules with a positively

charged hydrophilic terminal (e.g. quaternary ammonium

salts), have lower foaming activity. The most commonly

used detergents are soaps, which are products resulting

from saponification, i.e. the action of an alkali on a fatty

substance. The alkalinity induced by soaps can alter the ideal

pH of the skin surface. This is however, transient. In addition,

soap precipitates in hard water, producing insoluble calcium

or magnesium salts that prevent foam formation and leave

deposits on the hair as well as in the bathtub. The advantage of

soap is mainly its great stability, not requiring the inclusion of

preservatives.

The term

syndet

is a contraction of two words (

syn

thetic

det

ergents). Syndets can be produced at a desired pH and, while

they do not have the theoretical disadvantages of soaps, they

require preservatives. Like soaps, they can dry the skin if they do

not contain lubricant additives. The packaging of syndets can

lead to them being mistaken for emollients; prolonged skin

contact with these products will provoke irritation.

Bubble bath products, intended to replace soap and make

bathing more agreeable, have become very popular among

adults. In most cases, their pleasant characteristics are provided

by added dyes and perfumes, which however, will increase the

risk of sensitization.

Shampoos are liquid detergents, mostly containing anionic

surfactants, designed to cleanse the scalp and hair. Because of

their use close to the eyes, they should have a low ocular irrita-

tion index and a pH close to that of tears. Certain shampoos are

amphoteric, acting either as anionic or cationic agents depend-

ing on environmental pH. Special ingredients such as selenium

sulphide or zinc pyrithione may also be added to combat scalp

scaling.

The irritant properties of cleansing products should always

be considered. Currently the HRIPT (Human Repeat Insult

Patch Test) test seems adequate to determine the irritation

potential of bath or shampoo preparations.

1

Bathing habits

In skin cleansing of infants, it is firstly important to consider the

duration and frequency of the cleansing process, and the mode

(bath, showers or flannel).

Although it is sometimes recommended that bathing of

neonates be delayed until separation of the umbilical cord, this

can in fact start immediately after birth. Even though a shower

is theoretically more hygienic than a bath, it is unsuitable for

infants, and the bath is preferable. In the past, there was a great

deal of controversy surrounding the bathing of neonates. A

study in premature infants highlighted adverse physiological

and behavioural effects of bathing, providing evidence that

routine bathing should not be recommended for premature

infants.

2

However, another study concluded that healthy,

full-term newborns with a rectal temperature above 36.5

°

C can

be bathed almost immediately after birth.

3

At birth, the skin is coated with vernix caseosa, blood,

meconium and cellular debris. Vernix caseosa is a mixture of

both epidermal (triglycerides and cholesterol) and sebaceous

(squalene and waxes) lipids. Despite the fact that premature

infants tend to have less than those born at term, and post-

mature infants have little or none, the amount of vernix caseosa

found on the skin of the newborn shows considerable inter-

individual variation. Vernix caseosa is usually wiped off with

a clean towel immediately after delivery and before the infant is

washed for the first time. Although the degrees to which vernix

caseosa provides mechanical and/or microbial protection to

newborn skin are unknown, it seems sensible not to remove it

suddenly. We therefore advise bathing the newborn with water

alone. Some authors recommend the use of sterilized (boiled)

water, but we consider this unnecessary. The temperature of the

bath water should not exceed 37

°

C; a temperature between

34

°

C and 36

°

C appears to be ideal.

Regarding the duration of the bath, it should be remembered

that when the body is immersed in water, the superficial layers

of the skin are hydrated. They become thicker, with a corres-

ponding reduction in cellular cohesion. This overhydrated

skin is more fragile, and the threshold at which friction can

cause damage is lower. For these reasons, a bath for the newborn

should not last more than 5 min.

When the base of the umbilical cord has separated, the infant

can be washed with a mild detergent with a neutral or mildly

acidic pH. Common soaps or bubble bath products, even when

specially prepared for children, can dry the skin excessively and

thus irritate it, particularly when used too frequently or in too

great a concentration. The detergent should be gently applied

directly on to the skin with the hands, and must subsequently

be thoroughly rinsed off with fresh water. Finally the infant

must be carefully dried with a cotton or linen towel, paying

special attention to skinfold areas, but avoiding vigorous

rubbing. Shampoos are not advised in newborns with normal

skin. The same detergent used to wash the skin can also be

used for the scalp. In older infants, shampoos characterized by

mild tensioactives and by iso-lacrimal pH can be used, but with

caution.

Besides its cleansing activity, the bath can have less desirable

effects. In one study in infants, a hot bath had the same effect as

elevated environmental temperature or exercise in provoking

cluster headaches in 75 out of 200 patients.

4

This observation

accords with recognized precipitants (alcohol, histamine and

glyceryl trinitrate) and perhaps also results from generalized

vasodilatation or hypothalamic activation.

In another study, five patients aged between 6 months

and 2 years had seizures during bathing, with activity arrest,

hypotonia and vasoactive modification. Sometimes clonic

movements could be observed. In all cases, the diagnosis was

confirmed during the bath by EEG. The course of the seizures


14

GELMETTI


JEADV

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15 (Suppl. 1)

, 12–15

and of the psychomotor development was favourable.

6

The

incidence of such seizures may be underestimated.

However, bathing before sleep can be beneficial. In a study on

bathing and sleeping patterns, after bathing, young people

reported warmth in their hands and/or legs, while the elderly

often reported ‘good sleep’ or ‘rapidity of falling asleep’. During

the first 3 h of sleep, body movements were less frequent after

bathing for both the young and the elderly subjects.

5

The results

suggest that a bath before sleep enhances the quality of sleep.

Cleansing equipment

The equipment used for bathing is also of importance. Even

though plastic surfaces can be contaminated by micro-

organisms, they seem safer in terms of avoidance of trauma.

The danger of drowning is always present in infants, even when

the water level in the bath seems shallow. To date, only a few

bathtubs have been designed with the intention of reducing the

risk of drowning. In one study, a total of 32 drowning deaths

involving bath seats/rings were identified over a 13-year period.

The ages of the children ranged from 5 to 15 months (mean

8 months), and in more than 90% there was a reported lapse

in adult supervision (mean: 4 min). While making bathing

somewhat easier, bath seats/rings are useful for a relatively short

time period, as the child rapidly outgrows the product. Carers

also appear more likely to leave a child unattended in the tub if

one of these products is in use, and they cannot therefore be

recommended.

7

In addition to safety hazards, there can also be microbio-

logical hazards from bath toys. One ward survey yielded iso-

lates of multiresistant

P. aeruginosa

from a toy box containing

water-retaining bath toys, as well as from the toys themselves.

Pulsed-field gel electrophoresis of bacterial DNA demonstrated

identical band patterns of the isolates from patients, toys and

toy box water.

8

Cleansing atopic children

The problems of the skin in atopic dermatitis in terms of

hygiene are, firstly, that it is always colonized by pathogenic

micro-organisms, and, secondly, that it is dry. Some authors

have suggested that the dry skin of subjects with atopic

dermatitis does not tolerate frequent baths and the use of

soaps. It is likely that the dryness of the skin in atopic subjects

is primarily a result of a more or less clinically evident

inflammatory state, even though some studies show that the

transepidermal water loss is raised also in normal appearing

atopic skin. Although such skin would be likely to be irritated

by degreasing agents such as soap, many authors advocate fre-

quent baths because of their potential value in administration

of emollients.

Recommendations against cleansing the skin in atopic der-

matitis can also be criticised on microbiological grounds, since

even normal appearing atopic skin is heavily colonized by

Staphylococcus aureus

, which is a potential aggravating factor. On

this basis, some authors maintain that not only frequent baths,

but also regular use of soap are useful in atopic dermatitis. The

same authors postulate that the removal of crusts, scales and

other impurities present on the skin and helped by the frequent

use of soap, may act by enhancing percutaneous absorption of

topical medication, or by a direct inhibitory effect of soap on

the growth of

S. aureus

. Faced with these conflicting views, one

can only conclude that while each of the diverse theories con-

tains some element of truth, no rule in fact can be formulated

that is applicable to all subjects with atopic dermatitis. In the

absence of such rule, an empirical approach tailored to each

individual patient must be adopted. Should a child with atopic

dermatitis, having been placed in a bath, become more irritable

with increased itching, the daily bath should be substituted by

other techniques of hygiene. Should another child play in bath

without scratching, frequent bathing is permissible; in our

experience this applies to a majority of subjects with atopic

dermatitis. The bath should be followed by application of an

emollient ointment to preserve the bath-induced hydration

of the horny layer for as long as possible.

The chemical composition of the water itself may also be

relevant. For instance, water rich in calcium salts is likely to

irritate the skin more easily.

10

Antiseptic baths should thus be reserved for those patients

with atopic dermatitis in whom impetiginization is present or

expected. We commonly advise an oxidant such as potassium

permanganate (KMnO

4

) in very low concentration (1/10 000)

that is active from a microbiological point of view, but non-

toxic. Higher concentrations can dry and irritate the skin. In

practice, it must be kept in mind that potassium permanganate,

especially if not very diluted, can stain the tub as well as the skin.

The crystals, if not totally dissolved, can also burn the skin; we

advise parents to prepare a concentrated solution in a bottle

which then must be further diluted in the bath water: a rose-

lilac colour of the water indicates the correct dilution. Such a

solution can be used for limited sites with a sponge or as a wet

dressing. Chlorhexidine (5/1000–5/10 000), despite of one episode

of severe allergy,

11

can be considered safe and well tolerated.

Colloidal baths, generally in form of bath powders, have a

cereal base. Modern products are ready to be diluted in the bath

water and do not require any preparation beforehand. These

substances, complexes of poly- and oligo-saccharides, oils and

proteins are capable of adsorbing hydrophilic and lipophilic

material from the skin and can be defined as adsorptive cleans-

ing agents. A possibility of sensitization because of the content

of protein fractions should be considered.

In conclusion, the ideal paediatric detergent should be

very mild to avoid irritant dermatitis and very simple to avoid

allergic dermatitis.

12

Potentially irritating or sensitizing sub-

stances which are not essential for hygienic purposes should be

absent from paediatric products.



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JEADV

(2001)

15 (Suppl. 1)

, 12–15

References

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3 Penny-MacGillivray TA newborn’s first bath: when?

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Skin cleansing in children