Diaper dermatitis and skin trauma in children

The main thing in caring for a newborn boy is taking care of his skin. In infants, it is a sensitive organ that is both a way of interacting with the world and a protective barrier. The baby's skin is formed from cells of the same type as the nervous system, and therefore contains many receptors. Skin is a kind of mirror in which the well-being and health of the baby is reflected.

The skin also performs a respiratory function: 60% of all gas exchange occurs through it. Meanwhile, the thickness of the skin in a newborn baby is only 0.4 mm (in an adult - 2 mm), and the barrier stratum corneum is initially absent. That's why baby's skin is more susceptible to infections and various factors: water, heat, solar radiation, wind and, of course, detergents. It is not surprising that about 10% of doctors’ calls to children are related to skin diseases. Proper care of your baby's skin and careful selection of cosmetics will help you avoid many unnecessary problems.

Caring for a newborn: intimate hygiene

Almost every mother of a newborn boy has three main questions:

1. To wash or not to wash your baby after every diaper change?
2. Should I open the foreskin of the glans penis while washing?
3. Is it harmful for a child to wear diapers?

Let's answer them in order:

To wash or not to wash – that is the question

Caring for a newborn boy necessarily includes washing. Boys should be washed no less often than girls! That is, every 2-3 hours or with every diaper change. Unlike girls, boys can be washed in any direction, even from front to back, even vice versa, you can’t just do it in the pelvis (after defecation). Residues of enzymes and undigested food can cause infection of the genitourinary organs and irritation of the perineum, leading to diaper rash. Therefore, you only need to wash the boy with running water. And after washing, do not rush to put on a diaper and dry the skin properly. The more air baths your baby takes, the better for his skin! It is not recommended to use soap, solutions of soda and potassium permanganate and other detergents when washing, so as not to deprive the baby’s skin of the protective glycolipid mantle. After washing, inguinal folds and irritated areas can be lubricated with hygienic oil - olive, almond (sold at the pharmacy). The scrotum and penis do not need to be lubricated.

Failure to comply with the rules of intimate hygiene in a newborn boy can lead to balanoposthitis (inflammation of the glans penis) and a stage of phimosis (growth of the foreskin), which can only be corrected surgically. Inflammation of the genital organs suffered by a boy in childhood can result in infertility, impotence, prostatitis and other unpleasant problems in adulthood. Proper care of a newborn boy is the key to his good male health in the future.

Foreskin: to open or not to open the head of the penis?

Modern, progressive doctors strongly recommend leaving the foreskin of boys until they are 5–6 years old alone. At an earlier age, the inner surface of the foreskin is still firmly connected to the head of the penis. This phenomenon is absolutely normal; in medical language it is called physiological phimosis. Premature shifting of the baby's foreskin leads to the formation of small wounds, which, when healing, leave scars, which leads to an even greater narrowing of the foreskin.

Diapers: yes or no?

There is an opinion that constantly wearing diapers overheats the baby’s genitals, disrupting their natural formation and the process of sperm production. Studies were conducted at the Scientific Center for Children's Health, which showed that an increase in temperature by 2 ºС due to the use of diapers does not affect sexual function and the formation of the genital organs. This is also supported by the fact that a generation of children has already matured who grew up in diapers, but at the same time successfully have their own babies (although the percentage of primary male infertility has definitely increased these days, no matter what causes it). But experienced experts still recommend not keeping your baby in diapers all the time.

Sometimes a baby becomes allergic to a diaper, or rather, not to the diaper itself, but to the materials from which it is made. This doesn't mean you need to give up diapers altogether. Just change the manufacturer and always make sure that the diaper matches the baby's weight. For allergies in newborns, it is very good to use “natural baby swaddling systems.” At the first stage of their use, they require a little more time to learn than regular disposable diapers, but later, once you get used to them, you will appreciate that, firstly, they are more environmentally friendly, and secondly, in the end they are cheaper to use than disposable ones.

Diaper dermatitis and skin trauma in children

During infancy, the skin, like the entire body, functions in a state of unstable equilibrium, which means that the newborn baby is especially vulnerable to adverse factors. It is at this stage of child development that various microtraumas of the skin are possible due to the immaturity of the skin. The epidermis of a newborn is juicy and loose, the stratum corneum is thin and contains cells with nuclei up to the very top layers, as a result of which it cannot perform a full protective function. It is easily vulnerable to the slightest mechanical and/or chemical influences (bathing, swaddling, soaping) and is easily macerated. An insufficiently formed water-lipid mantle on the surface of the skin of newborns and increased alkalinity of the environment, especially in intertrigenous and seborrheic areas, play an important role in the susceptibility of the skin of newborns to bacterial infections. It should be noted that the immunobiological defense mechanisms of newborns are imperfect in the fight against pyogenic infection. The imperfection of natural immunity in newborns, which is largely associated with physiological hypogammaglobulinemia at an early (3-6 months) age, has a direct impact on the protective properties of the skin. In the infancy period, there is a tendency to increase the number of children with sluggish forms of streptoderma, manifested by itchy erythematous-squamous foci, damage to large and small folds with symptoms of maceration or oozing and hyperemia of the perianal area. Erroneous interpretation of the clinical manifestations of pyoderma as allergic leads to the prescription of topical glucocorticosteroids and, as a rule, a worsening of the disease [1, 2].

The peculiarity of the course of the pathological process on the skin of newborns is distinguished by the fact that during this period there is a special sensitivity to staphylococcal infection, which has a tendency to generalize. A common complication of pyoderma is sepsis. It should be noted that the general reaction of the body lasts much longer than the pathological process on the skin [2].

Traumatic damage to the skin due to poor care and friction by contacting surfaces of irritated skin or rough clothing leads to diaper rash, which in modern literature has received the second name “diaper dermatitis”. Diaper dermatitis is a widespread phenomenon, the incidence of its development ranges from 30% to 60%. The formation of diaper rash is facilitated by skin contamination, increased humidity under diapers or inside the diaper, difficult access of air, infection, poor hygiene with a lack of water procedures. Diaper dermatitis most often develops in children with atopic dermatitis or infantile seborrheic dermatitis. Diaper dermatitis can occur from the first weeks of life, but the peak of the disease is observed between the 7th and 12th months, when the child’s diet becomes more varied [2]. It has long been known that the incidence of diaper dermatitis is lower among breastfed infants, which is explained by the less acidity of urine and feces during breastfeeding [3].

The clinical picture is characterized by foci of erythema with fairly clear boundaries, located on skin surfaces in contact with each other, in the inguinal folds, and in the axillary areas. Erythema has different color intensities, from light to bright red; in severe cases, maceration, detachment of the epidermis, erosion, and weeping appear. Lack of proper care and treatment can lead to progression of the process and the development of superficial ulcers. If diaper dermatitis persists for more than 72 hours and does not respond to conventional treatment, it is assumed that the skin may be infected with Candida albicans or gram-positive and gram-negative flora, including Proteus and Pseudomonas aeruginosa. First of all, it is necessary to eliminate excess moisture, improve skin hygiene and child care. It is advisable to use modern disposable diapers, the inner cellulose layer of which contains a gel-forming material with high moisture-absorbing ability. The advantage of these diapers is that urine is absorbed and retained in the inner layer and the baby's skin does not come into contact with the moisture. In addition, the child should not be dressed too warmly; tight-fitting clothing should also not be used. Don't forget to wash your baby more often and then dry the skin thoroughly. Air baths for 5 minutes are needed every day 2-3 times a day. Shake mixtures are prescribed externally and antimicrobial and disinfectant substances are added. According to V.M. Delyagin (2013), talc or other “talc-free powders” should never be used. As adsorbents, they are ineffective, turning into “urinary compresses.” It is also harmful to use starch, which, by absorbing moisture, becomes a medium conducive to the growth of pathogenic flora [3].

The therapeutic and preventive effect for diaper dermatitis is provided by Bepanten® ointment, which forms a protective barrier against external irritants (urine, feces). The lanolin-based ointment base of the drug prevents transepidermal moisture loss, while preserving skin respiration processes, which allows the ointment to be used at any time of the year. A study of the effectiveness of Bepanten® ointment for the prevention of diaper dermatitis was carried out at the Scientific Center for Children's Health of the Russian Academy of Medical Sciences [4]. We observed 62 newborns with perinatal lesions of the central nervous system, gestational age from 32 to 40 weeks, 32.3% premature. 40 children were treated with Bepanten® ointment for preventive purposes at every diaper change. The second group (comparison group), which included 22 children, received a standard ointment based on petroleum jelly and sunflower oil. As a result of the study, in the 1st group of observed children, not a single case of diaper dermatitis was recorded, and in the comparison group, the development of diaper dermatitis of varying severity was observed in 45.5% of cases. These children were prescribed treatment with Bepanten® ointment; as a result of therapy, clinical improvement was noted after 2 days.

Skin injuries

Not a single child in the process of development avoids skin injuries. They lie in wait for him everywhere - at home, on the street, in kindergarten, in transport, while playing sports. The majority of them, fortunately, are mild. These include abrasions, scratches, shallow wounds, scratches resulting from scratching - that is, all those injuries that do not cause significant damage to health and heal quickly. Burns are more severe and dangerous skin injuries. Surgeons have alarming statistics: among the total number of people who received burns, more than 35% are children, almost half of whom are very young - under three years old. The younger the child, the greater the risk of burn injury. Even superficial burns, if they are extensive in area, always threaten the lives of children, and limited deep burns often lead to disability from an early age. According to foreign researchers, burns account for 3% to 8% of all accidents in children. In addition, 95% of all cases occur at home, predominantly as a result of scalding (73%), which usually occurs in the kitchen (62%) or bathroom (16%), more often in boys (59%) than girls (41). %), the average age of children is 24 months [5, 6].

The development of inflammation is a normal physiological response to skin damage. When the integrity of the skin is violated, neurohumoral mechanisms are immediately activated, the purpose of which is to restore the homeostasis of the body through the closure of the wound defect. The faster the skin recovers, the greater the likelihood of either scarless healing or healing with the formation of aesthetically acceptable scars. The speed of reparative processes in the skin depends on many factors (the area and depth of damage, the state of reactivity of the macroorganism, the presence of concomitant pathology, the state of the microvasculature, etc.) [7, 8].

Superficial skin injuries

The result of skin trauma can be complete restoration of the skin, without visible differences from healthy skin. This is possible with superficial injuries to the skin, with damage to the epidermis to the basement membrane and the apexes of the papillae. Such wounds always heal without scars due to increased proliferation of basal keratinocytes. In this case, the dermis remains practically intact, so the rate of healing depends on the proliferative ability of keratinocytes. This injury is more often observed in children with abrasions and scratches. Shallow skin defects occur with I–II degree burns. However, in young children, not only the depth of the lesion is important, but also its area. The size of the burn area is estimated using the “rule of the palm.” Conventionally, the surface of a child’s palm is taken as one percent of the total area of ​​the body. A burn whose size exceeds five palms, i.e. more than 5%, threatens the development of burn disease. For this reason, newborns must be hospitalized, regardless of the area of ​​burns, and children under one year of age if the burn area exceeds 5% of the total body surface area. Children over one year of age are sent to the hospital if the burn area exceeds 10% of the total body surface area. In addition, children with small burns with an area of ​​5% to 10% with respiratory and hemodynamic disorders, burns in the face, hands or perineum require hospitalization [5].

First aid for any burns is rinsing with running water. Cold stops the spread of high temperature deep into the skin and soothes pain, preventing the child from developing burn shock. You can water the burned area with tap water, apply snow, ice, or any frozen product from the refrigerator to it. Cooling should be long, at least 20 minutes, since high temperatures, which can cause cell death, can remain in the skin for a very long time - up to 6 hours. Quickly applying a dry bandage creates a heating pad effect and intensifies the burn, so it is better to cover the burned area with a damp cloth with an antiseptic solution (0.05% chlorhexidine solution, furatsilin solution). If a child is scalded by boiling water, the damage is much more serious. It takes a surprisingly short period of exposure to hot water (1 second at 70°C) for a deep burn to occur, especially on the thin skin of newborns. Over 65% of burns from boiling water occur in children under two years of age [5].

With a second degree burn, blisters form on the skin due to acantholysis of the epidermis. Contrary to the popular belief that blisters need to be opened, in our opinion, such a need arises extremely rarely - only if a secondary infection develops. Since the contents of the blisters are sterile, the eroded surface of the skin should not be exposed, creating ideal conditions for infection. Any careless intervention will infect the wound and lead to purulent complications and subsequent scars. If the bubble does open, a napkin soaked in a furatsilin solution is applied to this place and secured with a bandage. The use of anti-burn sprays immediately after injury is only possible for small and shallow burns in children over three years of age.

An innovative drug for healing wound surfaces of the skin is dexpanthenol. Upon penetration into the skin, dexpanthenol is converted into pantothenic acid, a structural element of coenzyme A. Coenzyme A is a key element of the Krebs cycle, which generates the energy necessary for regeneration and functioning processes. Dexpanthenol, the active ingredient of Bepanten®, has been successfully used for wound healing for several decades [9]. Modern scientific data demonstrate the direct effect of dexpanthenol on the proliferation of keratinocytes. When cell scrapings were treated with dexpanthenol, an increase in the production of Ki67 protein, a specific indicator of cell proliferation and activation of pro-inflammatory genes, including the gene encoding interleukin-6 (IL-6) was reliably established [9]. The effect of dexpanthenol is not limited only to the activation of fibroblasts; the results of recent in vitro studies have demonstrated the anti-inflammatory effect of the drug. Dexpanthenol induces the expression of the HMOX-1 gene (HO-1 protein), which is involved in the wound healing process, exhibiting an antioxidant effect, and also provides protection against the damaging effects of reactive oxygen species in the mitochondria of Ehrlich ascitic tumor cells [9].

On wound surfaces, it is better to use the dosage form of dexpanthenol - Bepanten® plus, which has a double effect due to the components it contains: dexpanthenol and chlorhexidine.

Firstly, chlorhexidine forms a film on the wound surface, providing its main antiseptic effect for a long time. Chlorhexidine is a well-known antiseptic drug, active against gram-positive and gram-negative bacteria (Treponema pallidum, Chlamydia spp., Ureaplasma spp., Neisseria gonorrhoeae, Gardnerella vaginalis, Bacteroides fragilis, except for Mycobacterium tuberculosis); protozoa (Trichomonas vaginalis); herpes virus. Secondly, the cream base of the drug allows dexpanthenol to penetrate deeper into the wound, activating the synthesis of adenosine triphosphoric acid (ATP) and the proliferation of fibroblasts. As a result, a double effect is achieved - a film of chlorhexidine is formed on the surface, which disinfects the wound, and dexpanthenol, which penetrates deeper, stimulates regeneration. Such features allow you to quickly achieve healing in those areas of the skin where there is constant exposure to the wound surface (flexion and extension).

Deep skin injuries

Skin injuries located deeper than the apexes of the papillae result in damage to the basement membrane and capillaries of the superficial vasculature. Bleeding and pain are the first symptoms of such an injury. Such skin damage can be observed with burns of II–IIIa degrees, and it heals, as a rule, without scars due to preserved fragments of the basement membrane with basal keratinocytes, from the epithelial cells of the hair follicle and from the epithelium of the sebaceous gland ducts. Such an injury heals according to the principle of tension; basal keratinocytes begin to actively divide and rush to the bottom of the wound, crawling from the edges, creating first a monolayer of cells, and then a multilayer layer, under which the process of repairing the skin defect and restoring the skin is completed. Under aggravating circumstances (secondary infection, decreased immunity, endocrinopathies, etc.), the skin defect deepens below the basement membrane; in this case, after repair of the skin defect, depigmentation may develop. The key to preventing pathological scarring is the activity of keratinocytes, which ensures rapid wound healing. For this reason, drugs that stimulate mitosis can prevent prolonged inflammation and subsequent formation of a pathological scar. According to the results of clinical testing conducted at the St. Petersburg Research Institute of Obstetrics and Gynecology, Bepanten® cream showed high clinical effectiveness in the treatment of non-infected skin lesions already on 2–3 days from the start of treatment. The drug was well tolerated and no side effects were recorded.

Scarring results in skin injuries below the ridges of the epidermis at the border of the papillary and reticular layers of the dermis. The depth of such wounds is comparable to IIIa degree burns. The type of scars can vary from normotrophic to hyper- and atrophic. Pathological scars develop in the presence of accompanying aggravating factors that reduce the reactivity of the body.

Deep injuries with destruction of underlying tissues, namely damage to subcutaneous fat, always heal with the formation of deforming scars. In this case, the preconditions for a hypotrophic scar always arise. With the development of prolonged inflammation, prerequisites arise for the formation of hypertrophic scars [8, 10, 11]. First aid for such skin injuries is to wash the wound, stop the bleeding and apply a sterile bandage. Antiseptic drugs are used to prevent infection. Many of them, in addition to their antiseptic effect, have an anti-inflammatory effect and also promote healing processes. Solutions containing ethyl alcohol, if they get deep into the wound, can cause tissue necrosis, preventing further healing. Alcohol solutions are used to treat the skin around the wound and the edges of the wound.

During the healing of skin defects, the emphasis of the cellular spectrum shifts only towards proliferation, differentiation and transformation of fibroblasts and proliferation of keratinocytes. It is known that the faster the inflammation is stopped and the wound defect is closed by fibrous and cellular structures of the connective tissue with subsequent epithelization, the more favorable the appearance of the scar. That is, the more accelerated epithelization occurs, the more aesthetically pleasing the scar will look. It is important at this moment to prevent inflammation and divergence of the edges of the wound. To prevent pathological scarring on days 2–3 after skin injury, it is recommended to use agents that enhance cell proliferation (Solcoseryl, Actovegin, Bepanten® plus) [10, 11].

Skin trauma is a concomitant process in the life of any child. In such situations, the doctor must first of all prevent infection of the wound surface, and then make every effort to stimulate rapid epithelization and aesthetic formation of the scar.

Literature

1. Suvorova K. N., Kasikhina E. I., Grishko T. N., Basse F. B. Modern features of the course of dermatoses in children of the first year of life. I Moscow Forum “Dermatovenereology and cosmetology: synthesis of science and practice.” Abstracts of reports. Moscow, 2011. P. 31.
2. Suvorova K. N., Kuklin V. T., Rukovishnikova V. M. Pediatric dermatovenerology. Kazan, 1996. 441 p.
3. Delyagin V. M. Diaper dermatitis // Medical Council. 2013, no. 1. pp. 56–58.
4. Putet G., Guy B., Pages S., Gibaud C., Andres P., Sirvint A., Puffay P., De bony R., Girard P. Efficacy of Bepanten® Ointment in the prevention of diaper dermatitis in premature and full-term infants: open pilot study // Realites Pediatriques. 2000, no. 52. pp. 2–7.
5. Korolev V. M., Korablev V. N. Organization of medical care for victims with combined trauma in a first-level trauma center. Monograph. 2012.
6. Dyachenko V. G., Rzyankina M. F., Solokhina L. V. Guide to social pediatrics. 2010.
7. Myadlets O. D., Adaskevich V. P. Morphofunctional dermatology. M.: Medlit, 2006. 752 p.
8. Ozerskaya O. S. Hypertrophic scars // Journal of dermatovenerology and cosmetology. 2002, no. 1. pp. 60–63.
9. Wollina U. Recessive Epidermolysis Bullosa Dystrophicans (Hallopeau-Siemens) — Improvement of Wound Healing by Autologous Epidermal Grafts on an Esterified Hyaluronic Acid Membrane // The Journal of Dermatology. 2001, Vol. 28, pp. 217–220.
10. Gallyamova Yu. A. Diseases of the skin and hair (current issues). M.: RMAPO. 2011. 328 p.
11. Gallyamova Yu. A. Kardashova Z. Z. Hypertrophic and keloid scars // Attending Physician. 2009, no. 10, pp. 20–23.

Yu. A. Gallyamova, Doctor of Medical Sciences, Professor

GBOU DPO RMAPO Ministry of Health of the Russian Federation, Moscow

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Caring for a newborn boy: bathing

Caring for a newborn up to six months of age involves daily bathing. In the future, you can bathe the baby every other day or even two. Bathing is intended, first of all, not to cleanse dirt (a baby who cannot walk or crawl does not get particularly dirty yet), but to wash away the waste products of the sebaceous and sweat glands from the skin and give it the opportunity to breathe fully.

At the beginning of life, a newborn has a neutral skin pH and is therefore very vulnerable to bacteria and external influences. Only by six months the environment becomes more acidic and a protective glycolipid mantle forms on the skin. It should be protected from excessive use of detergents and maintained by lubricating the skin with natural oils. Olive, almond and other natural oils have a composition similar to that of sebum, so they easily penetrate deep into the skin and saturate it with beneficial substances that increase its protection. After each bath, you can carefully lubricate all the folds of the newborn’s skin with a thin layer of sterile hygienic oil, baby cream or milk. Close attention should be paid to the area behind the ears, where the delicate skin often gets wet and crusts form. After six months, you can moisturize your baby’s skin as needed.

Herbal medicine - the use of herbal decoctions - is at your discretion, just do not forget the fact that recently more and more babies are born with a predisposition to allergies.