Changes in skin pH after the use of baby wipes

Baby wipes and nappy rash - what is the relationship? A review

Baby wipes are a commonly used cleansing method for infants. A literature review has been performed to assess if using baby wipes is beneficial or harmful compared to water and cloth in terms of nappy rash. This includes a detailed analysis of baby wipe ingredients, as many skin irritants as well as allergens are identified. MedLine, Embase and PubMed were searched and after 420 titles and abstracts were screened, 21 studies remained for inclusion. Baby wipes are deemed as superior to water and cloth in the majority of the literature. However, no definitive conclusion can be drawn as many studies are also industry funded. The most notable allergens identified are fragrances, such as linalool, cocamidopropyl betaine (surfactant), formaldehyde-releasing preservatives and other preservatives, including methylisothiazolinone and methylchloroisothiazolinone. As not all allergens are listed on the label accurately, this can be misleading for the consumer.

The science behind wet wipes for infant skin: Ingredient review, safety, and efficacy

In the diapered area, the continuous exposure to excess moisture and irritants from urine and feces weakens the stratum corneum, making the skin more susceptible to irritation. The use of wet wipes for infants (baby wipes) is a common practice to clean skin after urine or a bowel movement, and this practice even extends to cleaning the hands and face, resulting in repeated daily use. Therefore, ensuring that baby wipes contain ingredients that are safe and mild on skin is important to help minimize skin irritation and discomfort. While disposable baby wipes have been shown to be effective and gentle at cleaning infant skin, even the skin of premature infants, there is growing public concern regarding their safety and tolerability. Not all products are made the same, as differences exist in manufacturing processes, ingredients, materials, safety, and quality testing. Therefore, it is important that healthcare professionals have accessible evidenced-based information on the safety and tolerability of common ingredients found in baby wipes to optimally educate their patients and families. Herein, we provide a review on best practices for ingredient selection, safety, and efficacy of baby wipes.

Recommendations from a European Roundtable Meeting on Best Practice Healthy Infant Skin Care

BACKGROUND

European roundtable meeting recommendations on bathing and cleansing of infants were published in 2009; a second meeting was held to update and expand these recommendations in light of new evidence and the continued need to address uncertainty surrounding this aspect of routine care.

METHODS

The previous roundtable recommendations concerning infant cleansing, bathing, and use of liquid cleansers were critically reviewed and updated and the quality of evidence was evaluated using the Grading of Recommendation Assessment, Development and Evaluation system. New recommendations were developed to provide guidance on diaper care and the use of emollients. A series of recommendations was formulated to characterize the attributes of ideal liquid cleansers, wipes, and emollients.

RESULTS

Newborn bathing can be performed without harming the infant, provided basic safety procedures are followed. Water alone or appropriately designed liquid cleansers can be used during bathing without impairing the skin maturation process. The diaper area should be kept clean and dry; from birth, the diaper area may be gently cleansed with cotton balls/squares and water or by using appropriately designed wipes. Appropriately formulated emollients can be used to maintain and enhance skin barrier function. Appropriately formulated baby oils can be applied for physiologic (transitory) skin dryness and in small quantities to the bath. Baby products that are left on should be formulated to buffer and maintain babies' skin surface at approximately pH 5.5, and the formulations and their constituent ingredients should have undergone an extensive program of safety testing. Formulations should be effectively preserved; products containing harsh surfactants, such as sodium lauryl sulfate, should be avoided.

CONCLUSION

Health care professionals can use these recommendations as the basis of their advice to parents.

Clinical approaches to skin cleansing of the diaper area: practice and challenges

Cleansing and care of the diaper area require special consideration to maintain barrier function of the skin in this area and repair the barrier when it is compromised. Diaper dermatitis occurs commonly; understanding and modification of predisposing factors are imperative for caregivers. In this paper, we review important factors in diaper area care, including skin pH, the local microbiome, irritant and allergic potential of contactants, and application of topical agents.

Prevention of diaper dermatitis in infants--a literature review

Diaper dermatitis (DD) is one of the most common skin conditions in neonates and infants, with a peak between the ages of 9 and 12 months. Appropriate skin care practices that support skin barrier function and protect the buttocks skin from urine and feces are supposed to be effective in the prevention of DD. Despite many recommendations for parents and caregivers on proper diaper skin care, there is no up-to-date synthesis of the available evidence to develop recommendations for DD prevention practice. Therefore we performed a systematic literature review on the efficacy of nonmedical skin care practices on the diapered area of healthy, full-term infants ages 0 to 24 months. We identified 13 studies covering skin care practices such as cleansing, bathing, and application of topical products. DD prevalence and incidence and physiologic skin parameters were used as efficacy parameters. The results of this review indicate that cleansing of the diaper area using baby wipes or water and a washcloth have comparable effects on diapered skin. Bathing with a liquid baby cleanser twice weekly seems comparable with water alone. The application of ointments containing zinc oxide or petrolatum with or without vitamin A seems to have comparable effects on DD severity. There seems to be no information on whether single skin care practices such as cleansing, bathing, and application of topical preparations can prevent DD. High-quality randomized clinical trials are needed to show the effectiveness of skin care practices for controlling and preventing DD.

Effect on skin hydration of using baby wipes to clean the napkin area of newborn babies: assessor-blinded randomised controlled equivalence trial

BACKGROUND

Some national guidelines recommend the use of water alone for napkin cleansing. Yet, there is a readiness, amongst many parents, to use baby wipes. Evidence from randomised controlled trials, of the effect of baby wipes on newborn skin integrity is lacking. We conducted a study to examine the hypothesis that the use of a specifically formulated cleansing wipe on the napkin area of newborn infants (<1 month) has an equivalent effect on skin hydration when compared with using cotton wool and water (usual care).

METHODS

A prospective, assessor-blinded, randomised controlled equivalence trial was conducted during 2010. Healthy, term babies (n=280), recruited within 48 hours of birth, were randomly assigned to have their napkin area cleansed with an alcohol-free baby wipe (140 babies) or cotton wool and water (140 babies). Primary outcome was change in hydration from within 48 hours of birth to 4 weeks post-birth. Secondary outcomes comprised changes in trans-epidermal water loss, skin surface pH and erythema, presence of microbial skin contaminants/irritants at 4 weeks and napkin dermatitis reported by midwife at 4 weeks and mother during the 4 weeks.

RESULTS

Complete hydration data were obtained for 254 (90.7 %) babies. Wipes were shown to be equivalent to water and cotton wool in terms of skin hydration (intention-to-treat analysis: wipes 65.4 (SD 12.4) vs. water 63.5 (14.2), p=0.47, 95% CI -2.5 to 4.2; per protocol analysis: wipes 64.6 (12.4) vs. water 63.6 (14.3), p=0.53, 95% CI -2.4 to 4.2). No significant differences were found in the secondary outcomes, except for maternal-reported napkin dermatitis, which was higher in the water group (p=0.025 for complete responses).

CONCLUSIONS

Baby wipes had an equivalent effect on skin hydration when compared with cotton wool and water. We found no evidence of any adverse effects of using these wipes. These findings offer reassurance to parents who choose to use baby wipes and to health professionals who support their use.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN86207019.

Standardized diaper care regimen: a prospective, randomized pilot study on skin barrier function and epidermal IL-1α in newborns

Adaptation of skin barrier function and interleukin-1α (IL-1α) content in diapered and nondiapered skin are poorly characterized in newborns receiving standard skin care. In a monocentric, prospective pilot study 44 healthy, full-term neonates were randomly assigned to skin care with baby wipes (n = 21) or water-moistened washcloth (n = 23) at each diaper change. Transepidermal water loss (TEWL), skin hydration, skin-pH, IL-1α, and epidermal desquamation were measured on days 2, 14, and 28 postpartum. Microbiological colonization was evaluated at baseline and on day 28. Significantly lower TEWL was found on the buttock in the group using baby wipes compared to water. IL-1α and skin hydration significantly increased and pH decreased independent of skin care regimen. IL-1α was significantly higher in diapered skin compared to nondiapered skin. Although skin care with wipes seems to stabilize TEWL better than using water, the skin condition and microbiological colonization were comparable using both cleansing procedures. Increase of epidermal IL-1α may reflect postnatal skin barrier maturation. These data suggest that neither of the two cleansing procedures harms skin barrier maturation within the first four weeks postpartum. Longer observations on larger populations could provide more insight into postnatal skin barrier maturation.

Diaper dermatitis-frequency and contributory factors in hospital attending children

The incidence and prevalence of diaper dermatitis varies widely between published studies. It is a condition which causes considerable parental anxiety. To better understand the frequency of diaper dermatitis, treatment practices, and the current importance of previously identified etiologic factors, a questionnaire survey of parents who had children wearing diapers (n = 532) attending a large United Kingdom district general hospital was undertaken. At the time of survey, only 16% of the study population had diaper dermatitis. Forty-eight percent of the study population had never had an episode of diaper dermatitis. In a multivariate analysis, current diaper dermatitis was independently associated with four factors: presence of oral thrush, number of previous episodes, frequency of diaper changes, and diarrhea. Recurrent episodes of diaper dermatitis were associated with increasing age, lack of barrier cream use, current diaper rash, and frequency of diaper changes. In the majority of children with diaper dermatitis at the time of survey, treatment had been instituted in the community. Diaper dermatitis usually presents and is treated successfully outside the hospital setting and is not a common clinical problem in secondary care.

Diaper dermatitis that does not quit

Diaper dermatitis is one of the most common skin disorders in infants. The humid, moist environment under the diaper makes the skin more susceptible to injury from exposure to irritants particularly related to urine and feces. A gentle cleansing routine, frequent diaper changes, and a thick barrier cream help control this condition. Irritant diaper dermatitis should be distinguished from other skin conditions that may develop in this sensitive area.

The acidic milieu of the horny layer: new findings on the physiology and pathophysiology of skin pH

The acidic pH of the horny layer, measurable on the skin surface, has long been regarded as a result of exocrine secretion of the skin glands. The 'acid mantle' was thought to regulate the bacterial skin flora and to be sensitive primarily to skin cleansing procedures. In recent years, an increasing number of investigations have been published on the changes in, and constituents and functions of, the pH of the deeper layers of the stratum corneum, as well as on the influence of physiological and pathological factors. A central role for the acidic milieu as a regulating factor in stratum corneum homeostasis is now emerging. This has relevance to the integrity of the barrier function, from normal maturation of the stratum corneum lipids through to desquamation. Changes in the pH and the organic factors influencing it appear to play a role, not only in the pathogenesis, prevention and treatment of irritant contact dermatitis, but also of atopic dermatitis and ichthyosis and in wound healing. On the basis of these findings, a broader concept, exceeding the superficial 'acid mantle' theory, has been formulated.

Skin physiology of the neonate and young infant: a prospective study of functional skin parameters during early infancy

Although neonatal and adult epidermis are similar with respect to thickness and lipid composition, skin development is not complete at birth. Previous studies indicate that the skin undergoes a process of adaptation and maturation postnatally. Postnatal skin physiology has not yet been evaluated comprehensively in a prospective study. We assessed skin function parameters prospectively in a cohort of 202 healthy term neonates (98 boys) of Caucasian descent. Measurements were performed at 3 days, 4 weeks, and 12 weeks of age and at four different body sites (frontal area, cheek, volar forearm, and gluteal surface). The following parameters were assessed: skin surface pH, corneal layer hydration (capacitance), epidermal desquamation, and surface roughness. Data were presented in box and whisker plots. Our results were as follows. Surface pH decreased by 0.3-1.1 units (p < 0.001), while desquamation increased significantly during the observation period (p < 0.001), but only on the facial areas. There was a significant increase in stratum corneum hydration (p < 0.001) which was paralleled by decreasing skin roughness, indicating smoothing of the skin surface (p < 0.001). No significant differences were found between male and female infants. These findings reflect significant cutaneous adaptation processes, particularly during the neonatal period. Reference values for functional skin parameters may be helpful in delineating normal from pathologic skin conditions such as ichthyosis or atopic dermatitis at an early stage when intervention might help to prevent exacerbations. The usefulness of these reference values will have to be evaluated in clinical practice.

Cutaneous tolerance of baby wipes by infants with atopic dermatitis, and comparison of the mildness of baby wipe and water in infant skin

To confirm the safety and cutaneous tolerability of a new brand of baby wet wipes, we conducted the following clinical studies: (i) a double-blind in-use study in 102 infants over a period of 2 weeks, to compare skin tolerance of the wipes vs. water and a cleansing material (ii) a chamber scarification test on adults to assess the skin irritation potential of the baby wipe, and (iii) a 4-week clinical in-use study in 60 babies with atopic dermatitis, to confirm safety and skin tolerability in a sensitive skin subpopulation. In the clinical comparison with water and cleansing material, skin conditions were assessed visually for presence and severity of erythema and diaper dermatitis. The overall skin condition was not different in the group using wipes and in the group using only water and a cleansing material, indicating comparable skin mildness for both regimes. The chamber scarification test confirmed that the lotion contained in the wipe has a very low irritation potential, lower than that of a currently marketed baby wipe and comparable to that of water under occlusive patch test conditions. The good skin tolerance of the wipes was supported by the observations of a dermatologist in the clinical study in babies with atopic dermatitis. These data strongly support the suitability of the baby wipes tested in these studies for daily cleansing of the diapered area, even for infants with sensitive skin. These data also provide useful information regarding the comparative skin mildness of baby wipes and water.

Diaper dermatitis and advances in diaper technology

During the last decade, a number of technological innovations in disposable diaper designs and materials have aimed at reducing dermatological problems in the diaper area. The introduction of absorbent gelling materials led to a decrease in skin overhydration and made possible a more beneficial pH in the diaper area. A retrospective evaluation of clinical studies conducted before and after the introduction of absorbent gelling materials confirms that utilization of these materials has been associated with a marked reduction in the severity of diaper dermatitis. More recently, a novel diaper designed to deliver dermatological formulations to the skin also appears to improve the condition of diapered skin. Disposable wipes now are available that are nonirritating and suitable for use on damaged or broken skin. Ongoing innovative efforts in this area promise to further decrease the prevalence of diaper-associated dermatologic conditions.

Neonatal skin care

The relative importance of neonatal health and neonatal skin care has been highlighted in recent years as infant mortality rates have decreased while death rates during the neonatal period remain unacceptably high in many areas of the world. During the neonatal period, many newborns develop preventable, clinically apparent skin problems, and many more, especially preterm neonates, experience morbidity caused by compromised skin barrier integrity. Several strategies are available for protecting the integrity and promoting the hygiene of the skin and augmenting its function as a barrier to TEWL and heat loss and the entrance of infectious or toxic agents. Research defining optimal applications of many of these strategies, however, and the development of new approaches in skin care is one of the greatest challenges in pediatric dermatology and holds promise for improving neonatal outcome in the future. The ability to modulate epidermal barrier function and integrity relies largely on the topical use of protective materials and substances and manipulation of the external environment. As understanding of epidermal barrier development advances, perhaps pharmacologic manipulation of barrier development, as now practiced for augmentation of neonatal lung maturity, will become a reality. In the meantime, greater awareness among neonatal health care practitioners of state-of-the-art strategies for optimizing skin integrity in neonates is an important step toward improving neonatal health.

Diaper dermatitis

The primary goals of preventing and treating diaper dermatitis include keeping the skin dry, protected, and infection free. Frequent diaper changes with the superabsorbent disposable diapers may be the best tactic for infants' skin, if not the environment. Also, the more time that infants spend without diapers, the less dermatitis they experience, but a practical balance must be struck. Gentle cleansing and barrier creams are beneficial, and candidal infection must be treated. Finally, any recalcitrant diaper dermatitis must be further investigated to uncover underlying disease (Fig. 6).