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Ilmu Kesehatan Kulit dan


Fakultas Kedokteran April 2019
Universitas Pattimura


A. Mudrikah H Dirgahayu (2017-84-027)

Teisha J V Marantika (2017-84-029)
dr. Hanny Tanasal, Sp. KK
dr. Rita Sugiono Tanamal, Sp.KK
Dibawakan Dalam Rangka Tugas Kepaniteraan Klinik
Bagian Ilmu Kesehatan Kulit dan Kelamin
Fakultas Kedokteran
Universitas Pattimura


• The efficacy of this barrier is proportional to its thickness and
lipid composition.
• During late gestation, the number of epidermal layers and
the thickness of the stratum corneum increase with fetal age.
Vernix Caseosa

Vernix Caseosa
• During the last trimester of gestation, the fetus is covered by a protective
biofilm called vernix caseosa.

• It forms a mechanical ‘shield’ against maceration by amniotic fluid and

bacterial infection.

• Application of vernix to normal adult skin has been shown to increase

surface hydration
• Unlike postnatal skin, sebum and keratinocytes are not shed in the
fetal period but adhere to the skin;
• accumulation of vernix  compensate for the relative lack of barrier
lipids in fetal skin.
• Shedding of vernix  maturation of the transepidermal barrier


protects against
- Evaporation - Epidermis thickness
Epidermis - Percutaneous absorption of - Barrier lipid content

depend on
toxic substances
- Physical damage
- Microbial infection
Gestational age
The number of epidermal
cell layers
thethickness of the
stratum corneum 
increase progessively
with age.

The most important lipids

required for barrier
function (i.e. ceramides,
cholesterol and free fatty
are synthesized in the
lamellar bodies within the
granular layer.
Epidermis (cont’d)
There is a patterned succession of epidermal expression of mRNA and of enzymes involved in
lipid synthesis preceding the formation of an effective epidermal barrier.
Peroxisome proliferator-activated receptor-α (PPAR-α ).
◦ One of the most important factors regulating the sequence of epidermal differentiation and stratum
corneum formation
◦ PPARs  expressed abundantly in early fetal epidermis;
◦ PPARs regulate the activity of key enzymes required for barrier ontogenesis (e.g. β - glucocerebrosidase
and steroid sulphatase)
Epidermis (cont’d)
Glucocorticoids, thyroid hormones and oestrogens accelerate barrier formation
Androgens retard barrier formation
Initiation of skin barrier formation in the human fetus starts at around 20 – 24 weeks ’ gestation
The process of keratinization  temporal and spatial pattern
◦ starting at and spreading from distinct epidermal initiation sites such as forehead, palms and soles.
Transepidermal Water Loss
TEWL  to assess the intactness of the epidermal barrier
TEWL is proportional to the vapour pressure gradient measured with an evaporimeter.
◦ Influenced by gestational age, site and ambient humidity

In term neonates, the TEWL ranges from 4 to 8 g/m2/h.

◦ slightly lower than in adults
◦ eccrine sweating is low or absent in the newborn infant.

In the premature infant, TEWL is inversely proportional to gestational age (Fig. 3.3 ).
TEWL (cont’d)
In very immature infants (24 – 26 weeks ’ gestation), it can be as high as 100 g/m2/h
◦ if left in a dry atmosphere, could lose 20 – 50% of their body weight within 24 h.
◦ lead to hypernatraemia, polyglobulia and hypothermia intracranial haemorrhage and death.

TEWL can be prevented by raising the ambient humidity.

◦ as TEWL represents passive diffusion of water along a water vapour gradient.
◦ common practice: to humidify incubators for premature babies (particularly those of less than 32 weeks ’
◦ The humidity  80 – 90% within the first days
◦ to prevent heat and fluid loss.

Prevention of hypothermia and TEWL  using polyethylene caps or wraps immediately after delivery.
In underdeveloped countries, postnatal topical emollient therapy with sunflower seed oil or mineral
oils (petrolatum)  reduce mortality rates in premature infants significantly.
TEWL (cont’d)
TEWL  regional variability
◦ highest through the abdominal skin, where maturation of the epidermal barrier occurs latest

Preterm infants nursed under a radiant heater exhibit higher rates of evaporation
It is increased (by 20%) during phototherapy,
◦ even if relative humidity and ambient temperature are tightly controlled;
◦ probably caused by increased dermal blood flow during phototherapy
◦ Maintenance fluid intake of preterm infants should therefore be adequately increased during

Neonatal epidermis can easily be hurt (e.g. by removal of plastic adhesives), which induces a
measurable disruption of the skin barrier function.
TEWL (cont’d)
Air exposure leads to acceleration of postnatal barrier maturation.
◦ TEWL in most premature infants approaches that of term infants within 10 – 15 days.
◦ This functional maturation is paralleled by an increase in stratum corneum thickness, the number of
lamellar bodies in stratum granulosum cells and the barrier lipid content of the stratum corneum
◦ In ultra-low-birthweight infants (23 – 25 weeks of gestational age), take significantly longer.
◦ Inmature babies it takes up 12 months until TEWL normalizes to levels seen in older children and adults;
this process is paralleled by a constant increase of natural moisturizing factor levels within the
Percutaneous Absorption
The immature epidermis is prone also to the accidental transcutaneous resorption of toxic
substances applied to the skin surface.
Skin permeability is inversely proportional to gestational age
◦ in the term infant, transcutaneous absorption is more readily achieved.

Low - molecular - weight chemicals (< 800 Da) penetrate more easily.

• Topical antiseptics (hexachlorophene,

• Antibiotics (particularly neomycin, which
is highly ototoxic), Neonatal Toxicity
associated with
• Alcohol dressings, (particularly in the preterm
• Salicylates, infant)
• Urea and others
Skin surface pH
Acidification of the skin surface is effected by acidic components in the sweat, sebum and horny
Three classes of molecules are considered to be the most likely sources of protons in the
◦ some amino acids and filaggrin-related breakdown products such as urocanic acid and pyrrolidone
carboxylic acid;
◦ α-hydroxy acids such as lactic acid;
◦ acidic lipids such as cholesterol sulphate and free fatty acids.

At birth, neonates exhibit skin surface pH of 6.2 – 7.5.

In both term and preterm infants, the pH declines rapidly in the first week, and slowly thereafter
up to the fourth week of life, when a range of 5.0 – 5.5 is reached, which is similar to that in
older children and adults.
Stratum corneum hydration
and skin roughness
Neonatal skin is relatively dry and rough compared with that of older infants.
Stratum corneum hydration and skin roughness are correlated
◦ In healthy term neonates, corneal layer hydration increases and skin roughness decreases proportionate
to age.

The skin surface of the newborn is rather hydrophobic,

◦ limits epidermal adsorption of water
◦ The heat loss caused by evaporation of amniotic fluid from the skin of the newborn is thus minimized.

Dermis supplies
• Dermal vessels are most important for the regulation of skin and body

• The dermis connects the epidermal sheath with the underlying fatty tissue 
provides stability and protection against trauma to the skin.
Sebaceous gland activity
• Squalenes and monoester waxes  sebum

• Sebum levels during 1st month = adults   until puberty

• Stimulation of sebaceous glands by maternal androgens starts

before birth.
• Density of sweat glands is > in adults, thermal sweating is reduced in the term

• Sweating occurs first on the forehead  the trunk and extremities

• The intensity of sweating --> depends on gestational age.

• Preterm babies  unable to sweat 1st day of life

• Preterm babies  able to sweat 13 days age

• Emotional sweating (palmoplantar)  hunger/pain. (≥36–37 wg)

• Functional immaturity of the sweat glands appears to be without clinical

significance in the neonatal period.

• anhidrotic ectodermal dysplasia  hyperpyrexia (-)

• Neonates  risk of heat loss.

• Regional heat loss = the external temperature.

• The vasoconstrictive response to reduced temperature  diminished in the

newborn infant.

• Occlusive wrapping of very-low-birthweight infants has been shown to

prevent the dangerous postnatal evaporative heat loss.
Percutaneous respiration
• The absorption of oxygen and excretion of carbon dioxide through the skin
<2% of total respiration  In adults and mature neonates

• Interestingly, “kangarooing” between premature babies and their mothers 

improve gas exchange independent of postnatal age.
Wound healing
• wounded fetal tissue is characterized by overexpression of the homeobox gene Prx-2 and
decreased expression of HOXB13 compared with adult skin.

• Prx-2  regulation of extracellular matrix reorganization, matrix metalloproteinase 2, and

hyaluronic acid production.

• Fetal skin fibroblasts  lower expression of the integrin subunits α1 and α3 and
increased expression of α2.

• Fetal skin doesn’t exhibit dermal expression of some proteoglycans following trauma
decreased inflammatory and fibrotic responses.