The survival rates of infants born before 28 weeks of gestation have markedly improved over recent decades, thanks to advancements in neonatal intensive care and medical technology. While this progress is a cause for celebration, it also introduces complex challenges for healthcare providers and families alike, particularly in the domain of neonatal skin care. The skin of extremely preterm infants is extraordinarily fragile and underdeveloped, necessitating specialized approaches to maintain its integrity and prevent complications. Current clinical practices are fragmented, with significant variability influenced by geographic, institutional, and provider-specific factors. This inconsistency underscores an urgent need for rigorous, population-specific research to optimize skin care protocols tailored to this most vulnerable patient group.
Skin integrity in extremely preterm neonates is a foundational aspect that directly impacts infection control, pain management, and fluid balance. The epidermis and dermis of these infants have yet to reach adequate maturity, resulting in a permeability barrier that is both ineffective and prone to breakdown. As the largest organ of the body, the skin serves as the first line of defense against environmental insults, microbial invasion, and mechanical injury. In premature infants, compromised skin integrity elevates the risk of systemic infections and sepsis—a leading cause of mortality in this population. Moreover, compromised skin contributes to increased insensible water loss, which complicates fluid management and can exacerbate metabolic instability.
Despite the recognized importance of skin care in neonatal practice, there remains a significant gap in population-specific evidence that delineates best practices for extremely preterm infants. Much of the existing literature extrapolates data from studies involving moderately preterm or term infants, whose skin physiology and developmental needs differ substantially. Neonatal units worldwide deploy a variety of skin care strategies, encompassing different emollients, cleansing agents, and adhesive products. However, the efficacy and safety of these interventions remain inadequately studied in the extremely preterm cohort, resulting in divergent care standards that may compromise outcomes.
Addressing these challenges, the Skin InteGrity in extreme preterms research NETwork (SIGNET) has emerged as a pioneering collaborative initiative. SIGNET focuses on uniting clinicians, researchers, and policy-makers to systematically investigate skin physiological parameters, align clinical endpoints, and establish consensus-driven care protocols tailored to the delicate needs of this population. A cornerstone of SIGNET’s mission is the harmonization of outcome measures across studies to facilitate comparative analysis and evidence synthesis. This approach aims to ensure that data generated are robust, clinically meaningful, and translatable into practice.
Physiological studies spearheaded by SIGNET are critical to elucidate the microanatomical, biophysical, and biochemical characteristics of extremely premature skin. Parameters such as transepidermal water loss, skin pH, hydration levels, and barrier lipid composition are systematically evaluated to build comprehensive profiles reflective of gestational age-specific skin maturity. These metrics provide foundational knowledge that guides the development of targeted interventions designed to reinforce the skin barrier, reduce vulnerability, and support maturation. Such insights are pivotal in directing research on novel topical agents and protective modalities.
In tandem with physiological investigations, SIGNET champions the dissemination of knowledge through multidisciplinary forums and collaborative platforms. Knowledge exchange between neonatologists, dermatologists, nurses, researchers, and families fosters a holistic understanding of skin care challenges and solutions. This collaborative spirit is essential to break down traditional silos in neonatal care and ensure that evolving evidence informs bedside practices promptly. Education initiatives spearheaded by SIGNET also aim to equip healthcare teams with practical skills and awareness critical for consistent implementation of skin-friendly practices.
Importantly, SIGNET also recognizes the psychosocial dimensions intertwined with skin care in extreme prematurity. Families of these infants often grapple with stress and anxiety related to their child’s fragility, and involvement in skin care regimens can nurture bonding and confidence. By promoting skin care protocols that emphasize gentle handling and minimal disruption, SIGNET indirectly supports developmental care measures and parental empowerment. This dimension represents an underappreciated yet vital aspect of holistic neonatal care that underscores the importance of evidence-based, infant-centered approaches.
A significant portion of the variability in skin care outcomes is attributed to disparities in resource availability and clinician expertise across geographic settings. High-income countries may have access to advanced wound care products, emollients, and monitoring technologies, whereas low- and middle-income settings often rely on basic supplies and protocols. SIGNET’s global collaborative framework seeks to generate adaptable guidelines that incorporate these realities and promote equity in care quality. Through benchmarking and shared learning, SIGNET aims to elevate standards and reduce outcome disparities on a worldwide scale.
Technological innovation stands to revolutionize the monitoring and management of skin health in extremely preterm infants. Emerging modalities such as non-invasive imaging, digital skin assessments, and biomarkers of inflammation are being integrated into investigative protocols. These tools offer real-time insights into skin status and response to interventions, enabling personalized and dynamic skin care strategies. SIGNET’s support of technology-driven research paves the way for precision neonatal dermatology, which can significantly mitigate long-term morbidities associated with skin injury and chronic inflammation.
The clinical implications of improved skin care extend well beyond the neonatal intensive care unit. Skin integrity can influence systemic health trajectories by modulating infection rates, nutritional status, and pain burden. Longitudinal studies are needed to understand how early skin care interventions affect developmental outcomes and quality of life in survivors of extreme prematurity. SIGNET’s agenda prioritizes prospective cohort studies and randomized controlled trials to generate this critical longitudinal evidence, embedding skin care at the heart of comprehensive neonatal follow-up programs.
The network’s integrative approach amalgamates biological research, clinical trials, epidemiology, and health services research. By addressing barriers at multiple levels—from cellular pathophysiology to health system infrastructure—SIGNET aims to achieve sustained improvements in skin care delivery and outcomes. This systems-based perspective emphasizes implementation science and knowledge translation to ensure that findings do not languish in academic confines but actively transform care pathways and protocols.
In parallel with research endeavors, SIGNET is devoted to developing practical, evidence-based toolkits and guidelines for frontline clinicians and caregivers. These resources aim to standardize skin care practices and provide clear, actionable recommendations informed by the latest scientific insights. By facilitating adherence to optimized protocols, SIGNET anticipates reductions in infection rates, pain episodes, and fluid management challenges. Ultimately, these tools are designed to be adaptable, scalable, and sensitive to the unique needs of each clinical environment and patient.
The emergence of such a focused collaborative network is timely, given demographic shifts toward increased survival of extremely preterm infants worldwide. As populations of survivors grow, so too does the imperative to address the nuanced vulnerabilities they face, with skin care standing as a pivotal component. SIGNET’s leadership in mobilizing the neonatal community underscores the prioritization of skin integrity as an essential determinant of health and wellbeing. Continued investment in this domain promises to yield dividends in patient outcomes, family satisfaction, and healthcare system efficiency.
In summation, the improvement in survival among infants born before 28 weeks gestation necessitates a paradigm shift in neonatal skin care—transforming it from a supportive measure into a science-driven, standardized element of care. The SIGNET initiative represents a bold step in addressing this unmet need through collaborative research, technology integration, and knowledge dissemination. By championing population-specific evidence and practical tools, SIGNET aims to safeguard the skin health and overall wellbeing of the most immature infants, shaping a future where improved survival is accompanied by enhanced quality of life.
The challenges are formidable, but the convergence of expertise and commitment within SIGNET signals a new era in neonatal dermatologic care. Through sustained effort, innovation, and collaboration, the network offers hope for reducing the burden of skin-related complications, improving immediate and long-term outcomes, and empowering families alongside healthcare teams. The success of SIGNET’s mission will be reflected in the life stories of countless infants who benefit from safe, effective, and compassionate skin care at the start of their journey.
Subject of Research: Neonatal skin integrity and care for extremely preterm infants (<28 weeks gestation).
Article Title: Skin InteGrity in extreme preterms research NETwork (SIGNET) – improving skin care for the most immature infants.
Article References:
August, D., de Souza, S., Boyar, V. et al. Skin InteGrity in extreme preterms research NETwork (SIGNET) – improving skin care for the most immature infants. J Perinatol (2026). https://doi.org/10.1038/s41372-025-02487-8
Image Credits: AI Generated
DOI: 05 January 2026
Tags: complications in neonatal skin careepidermis development in infantsextreme preterm infant skin carefluid balance in preterm infantsfragile skin in premature infantshealthcare provider practices in NICUsinfection control in neonatesneonatal intensive care challengesneonatal skin integrity issuesoptimizing skin care protocolspopulation-specific healthcare researchspecialized approaches for preterm skin
