The newborn or neonatal period is the first 4 weeks of extrauterine life. The skin of the neonate differs from adult in several ways. The thickness of newborn skin is 40% to 60% of that of adult skin. It has weaker intercellular attachment and produces lesser amount of sweat.
A host of aberrations varying from physiological (Mongolian spot) and transient (erythema toxicum neonatorum) to grossly pathological (neonatal lupus erythematosus) are seen in the skin of neonates.
Majority of the neonatal cutaneous lesions are physiological and transient requiring no therapy. However, these cause concern not only to the parents but also to the physicians who are unfamiliar with these skin changes in newborn.
It is necessary to differentiate between benign and clinically significant skin lesions in newborn. Pigmented lesions at birth, such as Mongolian spots, are benign and almost always disappear by few years, whereas congenital melanocytic nevi are clinically significant because of future risk of malignant melanoma.
Therefore it is important to be aware of the innocent transient skin lesions in newborn and differentiate these from other serious conditions which will help avoid unnecessary therapy to the neonates and the parents can be assured of good prognosis of these skin manifestations.
The neonatal skin changes show a wide geographic and ethnic variation. Some skin lesions are common in darker skin races and
A hospital-based, cross-sectional, prospective study was conducted in the Department of Dermatology, Venereology and Leprosy, BLDE University, Shri B M Patil Medical College Hospital and Research Centre, Bijapur. One thousand neonates delivered in the Department of Obstetrics and Gynaecology of the same institution were surveyed for the presence of skin lesions. The study was conducted in the period of November 2007 to May 2009.
Neonates within the first 4 weeks of life irrespective of gestational age, sex, and mode of delivery were included in the study.
Neonates kept in neonatal intensive care unit were excluded from the study, as repeated handling of the babies can increase the chances of infection and sepsis.
Detailed history was recorded especially age of the mother, parity of mother, history of consanguinity, mode of delivery, and history of maternal illness during pregnancy. The neonates were examined thoroughly in daylight with accurate definition of morphology of skin lesions and findings were recorded. The sex, birth weight and age at the time of examination were noted in each case. In all instances, diagnosis of disorder was based on clinical impression. Skin biopsy was done in one case.
The observations pertaining to parameters under study among the newborn babies are expressed in percentage.
The relationship between skin lesions and various maternal-neonatal aspects is calculated using
Among 1000 newborns, 543 (54.3%) were males and 457 (45.7%) were females. Term newborns were 891 (89%), preterm were 93 (9.3%), and postterm were 16 (1.6%). Five seventy five (57.5%) newborns weighed <2.50 kg and 424 (42.4%) weighed >2.50 kg. History of consanguinity was present in 442 (44.2%) and absent in 558 (55.8%). The route of delivery was normal vaginal route in 688 (68.8%) and caesarean section in 312 (31.2%). The maximum number of mothers as in age group 20–30 (83.7%), 133 (13.3%) were of <20 yrs of age, and 30 (3.0%) were in age group >30–35 yrs. The relationship of skin lesions with maternal and neonatal factors is given in Table
Relationship of skin lesions with maternal-neonatal factors.
Maternal-neonatal factors | Total ( |
|
---|---|---|
(1) Sex | ||
|
543 |
|
|
457 | (<0.05) |
|
||
(2) Birth weight | ||
|
576 |
|
|
424 | (<0.05) |
|
||
(3) History of consanguinity | ||
|
442 |
|
|
558 | (<0.05) |
|
||
(4) Parity | ||
|
450 |
|
|
550 | (<0.05) |
|
||
(5) Route of delivery | ||
|
688 |
|
|
312 | (<0.05) |
Frequency of skin lesions in newborns.
Skin lesions |
|
Percentage (%) |
---|---|---|
(1) |
||
Vernix caseosa | 77 | 7.7 |
Physiological scaling | 105 | 10.5 |
Sebaceous gland hyperplasia | 894 | 89.4 |
Milia | 183 | 18.3 |
Epstein pearls | 891 | 89.1 |
Hypertrichosis | 353 | 35.3 |
Miniature puberty | ||
Hypertrophy of clitoris | 23 | 2.3 |
Hypertrophy of mammary gland | 75 | 7.5 |
Vaginal discharge | 35 | 3.5 |
Pigmentary changes due to melanin | ||
(a) Epidermal | ||
Linea nigra | 445 | 44.5 |
Pigmentation of pinna | 496 | 49.6 |
Knuckle pigmentation | 576 | 57.6 |
Genital pigmentation | 202 | 20.2 |
Axillary pigmentation | 256 | 25.6 |
(b) Dermal | ||
Mongolian spot | 847 | 84.7 |
Pigmentation other than melanin | ||
Physiological jaundice | 3 | 0.3 |
Color changes from vascular abnormalities | ||
Acrocyanosis | 309 | 30.9 |
Harlequin color change | 4 | 0.4 |
Cutis marmorata | 38 | 3.8 |
|
||
(2) |
||
Erythema toxicum neonatorum | 232 | 23.2 |
Miliaria crystallina | 30 | 3 |
Eosinophilic pustulosis | 1 | 0.1 |
|
||
(3) |
||
Napkin dermatitis | 1 | 0.1 |
Cradle cap | 12 | 1.2 |
|
||
(4) |
||
Vascular | ||
Salmon patch | 207 | 20.7 |
Haemangioma | 2 | 0.2 |
Pigmentary | ||
Congenital melanocytic nevi | 19 | 1.9 |
Café-au-lait macule | 13 | 1.3 |
|
||
(5) |
||
Cutaneous signs of spinal dysraphism | ||
Sacral dimple | 128 | 12.8 |
Acrochordons | 5 | 0.5 |
Meningomyelocele | 1 | 0.1 |
Dermoid cyst | 1 | 0.1 |
|
||
(6) |
||
Cleft lip | 1 | 0.1 |
Cleft lip & palate | 1 | 0.1 |
Umbilical granuloma | 1 | 0.1 |
Supernumerary nipple | 1 | 0.1 |
Accessory tragus | 1 | 0.1 |
Adnexal polyp | 1 | 0.1 |
Sacrococcygeal teratoma | 1 | 0.1 |
Omphalocele | 1 | 0.1 |
Perineal median raphe cyst | 1 | 0.1 |
|
||
|
||
Anhidrotic ectodermal dysplasia | 1 | 0.1 |
Congenital vitiligo | 1 | 0.1 |
Phimosis | 5 | 0.5 |
Cowlicks hair | 2 | 0.2 |
Vaginal tags | 18 | 1.8 |
Horizontal pigmented bands | 2 | 0.2 |
Congenital hydrocele | 1 | 0.1 |
Twin transfusion syndrome | 1 | 0.1 |
HIV positive | 1 | 0.1 |
Maternal varicella | 2 | 0.2 |
Linear & whorled hypermelanosis | 1 | 0.1 |
Among physiological skin lesions, sebaceous gland hyperplasia (Figure
There was no statistically significant difference in distribution of physiological skin lesions among males and females except for few cutaneous manifestations like vernix caseosa, physiological scaling, Epstein pearls, hypertrichosis, linea nigra, genital pigmentation, pigmentation of pinna, knuckle pigmentation, Mongolian spot, and acrocyanosis. As shown in Table
Relationship of physiological skin lesion with sex.
Skin lesions | Males | Females |
|
---|---|---|---|
Vernix caseosa | 28 | 49 |
|
Physiological scaling | 64 | 41 |
|
Epstein pearls | 492 | 399 |
|
Hypertrichosis | 194 | 159 |
|
Linea nigra | 244 | 201 |
|
Genital pigmentation | 113 | 89 |
|
Pigmentation of pinna | 215 | 281 |
|
Knuckle pigmentation | 327 | 252 |
|
Mongolian spot | 467 | 380 |
|
Acrocyanosis | 191 | 118 |
|
Vernix caseosa.
Sebaceous gland hyperplasia.
With respect to maturity, all skin lesions were commonly seen in term newborns, compared to preterm and postterm newborns. Vernix caseosa was seen in 62 (92.8%) full-term, 4 (5.9%) preterm, and 1 (1.5%) postterm neonates. Physiological scaling (Figure
Distribution of physiological skin lesions with respect to maturity.
Skin lesions | Full term | Preterm | Postterm | |||
---|---|---|---|---|---|---|
|
% |
|
% |
|
% | |
(1) Vernix caseosa | 62 | 92.5 | 4 | 5.9 | 1 | 1.5 |
(2) Physiological scaling | 97 | 92.38 | 5 | 4.76 | 3 | 2.85 |
(3) Sebaceous gland hyperplasia | 789 | 88.25 | 86 | 9.61 | 18 | 2.01 |
(4) Milia | 174 | 95.08 | 7 | 3.8 | 2 | 1.09 |
(5) Epstein pearls | 776 | 87.09 | 88 | 9.8 | 27 | 3.03 |
(6) Hypertrichosis | 293 | 83% | 53 | 15.01 | 7 | 1.99 |
(7) Miniature puberty | ||||||
(a) Hypertrophy of clitoris | 23 | 100 | ||||
(b) Hypertrophy of mammary glands | 69 | 92 | 3 | 4 | 3 | 4 |
(c) Vaginal discharge | 33 | 94.29 | 2 | 5.7 | ||
(8) Pigmentary changes due to melanin | ||||||
(a) Epidermal | ||||||
Linea nigra | 417 | 93.70 | 18 | 4.04 | 10 | 2.24 |
Pigmentation of pinna | 128 | 86.29 | 56 | 11.29 | 12 | 2.41 |
Knuckle pigmentation | 535 | 92.40 | 31 | 5.35 | 13 | 2.24 |
Genital pigmentation | 183 | 90.60 | 12 | 5.94 | 7 | 3.46 |
Axillary pigmentation | 241 | 94.14 | 8 | 3.13 | 7 | 2.73 |
(b) Dermal | ||||||
Mongolian spot | 765 | 90.31 | 68 | 8.02 | 14 | 1.65 |
(9) Pigmentation other than melanin | ||||||
Physiological scaling | 3 | 100 | ||||
(10) Color changes from vascular abnormalities | ||||||
Acrocyanosis | 270 | 87.37 | 32 | 10.35 | 7 | 2.26 |
Harlequin color change | 4 | 100 | ||||
Cutis marmorata | 28 | 73.68 | 10 | 26.31 |
Physiological scaling of newborn.
Milia.
Miliaria crystallina was seen in 20 (66.67%) males and 10 (33.33%) females and this difference was statistically significant (
Vascular birthmarks were seen in 209 (20.9%) and pigmentary birthmarks in 32 (3.2%). Salmon patch (Figure
Distribution of birthmarks in neonates.
Birthmarks | Total | Percentage (%) |
---|---|---|
Salmon patch | 207 | 20.7 |
Haemangioma | 2 | 0.2 |
Congenital melanocytic nevi | 19 | 1.9 |
Café-au-lait macule | 13 | 1.3 |
Congenital melanocytic nevi were seen in 19 (1.9%) newborns, out of which 11 (57.89%) were males and 8 were (42.11%) females (
Café-au-lait macule was seen in 13 (1.3%) newborns, out of which 7 (53.85%) were females and 6 (46.15%) were males (
Cutaneous signs of spinal dysraphism were seen in 135 (13.5%) newborns. Sacral dimple was most commonly seen in 128 (12.8%) neonates, meningomyelocele in 5 (0.5%), dermoid cyst in 1 (0.1%), and acrochordons in 1 (0.1%) neonate.
Other developmental defects seen were cleft lip (0.1%), cleft lip and palate (0.1%), supernumerary nipple (0.1%), umbilical granuloma (0.1%), adnexal polyp (0.1%), and accessory tragus (0.1%).
Anhidrotic ectodermal dysplasia (Figures
The appreciation of normal phenomena and their differentiation from the more significant cutaneous disorders of the neonate is critical. The prevalence of dermatoses among newborns has been documented in various studies conducted in different racial groups (Table
Prevalence of dermatoses in newborns in different racial groups.
Racial groups | EP (%) | SGH (%) | Milia (%) | MS (%) | ETN (%) |
---|---|---|---|---|---|
Australian neonate | 56.0 | 48.0 | 36 | 25.5 | 34.8 |
Iranian neonate | 70.2–88.27 | 43.7 | 7.5 | 71–81 | 11.1–54 |
Japanese neonate | — | — | — | 81.5 | 40.8 |
Turkish neonate | — | 31.8 | 1.4 | 13.2 | 30.9 |
Caucasians | 35.7 | 46.3 | — | 62.8 | 37.8 |
Black neonate | 29.1 | 28.2 | — | 86.6 | 11.6 |
Indian neonate | 43.8–61 | 21.4 | 26.2 | 72–89 | 25 |
Sebaceous gland hyperplasia (SGH), Epstein pearls (EP), Mongolian spot (MS), and erythema toxicum neonatorum (ETN) are the skin lesions which were commonly seen in the study. The prevalence of skin lesions is comparable to that of the previous study results [
Mongolian spot has been shown to be a good example of interracial difference. The prevalence of Mongolian spot has been as high as 80 to 90% in Asians [
Epstein pearls were seen in 891 (89.1%) neonates, with the commonest site of location being midline of palate. They occur commonly in 64–89% of normal neonates and are common in Caucasian infants. The similar prevalence rate has been noted in an Indian study conducted by Nanda et al. [
Erythema toxicum neonatorum was seen in 23.2% of neonates, similar to previous study conducted in India [
Among epidermal pigmentary changes, (Figure
Axillary pigmentation.
Bohn’s nodules.
Scaling in ectodermal dysplasia.
Senile changes in ectodermal dysplasia.
Mongolian spot over lumbosacral region.
Erythema toxicum neonatorum.
Miliaria crystallina.
Café-au-lait macule.
Salmon patch.
Physiological scaling, the most common finding, was seen in 105 (10.5%) neonates in the present study, compared to a study of Australian neonates, where the frequency of occurrence was 65% [
Salmon patch was the most common vascular birthmark seen (20.7%). The prevalence of salmon patch varies in different studies. It is 22.3% in a Japanese study [
The surveys of congenital melanocytic nevi in newborns showed a prevalence of 0.4 to 15.6%, with the highest percentage among nonwhitish babies [
Cutaneous signs of spinal dysraphism were seen in 135 (13.5%) neonates. Sacral dimple was seen in 128 (12.8%) neonates. The prevalence is higher than that in American neonates (1.4%) [
Vaginal tags and cowlicks hair pattern are two conditions which were not reported in previous observational studies on cutaneous manifestations in newborns. Vaginal tags were seen in 18 (1.8%) newborns. They are normal hymenal characteristic which can be seen in 59% of newborns [
Anhidrotic ectodermal dysplasia was seen in one neonate who had loss of eyebrows, eyelashes with periorbital pigmentation. Skin biopsy done from hypothenar eminence of palm showed absent sweat glands [
Sebaceous gland hyperplasia, Epstein pearls, Mongolian spot, and erythema toxicum neonatorum were the commonest physiological and transient skin lesions seen in the study.
The study of newborn skin provides information about normal variants occurring in neonatal period. It is important to be aware of the fact that most of the skin lesions in the newborn are transient and require no therapy.
Therefore, it is necessary for those who provide neonatal care to differentiate physiological skin lesions from other more serious skin conditions which will help avoid unnecessary therapy to neonates. The parents can be assured of good prognosis of these skin manifestations.
Patients consent was taken for photographs.
The authors declare that they have no conflict of interests regarding the publication of this paper.
This paper is read and approved by all authors.