|Year : 2014 | Volume
| Issue : 2 | Page : 86-92
Dermatoses in Indian neonates: A clinical study
Noopur Jain, Bhagirath S Rathore, Arvind Krishna
Department of Dermatology, Subharti Medical College, Meerut, Uttar Pradesh, India
|Date of Submission||03-Nov-2014|
|Date of Acceptance||11-Dec-2014|
|Date of Web Publication||29-Jan-2015|
MD, Department of Dermatology, Subharti Medical College, Delhi-Haridwar Bypass, Meerut, Uttar Pradesh - 250 005
Source of Support: None, Conflict of Interest: None
Neonatal dermatology, by definition, encompasses the spectrum of cutaneous disorders that arise during the first 4 weeks of life. A host of aberrations varying from physiological and transient to grossly pathological are observed in the skin of a neonate.
The aim of this work was to study the prevalence of dermatoses in neonates and to establish the correlation between various neonatal factors, maternal factors, and the occurrence of dermatoses.
Patients and methods
A total of 200 randomly selected live-born neonates delivered and admitted to the postpartum ward, neonates admitted to the Neonatal Intensive Care Unit, and neonates attending the Dermatology Outpatient Department were included in this study. A detailed assessment of history was performed and a detailed dermatological examination of each of the neonates was carried out. Laboratory procedures were performed as required.
The most prevalent findings were miniature puberty (71%), Mongolian spot (64.5%), lanugo hair (63%), sebaceous gland hyperplasia (62%), erythema toxicum neonatorum (38%), salmon patch (35%), physiological scaling of the newborn (30.5%), milia (27%), miliaria (18.5%), Epstein's pearls (17.5%), and iatrogenic bruises (17.5%).
A thorough knowledge of the skin changes, physiological as well as pathological, in neonates is of prime importance for the dermatologist as well as pediatrician.
Keywords: Dermatoses, Indian, neonates
|How to cite this article:|
Jain N, Rathore BS, Krishna A. Dermatoses in Indian neonates: A clinical study. Egypt J Dermatol Venerol 2014;34:86-92
What is already known on this topic?
- Skin lesions are fairly common during the newborn period.
- Most of the neonatal skin lesions are physiological, but can be a cause of concern for the parents.
- Early identification of potentially harmful lesions is essential for proper care of the newborn.
What this study adds?
- Correlation between the various dermatoses and the birth as well as maternal factors may be significant, but more studies are required with a larger sample size.
- Iatrogenic lesions are fairly common in the NICU setting and as they can be a potential source of infection, invasive procedures and tests should be kept to the minimum.
| Introduction|| |
Neonatal dermatology, by definition, encompasses the spectrum of cutaneous disorders that arise during the first 4 weeks of life. Many such conditions are transient, appearing in the first few days of life, only to disappear shortly thereafter.
The skin of a newborn differs from that of an adult in many ways: a higher skin surface area to weight ratio; the connection between the dermis and the epidermis is less strong; the skin is thinner and less elastic; the permeability of the stratum corneum is higher and the epidermal barrier is not well developed; and the production of melanin is less. The sebaceous glands, although large in number at birth, have no function until puberty and similarly, there are dense but less active sweat glands. In newborns and small infants, the pH of the skin surface is higher and the free fatty acid content is less than that in adult skin ,.
The definitive diagnosis of specific skin lesions requires an understanding of the physiologic characteristics and peculiarities of neonatal skin, recognition of primary skin lesions, and knowledge of their significance .
Factors influencing patterns of cutaneous changes in neonate are heredity, race, gestational age, and maternal health in addition to other external factors such as hygiene, socioeconomic status, customs, mode of delivery, etc.
Neonatal dermatoses can be classified as follows :
- Transient skin disorders.
- Congenital disorders - birthmarks and genodermatoses.
- Acquired skin disorders specific to the neonatal period.
- Iatrogenic dermatologic complications.
The literature was reviewed for similar studies from this part of the world. A number of studies on newborn dermatoses have been reported, but there are very few from the region of northern India, especially from western Uttar Pradesh.
| Patients and methods|| |
A total of 200 neonates, with cutaneous findings, who were born in the postpartum ward, admitted to Neonatal Intensive Care Unit (NICU), or those who presented to the Dermatology Outpatient Department, were included prospectively in this single-contact study. Written consent was obtained from the parents or guardians of the neonates included in the study. The birth history and relevant maternal history were recorded in a proforma. Photographic records were maintained. The relationships between the occurrence of the lesions with the various maternal and neonatal factors were analyzed. Statistical analysis was carried out using the z test for double proportion, with P value less than 0.05 considered to be significant. Simple investigations such as examination of scrapings for Gram staining, KOH smear, and Tzanck smear were performed whenever required.
| Results|| |
All the babies were examined within 28 days of birth, of whom 79% were examined within the first 5 days. Of the 200 neonates examined, 52.5% were males and 47.5% were females. Twenty-six percent were preterm, 67% were term, and 0.5% were post-term. Forty percent were delivered vaginally and 60% were delivered by cesarean section. Among the 200 neonates, 14.5% had a birth weight of less than 2 kg, 21% weighed 2-2.49 kg, 33.5% weighed 2.5-2.99 kg, and 21.5% weighed more than 3 kg. The birth weight and gestational age of the remaining neonates were not known because of the unavailability of their birth records as they were delivered elsewhere.
Among the mothers, 51% were 20-24 years old, 34% were 25-29 years old, and 15% were older than 30 years. Of the mothers, 40.5% were primipara, whereas 59.5% were multipara.
Prevalence and type of dermatoses
When the cutaneous lesions observed in the neonates were analyzed, it was found that the transient skin disorders that required no treatment were found to be the most common. Among the transient skin disorders, the various lesions observed were miniature puberty (71%), Mongolian spot (64.5%) [Figure 1], lanugo hair (63%), sebaceous gland hyperplasia (62%) [Figure 3], erythema toxicum neonatorum (ETN) (38%), salmon patch (35%), physiological scaling of the newborn (30.5%), milia (27%), miliaria (18.5%), Epstein's pearls (17.5%) [Figure 4], cutis marmorata (16%) [Figure 2], acrocyanosis (10.5%), vernix caseosa (8.5%), neonatal acne (2.5%), neonatal alopecia (2%), and sucking blister (0.5%).
The various congenital disorders and genodermatoses observed in the study included congenital melanocytic nevus (1.5%), sacrococcygeal dimple/sinus (1.5%), preauricular skin tag (1%), natal teeth (0.5%), and benign neonatal hemangiomatoses (0.5%).
Among the acquired skin disorders specific to the neonatal period, infantile seborrheic dermatitis (15%), diaper dermatitis (5%), neonatal oral candidiasis (2.5%), neonatal varicella syndrome (0.5%), and neonatal purpura fulminans (0.5%) were observed.
Iatrogenic dermatologic complications encountered in the NICU included bruise (17.5%), erosion (1%), and irritant contact dermatitis (0.5%). The bruises were mainly located over the hands and the feet because of the insertion of intravenous lines that are required for the administration of drugs and for the withdrawal blood samples for investigations.
The incidences of cutaneous lesions as observed in this study are shown in [Table 1].
On analyzing the sex differences among the various dermatoses, it was observed that miniature puberty was more common among males, whereas milia were more among females, and this difference was statistically significant. Other lesions that were more common among males were sebaceous hyperplasia, physiological scaling of the newborn, miliaria, and bruise. However, Mongolian spot, lanugo hair, ETN, and salmon patch were more common among females. The correlation between the common dermatoses and the sex of the neonates is shown in [Table 2].
Lanugo hair and bruises were associated with preterm neonates, the association being statistically significant. Term neonates showed a higher incidence of miniature puberty, Mongolian spot, salmon patch, physiological scaling of the newborn, milia, and miliaria, although this was not statistically significant. The correlation of the occurrence of the dermatoses with the gestational age is shown in [Table 3].
|Table 3: Incidence of lesions in association with the neonates' gestational age|
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Neonates with higher birth weight had a significantly higher incidence of lesions such as miniature puberty, Mongolian spot, ETN, and milia, whereas those with birth weight of less than 2 kg had a higher incidence of lanugo hair and iatrogenic bruise. The correlation between the birth weight and dermatoses is shown in [Table 4].
|Table 4: Incidence of lesions in association with the neonates' birth weight|
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With respect to the age of neonates at the time of examination, significant associations were observed between miniature puberty and Mongolian spot and neonates who were less than 24 h old, and ETN, salmon patch, and milia and neonates who were between 1 and 5 days old.
With respect to mode of delivery, it was observed that Lanugo hair was significantly more common among the neonates who were delivered by cesarean section compared with those delivered by the vaginal route. This difference was possibly because of the higher occurrence of lanugo hair among the preterm neonates and the higher frequency of delivery by cesarean section of the preterm neonates. This is shown in [Table 5].
No significant association was found between the incidence of dermatoses with the mother's age or parity.
The other common lesions that were not observed in this study were port wine stain, Bohn's nodules, infantile acropustulosis, and transient neonatal pustular melanosis. We also observed relatively fewer cases of infective disorders.
The three unusual cases that were encountered in this study were one case each of neonatal varicella syndrome, neonatal purpura fulminans, and benign neonatal hemangiomatoses. All three cases were clinically diagnosed [Figure 1],[Figure 2],[Figure 3] and [Figure 4].
| Discussion|| |
The spectrum of neonatal dermatology encompasses all the cutaneous disorders encountered during the first 4 weeks of life. Many such conditions are transient, appearing in the first few days of life, only to disappear shortly thereafter.
Several reports have appeared on the occurrence of certain specific dermatoses in newborn infants. Most of these articles have dealt with one or a very few individual types of cutaneous eruptions ,. The present study presents a comprehensive analysis on the basis of observations made on 200 neonates for skin disorders.
A comparison of the frequency of a given lesion between studies is complicated. In addition to the influence of characteristics specific to the country in which the study was carried out (climate, and ethnic groups), we should also consider differences in the time of examination, the inclusion criteria, and the terminologies used. Also, the frequency of deliveries performed by the cesarean section was considerably higher in the present study compared with the general population, in which it has been estimated to be about 8%.
The region of northern India, especially western Uttar Pradesh, has a mixed type of population - that is, Hindus and Muslims with various others. Also, the flora and climate of the region are such that a number of both physiological and pathological dermatoses are encountered in the neonates. The present work was therefore carried out study the incidence and prevalence of dermatoses in neonates in the region of western Uttar Pradesh and correlate it statistically with the available literature.
In the present study, out of the various physiological dermatoses, miniature puberty was found to be the most common, with an incidence of 71%. Gokdemir et al. , in their study, found miniature puberty in 43.5% of the neonates observed. Zagne and Fernandes  found the same in 42.86% of the neonates. We diagnosed miniature puberty if any of the features such as hyperpigmentation of genitalia or axilla, hypertrophy of mammary glands, or large well-developed genitalia in males and succulent genitalia or vaginal discharge in females were present.
We observed a statistically significant difference in the incidence of minipuberty between the sexes, the phenomenon being more common in male neonates. This is in agreement with the findings of Boccardi et al. , Zagne and Fernandes , and Hidano et al. . The significant association that we observed between miniature puberty and higher birth weight has not been reported earlier. As also observed by Zagne and Fernandes  and Monteagudo et al. , we found a higher incidence in neonates born by the vaginal route, although this was not statistically significant.
The second most common dermatosis observed in our study was Mongolian spot, found in 64.5% of the neonates. They were most frequently located over the lumbosacral region, but a few were observed at atypical sites such as over the ankle and the thigh. The incidence observed in the present study is in agreement with that reported by other workers such as Nanda et al.  (62.2%), Sachdeva et al.  (60.2%).
As also observed by Sachdeva et al. , we found a significantly higher incidence of Mongolian spot among neonates with higher birth weight. Other associations of this lesion that we found were with term neonates and those born to multipara, which are in agreement with the findings of Sachdeva et al. .
The incidence of lanugo hair in our study was 63%. This is in agreement with the findings of Boccardi et al.  and Zagne and Fernandes , who observed lanugo hair in 68.4 and 69.46% of the neonates observed, respectively. Our observation differs from that of Gokdemir et al. , Nobby and Chakrabrty , Sachdeva et al. , and Ferahbas et al. , who found the incidence of lanugo hair in their studies to be 13.99, 14.6, 14.4, and 7.8%, respectively.
In the present study, a higher incidence of sebaceous gland hyperplasia was found among male, preterm, normal vaginal delivery and babies born to mothers who were older than 30 years old and multipara. Sachdeva et al.  also made similar observations, finding the lesion to be more common among neonates born vaginally and those born to multipara. Our finding of a higher occurrence of this lesion among preterms is in agreement with that of Nanda et al. . With respect to the sex of the neonate, our findings are similar to those of Zagne and Fernandes , but in contrast to those of Gokdemir et al. .
ETN is a benign self-limited condition occurring in the first week of life. It was observed in 38% of the neonates examined in the present study. The maximum incidence (i.e. 43.28%) was observed in the neonates who were between 1 and 5 days old. Various workers , have reported an association between ETN and higher birth weight, which is in agreement with our findings. The statistically significant finding of ETN being more commonly observed in neonates 1-5 days old is in agreement with the literature . Most workers, namely, Sachdeva et al. , Nanda et al. , and Baruah et al. , observed a higher incidence among term neonates; however, we found a slightly higher occurrence among preterm neonates, although this was not found to be statistically significant.
Carr et al. , from their study, concluded that the discrepancies in the reported incidence of erythema toxicum are because of the difficulty of recognition of erythema in pigmented skin; because the incidence decreases with decreasing maturity and was not observed in infants of less than 30 weeks' gestation; and because the onset in 61% of cases occurred during the second 24 h of life.
The incidence of salmon patch in the present study was 35%, which is agreement with the incidence reported by Jacobs and Walton , who observed this lesion in 40.3% of the neonates examined in their study. The female preponderance of this lesion that we found in our study confirms the earlier observations made by Zagne and Fernandes  and Hidano et al. . Sachdeva et al. , in their study, observed salmon patch to occur more frequently among neonates with higher birth weight and also those born to multipara, which is similar to our findings. In the present study, we also found an association with gestational age, the lesion being more common in term neonates, which has also been reported in earlier studies, by Kanada et al. . The statistically significantly higher incidence of this lesion that we found in neonates that were 1-5 days old has not been reported in other studies.
Physiological scaling of the newborn was observed in 30.5% of the neonates in our study. The same was reported to be 31.29% by Gokdemir et al. , 40% by Sachdeva et al. , 18.23% by Zagne and Fernandes , and 83% by Baruah et al. . We found a higher incidence of this benign desquamation among male neonates, which has also been reported by Sachdeva et al.  and Zagne and Fernandes . We found a higher incidence among neonates with a birth weight of more than 2.5 kg, similar to the findings of Sachdeva et al. . However, our observation of a higher occurrence of this lesion in neonates born to primipara differs from the observation made by Sachdeva et al. .
We found a statistically significant association between the occurrence of milia and female sex, which confirms the findings of Gokdemir et al. , but differs from that of Zagne and Fernandes .
Miliaria, which occurs because of the occlusion of sweat ducts, was observed in 18.5% of the neonates observed in the present study. It was significantly more common among those neonates who were admitted in the NICU. The reason for this could be that these neonates were kept in incubators under conditions of high humidity, predisposing them toward the development of this lesion.
Iatrogenic bruises were exclusively observed in the neonates who were admitted in the NICU, with an incidence of 17.5%, in the present study. These were mainly because of the insertion of an intravenous cannula and needle puncture for various diagnostic and therapeutic procedures in the NICU. The most common sites where bruises were observed were the dorsa of the hands and feet. Fontenele and Cardoso , in their study on hospitalized neonates, observed hematoma in 46%, erythema in 18%, excoriations in 12%, ecchymosis in 10%, and pustules in 6% of cases. Bruises were significantly more common among preterm neonates and those with lower birth weight, probably because of their higher rates of admission in the NICU for various systemic complaints.
There was one (0.5%) clinically diagnosed case of neonatal varicella in our study. The mother had a history of chicken pox at 5 days after delivery, which confirmed the diagnosis. No other study has reported this finding. Neonatal purpura fulminans was observed in our study in one (0.5%) case. One (0.5%) case of benign neonatal hemangiomatosis was observed in the present study. Other similar studies have not reported this finding.
| Conclusion|| |
Neonatal skin lesions are mostly harmless and transient, but need to be differentiated from more serious or life-threatening conditions. The identification of normal phenomena and their differentiation from more significant cutaneous disorders of the newborn are critical for the general physician, obstetrician, and pediatrician, as well as for the pediatric dermatologist.
| Acknowledgements|| |
All authors participated in the design of the study. N. Jain: collected data, carried out data analysis, drafted the initial manuscript, approved the final manuscript submitted, and was responsible for the overall content as guarantor. B.S. Rathore: critically reviewed methods and the manuscript and approved the final manuscript as submitted. A. Krishna: collected data, carried out data analysis, critically reviewed the manuscript, and approved the final manuscript as submitted.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sarkar R. Care of the skin. In: Gupta P, editor. Essential pediatric nursing. New Delhi: CBS Publishers and Distributors 2007; 217-226.
Ramasastry P, Downing DT, Pochi PE, Strauss JS. Chemical composition of human skin surface lipids from birth to puberty. J Invest Dermatol 1970; 54
Solomon LM, Esterly NB Neonatal dermatology. I. The newborn skin. J Pediatr 1970; 77
Parikh DA. Neonatal skin disorders. In: Valia RG, Valia AR, editors. IADVL textbook of dermatology. 3rd ed. Bombay: Bhalani Publishing House; 2001; 1
Keitel HG, Yadav V. Etiology of toxic erythema. Erythema toxicum neonatorum. Am J Dis Child 1963; 106
Gordon I. Miliary sebaceous cysts and blisters in the healthy newborn. Arch Dis Child 1949; 24
Gokdemir G, Erdogan HK, Koslu A, Baksu B. Cutaneous lesions in Turkish neonates born in a teaching hospital. Indian J Dermatol Venereol Leprol 2009; 75
Zagne V, Fernandes NC. Dermatoses in the first 72 h of life: a clinical and statistical survey. Indian J Dermatol Venereol Leprol 2011; 77
Boccardi D, Menni S, Ferraroni M, Stival G, Bernardo L, La Vecchia C, Decarli A. Birthmarks and transient skin lesions in newborns and their relationship to maternal factors: a preliminary report from northern Italy. Dermatology. 2007; 215
Hidano A, Purwoko R, Jitsukawa K. Statistical survey of skin changes in Japanese neonates. Pediatr Dermatol 1986; 3
Monteagudo B, Labandeira J, León-Muiños E, Romarís R, Cabanillas M, Ramírez-Santos A, et al
. Prospective study of hyperpigmentation of the genital area in Spanish newborns: frequency and predisposing factors. Med Cutan Iber Lat Am 2013; 41
Nanda A, Kaur S, Bhakoo ON, Dhall K. Survey of cutaneous lesions in Indian newborns. Pediatr Dermatol 1989; 6
Sachdeva M, Kaur S, Nagpal M, Dewan SP. Cutaneous lesions in new born. Indian J Dermatol Venereol Leprol 2002; 68
Nobby B, Chakrabrty N. Cutaneous manifestations in the new born. Indian J Dermatol Venereol Leprol 1992; 58
Ferahbas A, Utas S, Akcakus M, Gunes T, Mistik S. Prevalence of cutaneous findings in hospitalized neonates: a prospective observational study. Pediatr Dermatol 2009; 26
Baruah CM, Bhat V, Bhargava R, Garg RB, Kumar V. Prevalence of dermatoses in the neonates in Pondichery. Indian J Dermatol Venereol Leprol 1991; 57
Paige DG, Gennery AR, Cant AJ. The neonate. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook′s textbook of dermatology. 8th ed. Oxford: Blackwell 2010; 17
Carr JA, Hodgman JE, Freedman RI, Levan NE. Relationship between toxic erythema and infant maturity. Am J Dis Child 1966; 112
Jacobs AH, Walton RG. The incidence of birthmarks in the neonate. Pediatrics 1976; 58
Kanada KN, Merin MR, Munden A, Friedlander SF. A prospective study of cutaneous findings in newborns in the United States: correlation with race, ethnicity, and gestational status using updated classification and nomenclature. J Pediatr 2012; 161
Fontenele FC, Cardoso MV. Skin lesions in newborns in the hospital setting: type, size and affected area. Rev Esc Enferm USP 2011; 45
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]