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Newborn Skin

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  1. Newborn Skin • Newborn skin is nearly half as thin as adult skin • Weaker intercellular attachments • Fewer eccrine and sebaceous gland secretions • The stratum corneum in premature infants born before 32 weeks is markedly thinner than term infant skin, resulting in water loss

  2. Care of Newborn Skin • Only water is really required for routine bathing by parents (all soaps mild irritants) • Bathe only once to twice a week • Avoid adhesives • Avoid excessive thermal and UV radiation

  3. Terminology

  4. Macule: Well circumscribed flat skin lesion that has a color change, size up to 1 cm (café au lait) Patch: Well circumscribed flat skin lesion that has a color change, size greater than 1 cm (Mongolian spot)

  5. Papule: Solid, raised lesion <1 cm in diameter (wart, milia) Plaque: Solid, raised lesion >1cm in diameter (nevus sebaceous)

  6. Vesicle: Elevated lesion < 1 cm containing clear, serous fluid (herpes simplex, varicella) Bulla: Elevated lesion >1 cm containing clear serous fluid (sucking bulla)

  7. Pustule: Vesicle >1cm containing purulent fluid (erythema toxicum)

  8. Ulcer: Full thickness loss of the epidermis with damage into the dermis

  9. Open Comedone: wide opening of the sebaceous follicle filled with plug of stratum corneum cells (black color from oxidized melanin)

  10. Closed Comedone: Obstruction just below the follicular opening with cystic swelling

  11. Transient Benign Lesions

  12. Erythema Toxicum Neonatorum • Papulovesicular lesions 1-2 mm in diameter with erythematous area around lesion • Located on trunk, arms and legs (not palms, soles) • Immaturity of the pilosebaceous follicles plays a role • Lesions contain eosinophils (at times neutrophils) • Affects 30-70% of all infants and noted 24 hours to 2 weeks after birth

  13. Transient Neonatal Pustular Melanosis • Superficial pustules or pigmented macules usually present at birth • May develop anywhere, especially over chin, neck, upper chest, lower back • Progresses from vesicopustules to scale to hyper-pigmentation • Cause is unknown • Pustules contain neutrophils • Noted in 4.4% of African American and 0.2% of European Americans

  14. Umbilical Granuloma • Pink papules that bleed easily and feel velvety • Presents when cord dries and falls off • Granulation tissue at the stump of the umbilical cord caused by incomplete healing • Treat with silver nitrate

  15. Miliaria • Caused by obstructed eccrine sweat ducts • Located on trunk, forehead, intertriginous and occluded areas • Heat and humidity play a role • Treatment is to avoid heat or occlusion • In warm climates may occur in 15% of infants • Miliaria crystallina--grouped vesicles from sweat trapped superficially

  16. Miliaria rubra grouped papules, pustules1-3 mm papules • Mimics neonatal infections such as Staph or HSV • Occlusion at the stratum corneum with extension deeper and subsequent inflammatory response

  17. Subcutaneous Fat Necrosis • Erythematous nodules or plaques • Located on cheeks or buttocks • Occur between days 1-7 of life • Cold injury may predispose • Usually resolve over several weeks, though may calcify

  18. Milia • White papules 1-2 mm in diameter • Located on nose, forehead, cheeks and when on palate are Epstein pearls • Superficial inclusion cysts • Occur in about 40% of infants • Resolve spontaneously in several months • Can puncture to diagnose revealing white ball of keratinous material

  19. Sebaceous Hyperplasia • Yellowish papules regularly spaced at the opening of each pilo-sebaceous follicle • Located on the nose and upper lip (location of high density of sebaceous glands) • Androgen stimulation causes proliferation • Occurs in 1/2 of newborns and resolves in weeks

  20. Acne Neonatorum • Inflammatory pustules and papules on the face • May be caused in response to Pityrosporum • Difficult to distinguish from miliaria rubra • May be present at birth, but often develop at 3-4 weeks of age and resolves spontaneously

  21. Infantile Acne • Comedones, papules or nodules • Located on the face and may cause scaring • Androgenic hormones play a role • Appearance identical to adult acne • Appears at two to three months • May use acne soaps, and if persist 5% benzoyl peroxide wash with care

  22. Vasomotor instability • Acrocyanosis-- the blue coloration that results from vasoconstriction of hands, feet, lips in response to cold • More common in premature infants

  23. Vasomotor instability • Mottling or cutis maromata results from the constriction of capillaries and venules in response to the cold (causes reticulated, mottled pattern)

  24. Vasomotor instability • Harlequin color change--caused by vasodilatation of dependent side, causing reversible erythema that lasts seconds to minutes • Onset 2-5 days of life • More common in premature infants • Lasts up to 3 weeks

  25. Desquamation • Normal newborn skin peels at 24-48 hours • Premature infants will not desquamate until 2-3 weeks of life • Post term infants crack and peel

  26. Sucking Blister • Bullous lesion • Located on any body part that can be sucked • Usually present at birth • Diagnose by placing the affected area close to the mouth • May require topical antibiotics

  27. Hyperpigmented Lesions

  28. Mongolian spots (Dermal Melanosis) • Macules or patches that are blue, gray, or black located on the buttocks • Collection of melanocytes in the dermis (perhaps error in migration of the pigmented cells) • Association between gangliosidosis and Mongolian spots • 90% of Native American, Asian, and African infants • Usually resolve spontaneously

  29. Dermal Melanosis • Dermal melanosis on shoulder called nevus of Ito (distribution of the posterior supraclavicular and lateral brachial cutaneous nerves • Dermal melanosis in the trigeminal nerve distribution called nevus of Ota (may be associated with glaucoma) • Both may require laser therapy

  30. Hyperpigmented lesions Café au lait • Oval tan brown macules 1.5-2cm located anywhere on the body • Found in 10% of European Americans and 22% of African Americans • Usually benign • Neurofibromatosis should be suspected if 6 or more café au lait macules • Large linear macules with jagged margin associated with McCune-Albright (polyostotic fibrous dysplasia, endocrine dysfunction, café au lait)

  31. Hyperpigmented lesionsCongenital Melanocytic Nevi • Tan to dark brown macules/plaques with or without hair • Proliferation of melanocytes in the skin at birth or the first months of life • Described as small (less than 1.5cm), intermediate (1.5-20cm), and large • Small nevi in 1-2% of newborns, intermediate 0.6%, large 0.2%

  32. Hyperpigmentation • Hyperpigmentation of scrotum, labia, areolae in response to maternal hormones • When located on lower abdomen it is called linea nigra • May be seen in congenital adrenal hyperplasia

  33. Vascular Lesions

  34. Vascular birthmarks • Nevus simplex, salmon patch • erythematous macules over glabella, nape (storkbite), eyelids (angel’s kisses) • vascular malformations of the capillaries • Most resolve by 3-6 months, but 1/4-1/2 of nape lesions persist • Incidence 70% of European descent, 59% of African descent, 22% Asian descent

  35. Port Wine Stains • Bright red macules present at birth caused by capillary malformations • Usually require laser to eliminate • Associated with syndromes

  36. Sturge Weber Syndrome • Port-wine stain in the distribution of the ophthalmic branch of the trigeminal nerve. • Associated with seizures (80%), mental retardation(60%), hemiplegia(30%) and neonatal glaucoma.3 • 5-8% of those with a port-wine stain in this distribution develop Sturge-Weber syndrome

  37. Klippel-Trénaunay-Weber Syndrome • Port-wine stain over extremity, with soft tissue and bony hypertrophy • In 1/4 of these patients, an arteriovenous fistula is present • Measure the length and girth of the extremity every three to six months • Imaging studies for AV fistula if elongation of an extremity is noted

  38. Hemangiomas • Most common vascular tumor of newbors • Benign tumor of endothelial cells • Occur in 1-3% of healthy newborns • May not be identified at birth (telangiectasia or erethema as precursors)

  39. Hemangiomas • More common in premature infants • more common in females • Proliferation in utero • Regress as infant ages (50% by 5, 70% by 7, 90% by 9)

  40. Hemangiomas • 65% are superficial and appear as bright red lesions • 15% are deeper in the dermis and are bluish in hue • The remainder are mixed

  41. Hemangiomas • Treatment required for: • airway obstruction • visual obstruction • thrombocytopenia due to platelet trapping (Kasabach-Merritt syndrome) • high output failure from systemic malformations • Prednisone 1-2mg/kg for 4-6 weeks