Newborn Skin Exam

Aka: Newborn Skin Exam, Newborn Skin Conditions, Dermatologic Conditions in Infants, Newborn Rash, Dermatitis in Infants, Birthmark

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II. Definitions

  1. Birthmarks
    1. Skin abnormalities that are noted at birth (or shortly thereafter)
    2. Types
      1. Vascular Birthmarks (e.g. Hemangiomas)
      2. Pigmented Birthmarks (e.g. Congenital Melanocytic Nevus)
      3. Skin Markers of Spinal Dysraphism
  2. Melanocytic Lesions (Pigmented Lesions)
    1. Displaced Melanocytes or Melanocytes with atypical growth

III. Findings: Normal - Transient (resolves in minutes to hours)

  1. Miliaria (Heat Rash)
  2. Petechiae
    1. Scalp and face after vertex delivery
  3. Vernix Caseosa
    1. Cheesy white skin covering present at birth
  4. Transient vascular phenomena
    1. Cutis Marmorata (skin mottling related to cold exposure)
    2. Harlequin Color Change (positional erythema on the dependent side of the body)

IV. Findings: Normal - Short-term (resolves in days to months)

  1. Erythema Toxicum Neonatorum
    1. Yellow Papules (eos) on red base affected face and trunk, disappearing within days to a week
    2. Differentiate from Neonatal HSV
  2. Neonatal Pustular Melanosis
    1. Milky fluid filled Vesicles without erythema, <5 mm on torso, buttock, forehead, chin
    2. Pigmented Macule with scale after Vesicle ruptures and may persist for months
  3. Milia
    1. Pinpoint white, keratin-filled Papules (blocked Sebaceous Glands) on nose and cheeks
    2. Spontaneously rupture and resolve within the first few weeks of life
  4. Sucking Blister
    1. Develops from infant sucking on skin
  5. Lanugo
    1. Fine hair on Shoulders and back
  6. Spontaneous Fat Necrosis
  7. Acne Neonatorum

V. Findings: Normal - Birthmarks, Long-term (Persists for months to years - some do not resolve)

  1. Vascular
    1. Important vascular Birthmarks (e.g. Nevus Flammeus) are described under abnormal findings below
    2. Nevus Simplex (Salmon Patch)
      1. Macular pink to red capillary dilations that fade with time
      2. Occurrs on the upper Eyelids, forehead, and nape of neck (Stork bite)
      3. Differentiate from Nevus Flammeus
      4. In rare cases, may be associated with Genetic Syndromes
    3. Hemangioma
      1. Benign vascular lesions
      2. May result in focal obstruction (esp. airway Hemangioma)
  2. Pigmented or Melanocytic
    1. Important pigmented Birthmarks (e.g. Congenital Melanocytic Nevi) are described under abnormal findings below
    2. Mongolian Spots (Dermal Melanosis)
      1. Large (up to 10 cm) bluish-gray pigment patches on extremities as well as lumbar, sacral and buttock region
      2. Occurs with darker skin (black, hispanic and native american)
    3. Smooth Muscle Hamartoma
      1. Hyperpigmentation and Hypertrichosis overlies a firm nodular base
      2. Distinguish from Congenital Malanocytic Nevus (biopsy needed to differentiate)

VI. Findings: Abnormal - Birthmarks

  1. See Skin Markers of Spinal Dysraphism
  2. Vascular
    1. Nevus Flammeus (port wine stain)
      1. Dark purple or red capillary malformation that does not typically fade
      2. Refer to ophthalmology if involvement near the eye
      3. Associated Conditions
        1. Sturge-Weber Syndrome (trigeminal region)
        2. Klippel-Trenaunay-Weber Sydrome (extremity)
  3. Pigmented
    1. Congenital Melanocytic Nevi
      1. See Congenital Melanocytic Nevi
    2. Nevus Sebaceus
      1. Yellow hairless Plaque on scalp or face
      2. May be associated with epidermal nevus syndrome and carries risk of future Skin Cancer in 10-15% of cases
    3. Cafe-Au-Lait Macule
      1. "Coffee with milk" (tan to brown) colored flat Macule
        1. Size <4 cm in infants and up to 30 cm in adults
        2. Usually located on the trunk
      2. Six of more lesions (>5 mm prepubertal, >15 mm postpubertal) associated conditions
        1. Neurofibromatosis
        2. Tuberous Sclerosis
        3. Albright Syndrome

VII. Findings: Important Infections

  1. Congenital Candida
    1. Rare, but serious infection with risk of disseminated candidemia
    2. Onset at birth or in the first week of life
    3. Diffuse erythematous, desquamating maculopapular or papulopustular dermatitis
    4. Diagnosis with a Potassium Hydroxide preparation (KOH prep) showing pseudohyphae or spores
    5. Early systemic Antifungals prevents progression to disseminated candidemia
  2. Neonatal Herpes Simplex Virus
    1. Vesicular Lesions in infant born to mother with HSV (maternal HSV is often occult and unrecognized)
    2. Early, emergent IV Acyclovir is critical to reduce complications (e.g. Encephalitis)
  3. Congenital Cytomegalovirus (Congenital CMV)
    1. Asymptomatic at presentation in 90% newborns
    2. Petechiae may be present (associated with Thrombocytopenia)
    3. Risk of longterm neurodevelopmental delay and Hearing Loss
  4. Congenital Syphilis
    1. Steadily increasing Incidence with nearly 1000 U.S. cases in 2017
    2. Devastating lifelong multisystem complications
    3. Small copper-red maculopapular lesions on palms and soles
    4. Lesions desquamate and crust over a 3 week period
  5. Neonatal Scabies
    1. Infants have more severe, diffuse cases that may result in Failure to Thrive
  6. Staphylococcal Scalded Skin Syndrome
  7. Impetigo

VIII. Findings: Abnormal Skin Coloration

  1. Pallor
    1. Anemia
  2. Jaundice onset within first day of life
    1. See Hemolytic Disease of the Newborn
    2. See Neonatal Jaundice
  3. Cyanosis
    1. See Cyanosis in Infants
  4. Mottling
    1. Consider Sepsis, Hypothermia
    2. Distinguish from the normal Cutis Marmorata, Harlequin Color Change
  5. Gray Skin Coloration
    1. Acidosis (Inborn Errors of Metabolism)

IX. Findings: Other Skin Findings

  1. See Cutaneous Signs of Dysraphism
  2. Neonatal Pustules and Vessicles
    1. See Neonatal Pustules and Vessicles
    2. Vesicles
      1. Consider Neonatal HSV
      2. Distinguish from Erythema Toxicum Neonatorum
    3. Bullae
      1. Consider Bullous Impetigo
  3. Aplasia Cutis Congenita
    1. May be associated with skull deformities

X. References

  1. Claudius and Behar in Herbert (2020) EM:Rap 20(8): 5-7
  2. O'Connor (2008) Am Fam Physician 77(1): 47-52 [PubMed]
  3. Snyder (2024) Am Fam Physician 109(3): 212-6 [PubMed]

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