Common neonatal skin problems

Presented by

Surg Lt Cdr Manas R Mishra

COMMON NEONATALCOMMON NEONATALSKIN PROBLEMSSKIN PROBLEMS

Diaper Rash

‘Nappy rash’, ‘ammoniacal dermatitis’Irritant dermatitisExposure to

urine & stools

Diaper Rash

Skin creases sparedExclude superimposed Candidal infection

Diaper Rash

RxFrequent diaper changesExposure of region to allow dryingZinc oxide creams; even prophylactically

Candida albicans Rash

Moist, warm areasFrequently intertriginous areas

Neck folds, axillaediaper area

Confluent,erythematousplaques with sharplydemarcated edges

Candida albicans Rash

Satellite lesions (pustules on contiguous areas of skin)

Skin folds involved

RxMiconazole cream,

powder

Staphylococcus aureus

Staphylococcal pustulosis

Bullous Impetigo

Staphylococcal Scalded Skin Syndrome

Staphylococcal Pustulosis

Usually at 3-5dys old

Discrete pustules witherythematous base

Staphylococcal Pustulosis

Diaper area, periumbilical, neck, lateral aspect of chest

RxSystemic

Cloxacillin

Bullous Impetigo

Flaccid blisters, rupture quickly, become superficial round/oval erosions

RxSystemic Cloxacillin,

Cephalosporin

Seborrhoeic Dermatitis

Onset within 1st 2mths

Greasy yellow scaleson an erythematousbase, minimalpruritus

Seborrhoeic DermatitisFace, eyebrows, scalp (cradle cap)

Seborrhoeic DermatitisDiaper area, flexural areas (posterior auricular sulcus, neck,

axillae, inguinal folds)

Seborrhoeic Dermatitis

Localised or generalisedIf severe, fissures may develop & become

secondarilyinfected

CausePityrosporum ovale

(yeast)

Seborrhoeic Dermatitis

Spontaneously improves by end of1st yr

RxCradle cap shampooOlive oil on scalp to soften crusts (for 1hr before washing off)1% Hydrocortisone cream sparingly

Atopic Dermatitis

Atopic dermatitis& seborrhoeicdermatitis shareclinical features

Atopic Dermatitis

Difficult to distinguishduring neonatalperiod

Atopic Dermatitis

Differentiating featuresPruritic (cardinal feature)

Irritable, scratching & rubbing against nearby objectsDiaper area sparedRecurrence after clearingDry, white scalingStrong family history of atopy

Atopic Dermatitis

RxEmollients liberally particularly immediately after bath0.5% or 1% Hydrocortisone cream sparinglyTreat superimposed infections

Erythema Toxicum

50-70% of term babies; rare in preterm

Basic lesion is a small(1-3mm) papule,evolves into pustulewith a prominenthalo of erythema

Erythema Toxicum

Few to numerous, small areas of red skin with yellow-white centre

Usually on trunk, frequently on extremities& face

Palms & solesalmost alwaysspared

Erythema Toxicum

Most noticeable at48hrs; may appearas late as 7-10dys

Smear: EosinophilsBenign, resolves

spontaneously

Salmon Patch

Naevus simplex or macular haemangioma30-40% infantsDistended dermal

capillariesFlat, pink macular lesion

Salmon Patch

ForeheadUpper eyelidNasolabial area

Most resolve by 1 yr

� Crying makes fadinglesion more prominent

Salmon PatchGlabella (‘angel’s kiss’)Nape of neck (‘stork bite’) Most resolve by 1 yr

Usually persists

Port-wine Stain

Nevus flammeus0.3% neonates, seen at birthMost commonly on

faceAlso trunk, back,

limbsOften unilateral

Port-wine Stain

At birth, pink & macularWith time, darken to reddish purple (especially face),

papulonodular surface (on limbs greater tendency to fade)

Port-wine Stain

Vascular malformation of dilated capillary-like vesselsDo not involuteMajority are isolated

Port-wine Stain

Exclude Sturge-Weber syndrome, Klipple-Trenaunay syndrome

RxPulse-laser therapy

Strawberry Haemangioma

Bright red, raised, well circumscribed

Strawberry Haemangioma

At birth, may beabsent or pale maculewith irregular margins

Strawberry Haemangioma

Grow rapidly during 1st 6mths; continue to grow till 1yrMore common in head, neck & trunk; in premature

infants

Strawberry Haemangioma

Majority involute with by age 4-5yrs(50% by 5 yrs)

Strawberry Haemangioma

ComplicationsObstruction: Eye, ear, airway

Strawberry Haemangioma

ComplicationsUlceration

Strawberry Haemangioma

ComplicationsBleeding

Associated visceral involvementLiver, GIT, lungs, CNS

Naevus Sebaceum

Single yellowishslightly raisedhairless plaque

Scalp or face

Naevus Sebaceum

Excessive sebaceous glands & malformedhair follicles

Naevus Sebaceum

Risk of benign or malignant tumours in 15% (rarely before puberty)

RxExcision

before puberty

Basal Cell Carcinomadeveloped onNaevus Sebaceum

Basal Cell Carcinomadeveloped onNaevus Sebaceum

Café au lait Spots

Light brown, round or oval, maculesSmooth edgesVary in size

Café au lait Spots

Do not resolve with timeHistology: Increased melanin within basal keratinocytes,

without melanocyteproliferation

Few small spotsof littlesignificance

Café au lait Spots

NeurofibromatosisMcCune-Albright syndromeRussell-Silver syndromeMultiple lentigenesAtaxia telangiectasiaFanconi anaemia

Tuberous sclerosisBloom syndromeEpidermal naevus syndromeGaucher diseaseCh diak-Higashi syndromeē

Disorders with Café au lait Spots

Café au lait Spots - NeurofibromatosisCafé au lait Spots - Neurofibromatosis

Mongolian Spots

90% blacks, 80% asians, 10% whitesBrown, grey, blue maculesCommonly

lumbosacral area;occasionally upperback, limbs, face

Vary in size &number

Mongolian Spots

Infiltration of melanocytes deepin dermis

Often fade within 1st fewyrs due to decreasingtransparency of skinrather than truedisappearance

Sucking Blisters

Clear blisterLip, finger, hand, wristFriction of

repeated sucking

Sucking BlistersSome may be healed & appear like callusesResolves spontaneously

Sucking PadSucking Pad

CephalhaematomaCephalhaematoma

CephalhaematomaCephalhaematoma� from prolonged stage II of labour� instrumental delivery, especially ventouse� the misshapen head can cause some parental alarm� subperiostial swelling � boundaries is limited by bony margin, doesn't cross midline

Treatment� Reassurance� will resolve with time 4-8 weeks.complications � Anaemia from the quantity of bleed into the haematoma � Jaundice from haemolysis within it. � Calcification

CephalhaematomaCephalhaematoma

Oral CavityOral CavityOral CavityOral Cavity

Oral Thrush

White curd-like plaques on orobuccal mucosa, extends to pharynx if severe

Adherent,difficult toscrape off

Oral Thrush

May affect feeding

RxMiconazole oral gelSyrup Nystatin 100 000U qds

Umbilical CordUmbilical CordUmbilical CordUmbilical Cord

Umbilical Cord

Routine care: Clean with alcohol to base of cord (where it attaches to skin), exposure to air to help dry cord

Umbilical Cord

Usually separates within 1wk after birth (mean 7-14dys)Delayed separation (> 14dys)

Neutrophil function/chemotactic defectsBacterial infection

Umbilical Sepsis

Periumbilical erythema& induration

Purulent discharge

Umbilical Sepsis

Risk of haematogenous spread, extension to liver, portal vein phlebitis & later portal hypertension

RxPrompt parenteral antibacterial therapy

Umbilical Granuloma

CommonGranulation tissue at baseSoft, granular,

dull red or pinkSeropurulent

secretion

Umbilical Granuloma

Differentiate from gastric/intestinal mucosa

RxCauterisation with silver nitrateRepeat at intervals of several dys until base is dry

Umbilical Polyp

RareRemnant of vitelline duct or urachusFirm &

bright red(intestinal orurinary tractmucosa)

Umbilical Polyp

Mucoid secretion, faecal material or urineRx

Surgical excision of entire VI or urachal remnant

SpineSpineSpineSpine

Spinal DysraphismLumbosacral region

Skin dimple/sinus tractHairy patchPigmented naevusHaemangiomaLipoma

Ultrasound spine

JaundiceJaundiceJaundiceJaundice

Neonatal Jaundice

Common CausesPhysiologicHaemolytic

ABO/Rh incompatibilityG6PD deficiency

Breastmilk jaundiceBreastfeeding jaundice

Physiologic JaundiceAppears around D2-3

Peaks around D4-5

Falls after D5-7

Neonatal Jaundice

Management

Adequate fluid intake

PhototherapyCriteria dependent on birthweight, postnatal age & presence of

haemolysis

Neonatal JaundiceSunning

Not recommendedNot effectiveRisk of dehydration & sunburn

Prolonged Neonatal Jaundice

Jaundice beyond

14dys in term baby

21dys in preterm baby

Prolonged Neonatal JaundiceSome Causes

Breastmilk jaundiceHypothyroidismUrinary tract infectionBiliary atresiaNeonatal hepatitis

Prolonged Neonatal Jaundice

Investigations

Liver function testTotal & direct bilirubin

Urine FEME & cultureThyroid function test

Breastfeeding Jaundice‘Breast-nonfeeding’ or ‘starvation jaundice’Early onset, exaggeration of early jaundice with higher SB in

1st 5dysDue to inadequate frequency of breastfeeding & insufficient

caloric intake which enhances bilirubin absorption

Breastmilk Jaundice

Late onsetProlongation of physiologic jaundice, SB continues to rise

from D5Levels stay elevated, then fall slowly, returning to normal by

4-12wksIn 3rd wk, ~ 1/3 full term exclusively breastfed babies will be

clinically jaundiced

Breastmilk Jaundice

Baby is well with good weight gainLFT is normalIf breastfeeding is stopped, SB will fall rapidly in 48hrsIf resumed, SB may rise a little, if at all, but will not reach

previous high level