|Year : 2013 | Volume
| Issue : 3 | Page : 62-66
Cutaneous lesions in neonates admitted in a tertiary setup neonatal intensive care unit
Noopur Jain1, Bhagirath Singh Rathore2, Arvind Krishna Agarwal2, Abhishek Bhardwaj2
1 Department of Dermatology, Subharti Medical College, Meerut, Uttar Pradesh, India
2 Department of Venereology and Leprology, Subharti Medical College, Meerut, Uttar Pradesh, India
|Date of Web Publication||26-Nov-2013|
Department of Dermatology, Subharti Medical College, Delhi-Haridwar Bypass, Meerut 250 005, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Objective: The objective of this study is to determine the frequency of physiologic and pathologic skin findings in the neonates admitted in the neonatal intensive care unit.
Materials and Methods: A total of 60 neonates with cutaneous lesions, hospitalized in the NICU of Subharti Medical College, Meerut from November 2011 to August 2012, were examined. All physiological as well as pathological skin changes were observed and recorded. Mother's gestational history as well as relevant family history was taken.
Results: The most common 10 diagnoses were: Lanugo hair (78.33%), miniature puberty (70%), sebaceous hyperplasia (68.33%), iatrogenic bruises (48.33%), physiological desquamation (48.33%), Mongolian spot (45%), salmon patch (31.67%), seborrheic dermatitis (28.33%), miliaria (28.33%) and erythema toxicum neonatorum (23.33%). One case each of natal teeth, suckling blister, preauricular skin tag and micrognathia were also found.
Conclusion: The pattern of dermatoses as well as their correlation with various birth and maternal factors was studied. Data was analyzed and the same is being presented.
Keywords: Cutaneous, neonate, neonatal intensive care unit
|How to cite this article:|
Jain N, Rathore BS, Agarwal AK, Bhardwaj A. Cutaneous lesions in neonates admitted in a tertiary setup neonatal intensive care unit. Indian J Paediatr Dermatol 2013;14:62-6
|How to cite this URL:|
Jain N, Rathore BS, Agarwal AK, Bhardwaj A. Cutaneous lesions in neonates admitted in a tertiary setup neonatal intensive care unit. Indian J Paediatr Dermatol [serial online] 2013 [cited 2019 Oct 20];14:62-6. Available from: http://www.ijpd.in/text.asp?2013/14/3/62/122164
| Introduction|| |
The neonatal period is the first 4 weeks of extrauterine life, whereas infancy is the whole of the 1 st year.
Neonatal dermatoses are seen in almost every newborn if every cutaneous alternation is observed.  Neonatal skin is thinner, has weaker intercellular attachments, produces lesser sweat and sebum and is less effective in detoxifying and deactivating compounds that are applied on it.
Dermatoses of the newborn can be classified as: 
- Transient skin disorders
- Congenital disorders-birthmarks and genodermatoses.
- Acquired skin disorders
- Iatrogenic skin lesions.
Newborn skin lesions are quite common, both in healthy neonates, as well as in those needing hospitalization at neonatal intensive or semi-intensive care units, due to some disease. 
Structure and function of skin depend on whether the child is born at term or prematurely. Skin care is related to gestational age as well as other factors influencing the pattern of cutaneous changes such as heredity, race, maternal health and external factors such as hygiene, socio-economic status, customs, mode of delivery etc.
Iatrogenic skin disorders can occur before labor, during delivery or after birth.  No matter how simple and routine the delivery care may seem, between their admission and discharge, the neonates are submitted to a range of procedures, using life-support devices, which demand the application of care, including installment of catheters; capillary, venous and arterial punctures; probes, placement of adhesive devices, use of sensors, placement of electrodes, body hygiene, dressing change, position change, among others. All these situations represent aggravating factors for the appearance of lesions, due to their repetitive frequency during the hospitalization. 
Thus, the present study was undertaken to review the pattern of neonatal dermatoses observed in a neonatal intensive care unit (NICU) in this part of the world.
| Materials and Methods|| |
A total of 60 neonates, with cutaneous findings, who were hospitalized in the NICU of Subharti Medical College, Meerut from November 2011 to August 2012, were included prospectively in this single contact 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. The statistical analysis of the associations was done by the z-test. Simple investigations such as examination of scrapings for candida, smears for Gram staining and Tzanck smear from vesicles were performed whenever required.
| Results|| |
Of the 60 neonates, 35 (58.33%) were males and 25 (41.67%) were females. 36 (60%) were delivered by caesarian section, whereas 24 (40%) were delivered by the vaginal route. The birth weight of 29 (48.33%) was more than 2 kg and 26 (43.33%) was less than 2 kg. The birth weight of 5 (8.33%) neonates was not known as they were delivered at home. 32 (53.33%) were term, 26 (43.33%) were pre-term and one was post-term.
The various reasons for NICU admission included respiratory distress syndrome (35%), meconium aspiration syndrome (21.67%), hypoxic ischemic encephalopathy (20%), birth asphyxia (15%), intrauterine growth retardation (13.33%) and septicemia (11.67%) among others.
Maximum number, i.e., 40 (66.67%) of the mothers were in the age group of 20-25 years, 18 (30%) were in the age group of 25-30 years and 2 (3.33%) were more than 30 years old. 27 (45%) of the mothers were primigravida whereas 33 (55%) were multigravida.
Prevalence and Type of Dermatoses
Out of the 60 neonates, 58 (96.67%) had more than one cutaneous lesion. The most commonly observed skin lesions were Lanugo hair (78.33%), miniature puberty (70%), sebaceous hyperplasia (68.33%), iatrogenic bruises (48.33%), physiological desquamation (48.33%), Mongolian spot (45%), salmon patch (31.67%), miliaria (28.33%), seborrheic dermatitis (28.33%) and erythema toxicum neonatorum (23.33%).
The incidence of cutaneous lesions as observed in this study is shown in [Table 1].
Relation Between Sex of the Neonate and the Occurrence of Cutaneous Lesions
Most of the skin lesions were found to be more common in girls, except seborrheic dermatitis, miliaria, cutis marmorata and the iatrogenic bruises.
Relation Between Gestational Age and Lesions
Lesions like lanugo hair, sebaceous hyperplasia and salmon patch were more frequent in pre-terms, whereas, miniature puberty, physiological desquamation, Mongolian spot, seborrheic dermatitis, miliaria and erythema toxicum neonatorum were more common in the term neonates.
The association between the incidence of lesions and sex and the gestational age of the neonate is shown in [Table 2].
|Table 2: Incidence of lesions in association with the neonates' sex and gestational ages|
Click here to view
Relation Between Birth Weight and Lesions
The relation between the neonate's birth weight and the incidence of lesions is shown in [Table 3]. Most of the skin lesions observed was more frequent among the neonates with birth weight more than 2 kg, except, lanugo hair, sebaceous hyperplasia and iatrogenic bruises. The increased incidence of physiological desquamation among the neonates having higher birth weight was statistically significant as calculated by the z-test (z = 2.75, P < 0.01).
|Table 3: Incidence of lesions in association with the neonates' birth weight|
Click here to view
Relation Between Mother's Age and Incidence of Lesions
It was observed in our study that lesions like lanugo hair, sebaceous hyperplasia and iatrogenic bruises were more common in neonates whose mothers were between 20 and 25 years of age, whereas, miniature puberty, physiological desquamation, Mongolian spot, seborrheic dermatitis and erythema toxicum neonatorum were more common in those whose mothers were between 25 and 30 years of age.
| Discussion|| |
The prevalence of dermatoses in the newborn varies between 79.4% and 100%. , Although, most transient vesicular or pustular eruptions are non-infective, it is important for the dermatologist and the pediatrician to diagnose and treat the potentially fatal systemic infectious conditions such as streptococcal meningitis, which may present with rashes over the body. Similarly, the more persistent lesions and those with potential for malignant transformation, like a nevocellular nevus need to be given special attention. 
The most frequently observed lesion in our study was lanugo hair [Figure 1], seen in 47 (78.33%) which is comparable to a similar study conducted by Zagne and Fernandes.  It was observed to be more frequent in females, pre-terms and those born by ceserian section. Although other studies have reported a higher incidence of lanugo hair in pre-terms, the finding of increased occurrence among those born by ceserian section has not yet been documented.
Miniature puberty was diagnosed if there was the presence of genital or axillary hyperpigmentation, breast enlargement, pigmented linea alba or vaginal discharge in females. It was observed in 42 (70%) of the neonates which is higher than the incidence seen in some other studies. This may be due to racial differences as well as the difference in skin types, which was also reported by Alper and Holmes in their study.  We observed the features of miniature puberty to be more prominent among the term neonates as has been observed previously.
Sebaceous hyperplasia was found in 41 (68.33%) neonates. which is nearly comparable with that observed in other studies.  These were more frequently observed among females than males as also observed by Gokdemir et al. in their study. 
In our study, statistically significant association, by z-test, was found between delivery by ceserian section with lanugo hair as well as with erythema toxicum neonatorum. Our finding is in contrast to that of Sachdeva et al., who found an association between lanugo hair and vaginal delivery in their study. 
The incidence of physiological desquamation as observed in other studies varies from 7.2% to 83%. ,,,, In our study, its incidence was 48.33%. It was found to be more frequent in term neonates and those with birth weight more than 2 kg. There has been controversy regarding such association as some workers have found it to be more common in terms, , whereas others have found it to be more common in pre-terms.  It has been suggested that desquamation may be related to the loss of the vernix caseosa and poor barrier function of neonatal skin might allow transepidermal water loss with subsequent dehydration of the stratum corneum during the 1 st days of life. 
Among the congenital lesions Mongolian spot [Figure 1] and salmon patch were the most commonly observed, seen in 27 (45%) and 19 (31.67%) neonates, respectively. These were observed to be more frequent in females and those with a birth weight of more than 2 kg. Two cases of congenital melanocytic nevus were the other pigmentary birthmarks observed.
The frequency of Mongolian spots in our study is almost comparable with those of other Indian workers. ,,,,, Most of the Mongolian spots occurred on the sacrococcygeal area and buttocks and rarely on other sites including back, shoulders, and extremities. There have been various reports on the birthmarks among different races and countries. , Mongolian spots have been shown to be good examples of inter-racial differences. The prevalence of Mongolian spots has been as high as 80-90% in Asians  and it has been as low as 3-10% in Caucasians. 
Miliaria and seborrheic dermatitis were the most commonly observed acquired disorders, each observed in 17 (28.33%) neonates. These are almost comparable to the findings of Sachdeva et al.  We found their incidence to be higher in males, neonates of birth weight of more than 2 kg and the term neonates. Similar observations have also been made by other workers. ,
Iatrogenic dermatological complications were observed in 33 (55%) neonates out of which bruises, seen in 29 (48.33%) neonates, were the most common [Figure 2]. Interestingly, these lesions had a higher incidence in neonates with birth weight less than 2 kg, pre-term neonates and those born vaginally. The most common sites of the bruises were the dorsa of hands and feet, the sites of insertion of intravenous cannulae. A Brazilian study reported incidence of hematomas (46%), erythemas (18%), excoriations (12%), ecchymoses (10%), pustules (6%) and others (4; 8%). 
Unusual findings in our study were the observation of one case each of faun tail nevus, natal teeth and pre-auricular skin tag.
| Conclusion|| |
Neonatal skin lesions are mostly innocent and transient, but need to be differentiated from the more serious or life threatening conditions. Nursery staff should be aware of the susceptible and sensitive nature of the newborn skin so that proper care is provided, but at the same time unnecessary therapy or diagnostic tests can be avoided.
| References|| |
|1.||Pereira LB, Gontijo B, Silva CM. Dermatoses neonatais. An Bras Dermatol 2001;76:505-37 |
|2.||Parikh DA. Neonatal skin disorders. In: Valia RG, Valia AR, editors. IADVL Textbook of dermatology. 3 rd ed. Mumbai: Bhalani Publishing House; 2008. |
|3.||Fontenele FC, Cardoso MVLML. Skin lesions in newborns in the hospital setting: type, size and affected area. Rev Esc Enferm USP 2011;45:127-33 |
|4.||Stalder JF. Skin care of the newborn. In: Harper J, Oranje P, Prose NS, editors. Textbook of Paediatric Dermatology. Edinburgh: Blackwell Science; 2000. |
|5.||Fontenele FC, Cardoso MVLML. Skin lesions in newborns - premature infants in the neonatal intensive care unit. Rev RENE 2005;6:88-95. |
|6.||Baruah MC, Bhat V, Bhargava R, et al. Prevalence of dermatoses in the neonates in Pondicherry. Indian J Dermatol Venereal Leprol 1991;57:25-28. |
|7.||Taieb A, Boralevi F. Common transient neonatal dermatoses. In: Harper J, Oranje A, editors. Textbook of pediatric dermatology, 2 nd ed. Oxford: Blackwell, 2006;55-71,58-62. |
|8.||Zagne V, Fernandes NC. Dermatoses in the first 72 h of life: A clinical and statistical survey. Indian J Dermatol Venereol Leprol 2011;77:470-6 |
|9.||Alper JG, Holmes LB. The incidence and significance of birthmarks in a cohort of 4641 newborns. Pediatr Dermatol 1983;1:58-66. |
|10.||Gokdemir G, Erdogan HK, Koslu A et al. Cutaneous lesions in Turkish neonates born in a teaching hospital. Indian J Dermatol Venereol Leprol 2009;75:638. |
|11.||Sachdeva M, Kaur S, Nagpal M et al. Cutaneous lesions in new born. Indian J Dermatol Venereol Leprol 2002;68:334-7 |
|12.||Dash K, Grover S, Rashakrishnan S et al. Clincoepidemiologicol study of cutaneous manifestations in the neonate. Indian J Dermatol Venereal Leprol 2000;66:26-8 |
|13.||Kulkarni ML, Singh R. Normal variants of skin in neonates. Indian J Dermatol Venereal Leprol 1996;62:83-86 |
|14.||Rivers JK, Frederiksen PC, Dibdin C. A prevalence survey of dermatoses in the Australian neonate. J Am Acad Dermatol 1990;23:77-81 |
|15.||Nobbay B, Chakrabarty N. Cutaneous manifestations in the newborn. Indian J Dermatol Venereal Leprol 1992;58:69-72. |
|16.||Nanda A, Kaur S, Bhakoo N et al. Survey of Cutaneous Lesions in Indian Newborns. Pediatr Dermatol 1989;6:39-42. |
|17.||Hidano A, Parwoko R, Jitsukawa K. Statistical survey of skin changes in Japanese neonates. Pediatr Dermatol 1986;3:140-144. |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]