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ORIGINAL ARTICLE
Year : 2016  |  Volume : 17  |  Issue : 3  |  Page : 190-195

Early neonatal dermatoses: A study among 1260 babies delivered at a tertiary care center in South India


Department of Dermatology, Venereology, Leprosy, Vijayanagar Institute of Medical Sciences, Bellary, Karnataka, India

Date of Web Publication5-Jul-2016

Correspondence Address:
Divya Kalappa Gorur
Department of Dermatology, Venereology, Leprosy, Victoria Hospital, Bengaluru - 560 002, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-7250.179493

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  Abstract 

Introduction: A variety of lesions which may be transient, physiological, or pathological may be present during the neonatal period. However, most of these conditions are benign and self-limiting.
Objective: To study the hospital-based incidence and clinical pattern of dermatoses during the early neonatal period.
Methods: A hospital-based, cross-sectional study was conducted in a government hospital. A total of 1260 consecutive live babies delivered over a period of 1 year at the Department of Obstetrics and Gynecology were examined up to 7 days of extrauterine life.
Results: Among 1260 newborns, 1242 (98.5%) had cutaneous lesions. Among them, 700 (55.5%) were males and 560 (44.4%) were females. Of these, 1119 (88.1%) weighed >2.5 kg, whereas 141 (11.9%) weighe<2.50 kg. 1176 (93.3) were born at term, 66 (5.3%) were preterm, and 18 (1.4%) were postterm. History of consanguinity was present in 211 (16.7%) cases. 817 (64.8%) newborns were delivered by normal vaginal route and 443 (35.1%) by cesarean section. Majority, i.e., 764 (60.6%) mothers were in the age group of 21–25 years, 318 (25.23%) below 20 years, 162 between 26 and 30 years (12.86%), and 16 (1.26) were more than 30 years. Mongolian spot, milia, sebaceous hyperplasia, erythema toxicum, and physiological scaling were the common physiological and transient dermatoses seen. A few pathological conditions such as Waardenburg syndrome and bathing trunk nevus were seen.
Conclusion: The hospital-based incidence of neonatal dermatoses was 98.5% with no sexual predilection. Although common, most of the skin lesions in newborn are self-limiting requiring no treatment. Correct diagnosis and counseling the parents may relieve the anxiety and mental trauma.

Keywords: Neonatal dermatoses, physiological, transient


How to cite this article:
Gorur DK, Murthy SC, Tamraparni S. Early neonatal dermatoses: A study among 1260 babies delivered at a tertiary care center in South India. Indian J Paediatr Dermatol 2016;17:190-5

How to cite this URL:
Gorur DK, Murthy SC, Tamraparni S. Early neonatal dermatoses: A study among 1260 babies delivered at a tertiary care center in South India. Indian J Paediatr Dermatol [serial online] 2016 [cited 2019 Oct 16];17:190-5. Available from: http://www.ijpd.in/text.asp?2016/17/3/190/179493


  Introduction Top


The neonatal period is regarded as the first 4 weeks of extrauterine life. Early neonatal period usually refers to first 7 days of life, during which majority of the dermatoses occur. The transition from an aqueous atmosphere to a dry one represents a dramatic challenge to the skin of a newborn. Newborn skin is distinct, in terms of permeability, barrier function, absorption, and temperature regulation compared to that of an adult skin. These structural and physical properties are mainly dependent on the maturity of the neonate.

A variety of lesions which may be transient, physiological, or pathological may be present during the neonatal period.[1] However, most of these conditions are benign and self-limiting. Environmental and maternal factors may play a role in few of these dermatoses. Pattern of dermatoses may also change over time with regional and racial variations. This study was done to know the hospital-based incidence and clinical pattern of neonatal dermatoses in this part of the country.


  Methods Top


A hospital-based, cross-sectional study was conducted at our institute. A total of 1260 consecutive live babies delivered over a period of 1 year at the Department of Obstetrics and Gynecology, formed the study subjects. All consecutive live babies of both sexes, up to 7 days of extrauterine life were examined. Babies with structural anomalies, sexual ambiguity, and those delivered outside the hospital were excluded from the study.

Data were collected after obtaining informed consent from parent/guardian of each neonate up to 7 days of extrauterine life. Detailed history regarding the age of the mother, parity, consanguinity, mode of delivery, blood group of mother, and maternal illness during pregnancy was taken. The neonates were examined thoroughly. The morphology of skin lesions and findings was recorded. The sex, birth weight, presence of any systemic illness, and age at the time of examination were noted in each case. Diagnosis was made based on clinical features. When necessary, Gram's stains, potassium hydroxide mount, bacterial culture, maternal blood venereal disease research laboratory, and skin biopsy were done.

The results of the study were tabulated and analyzed. Simple proportions and percentages for incidence, comparison of different variables such as age and sex was used. The relationship between skin lesions and various maternal-neonatal aspects were calculated using Z-test, with P ≤ 0.05 considered statistically significant.


  Results Top


Among 1260 newborns included, 1242 (98.5%) had cutaneous lesions. 700 (55.6%) were males, while 560 (44.5%) were females. Of these, 1109 (88.1%) weighed >2.5 kg, 151 (11.9%) weighed <2.5 kg. While 1171 (93.3%) were born at term, 66 (5.3%) were preterm, and 23 (1.4%) were postterm. History of consanguinity was present in 88 (6.8%) cases. 817 (64.8%) newborns were delivered by normal vaginal route and 443 (35.2%) by cesarean section. Majority, i.e., 764 (60.6%) mothers were in the age group of 21–25 years, 318 (25.2%) below 20 years, 164 (12.9%) between 26 and 30 years, and 14 (1.3%) were more than 30 years.

In relation to blood group, babies of mothers whose blood group was O positive, 635 (50.4%) were the most common having skin lesions, followed by B positive 285 (22.6%), A positive 80 (19.6%) and others 7.2%. Most of the cutaneous lesions were seen in term neonates 1171 (93.3%) and babies weighing more than 2.5 kg 1109 (88.1%).

There were overlapping conditions (more than one neonatal dermatoses) in many neonates. Physiological skin lesions were the most common seen in 2343, followed by transient cutaneous lesion in 321 (26%), birthmarks in 41 (3.1%), and others in 7 (0.4%) babies. Among the physiological skin lesions, Mongolian spot was the most common seen in neonates 1179 (93.5%), followed by milia in 327 (26%), sebaceous hyperplasia 316 (25%), erythema toxicum neonatorum (ETN) in 241 (19.1%), and physiological desquamation in 130 (10.32%) and others [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6]. All the physiological skin lesions were more common in males except acrocyanosis and physiological jaundice. The lists of dermatoses seen are outlined in [Table 1].
Figure 1: Sebaceous hyperplasia

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Figure 2: Erythema toxicum neonatorum

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Figure 3: Giant congenital melanocytic nevi

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Figure 4: Aplasia cutis congenita

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Figure 5: Klippel-Trenaunay- Weber syndrome More Details

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Figure 6: Waardenburg's syndrome

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Table 1: Pattern of neonatal dermatoses

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Most of the physiological skin lesions were seen in term infants. With respect to maturity, all skin lesions were commonly seen in term newborns, compared to preterm and postterm newborns. Vernix caseosa, physiological scaling, and cutis marmorata were not seen in any of preterm neonates in our study. Lanugo hair was seen in 34 neonates of whom 30 (88.25%) were preterm neonates. Cutis marmorata, acrocyanosis, and rubor were not seen in any postterm neonates. 885 (70.2%) mothers had a regular antenatal checkup with dietary supplementation of iron and folic acid. Statistically significant increase in incidence of vernix caseosa 36 (97.2%), P < 0.001; milia 241 (74.9%), P < 0.02; and jaundice 4 (16%), P< 0.0001 were seen in neonates whose mothers had regular antenatal checkup (P < 0.05).


  Discussion Top


Cutaneous lesions are not uncommon among neonates. The incidence and pattern of lesions may depend on various factors. In our study, the hospital-based incidence was 98.5%. In a study from north India, 94.8% neonates had one or more cutaneous lesions.[1] The prevalence of neonatal dermatoses in different studies has varied in between 57% and 99.3%.[2] These differences in the results may be related to variations in study methods, environmental, and racial factors.

The incidence of ETN, sebaceous hyperplasia, and milia were similar to other Indian studies. The most common skin manifestation noted was Mongolian spots in our study. The incidence of Mongolian spots in our study was similar to others, which ranged from 56% to 98% in various studies.[2],[3],[4] Its incidence in Asiatic newborn was found to be 81% in one study.[2] Majority were found over lumbosacral region. It is evident that greater the degree of natural pigmentation, the higher is the occurrence of Mongolian spots in the newborn. Higher incidence in black babies, Asiatic babies, Ladino babies, and Mongolians point toward its racial variation.[2] These were seen more commonly in males and term babies, with a higher incidence in neonates born to multiparous women. There was no relation to maternal illness or mode of delivery similar to a study by Sachdeva et al.[2]

The incidence of milia in our study was comparable to that observed by other Indian workers.[1],[3] A higher incidence was seen in term babies and in babies weighing more than 2.5 kg, delivered vaginally, which has also been noted by other workers.[1],[3] Next common dermatoses were sebaceous hyperplasia, similar to study by Dash et al. and Sachdeva et al.[2],[3] It was seen more commonly in babies delivered by normal vaginal route and those weighing more than 2.5 kg. Occurrence of ETN was similar to that by Dash et al. and Sachdeva et al.[2],[3] All the babies were born at term which is in concurrence with other studies.[1],[3] Most of the babies developed ETN on day 2 or 3. The day of examination (second to 4th day) and onset of ETN showed statistical significance (P < 0.05).

We found one case of transient neonatal pustular melanosis with hyperpigmented macules and scaling mainly distributed over trunk. Gram stain showed neutrophils without any organisms. Transient neonatal pustular melanosis occurs in 0.2% of white infants and 4.4% of black infants.[5] A study done by Kulkarni and Singh showed the incidence of 2.6% of cases.[6]

The incidence of physiological scaling was low in our series. The incidence of superficial cutaneous desquamation has ranged from 72% to 83% in other studies.[2],[3],[4] The incidence varies depending on the day of examination, being more in studies where babies were followed up for more than 5 days. It was more in term and postterm neonates. The day of examination (5th–7th day) and onset of physiological desquamation showed statistical significance (P < 0.002). Epidermal hyperpigmentation and hypertrichosis were less common in our study, in contrast to Zagne and Fernandes [7] who reported a higher incidence of both epidermal hyperpigmentation (42.86%) and hypertrichosis (69.9%). This difference could possibly be related to racial and geographical variations.

Among transient infective conditions, neonatal impetigo was present in 41 (3.14%) of our cases, similar to an incidence of 1.2% by Nobby and Chakraborty.[8] Miliaria was seen in 3.49% cases. The incidence in other studies has varied between 2.6% and 9.6%[9] which may be attributed to climatic variations. We found a lower incidence lanugo, in contrast to Sachdeva et al. and Nobby et al.,[2],[8] who found an incidence of 14.4% and 14.6%, respectively. In our study, most of them (88%) were preterm similar to earlier studies.[9],[10] Lanugo has a preponderance to occur in preterm babies. The lower incidence in our study may be due to the overall lesser number of preterm babies.

Scrotal hyperpigmentation was seen in 40 (5.7%) neonates and labial hypertrophy in 14 (1.1%) as common findings of miniature puberty. One baby had bleeding per vagina which stopped by the 4th day. There was no history of maternal illness or drug intake. It was speculated that the variation in genital hyperpigmentation may be related to the differential activation of melanocytes. Therefore, racial factors and skin type may be important factors in determining genital pigmentation.[11]

The frequency of Cafe-au-lait macule (CALM) was slightly higher in our neonates. One baby had multiple CALMs with similar lesions in baby's mother and grandmother. Mother also had plexiform neurofibroma of the vulva. A study done in Arab and Israel showed the prevalence of CALMs in 0.48% and 0.11% neonates, respectively.[12] When multiple CALMs are present, babies have to be followed up for the development of neurofibroma, in conjunction with family history.

In our study, congenital melanocytic nevi were equivocal with previous studies. A giant congenital melanocytic nevus (bathing trunk nevus) was present in a baby, involving the entire trunk with multiple satellite lesions distributed all over the body. Baby succumbed to death due to asphyxia a few hours after birth. Congenital melanocytic nevi in newborns showed a prevalence of 0.4–15.6%, with the highest percentage among nonwhite babies.[13] Accessory tragus was present in one baby on right ear similar to a study by Baruah et al.[4] Accessory tragi can be part of syndromes involving the first branchial arch.[7]

An increased incidence of vernix caseosa and milia was seen in neonates whose mothers had a regular antenatal checkup with dietary supplementation of iron and folic acid. Monteagudo et al.[10] in his study found that the intake of dietary supplements was associated with increased prevalence of palatal cysts and vernix caseosa and decreased the frequency of jaundice. Palatal cysts and vernix caseosa are less common in premature and very low birth weight infants. An adequate supply of nutrients may be related to the presence of these two conditions. Furthermore, adequate nutrients reduce the onset of jaundice, which occurs, when associated with other predisposing factors such as low birth weight, lower gestational age, and congenital infections. Interestingly, we found an increased incidence of neonatal dermatoses among mothers with O positive blood group. This could possibly be coincidental. However, it could be due to increased prevalence of O positive blood group in general population.[14] Further studies need to be done to establish the true association between the occurrence of neonatal dermatoses and maternal blood group.

We found one case of aplasia cutis congenita, comparable to an earlier study from Pondicherry.[4] The baby had a single atrophic patch on the scalp with no secondary changes. Approximately, 0.03% of newborns are afflicted with aplasia cutis congenita, or congenital absence of skin. The lesion is present at birth and may be ulcerated, bullous, or atrophic in appearance. It is solitary in 70% of cases. The most common location is the scalp (near the vertex) although these lesions may occur anywhere on the body. Histopathologic examination reveals an absence of epidermis and dermal appendages. Smaller lesions typically heal as an atrophic scar and are easily covered by scalp hair. Larger lesions may require surgical intervention.[5]

Nevus flammeus associated with Klippel-Trenaunay-Weber syndrome was found in one baby, affecting the entire right upper limb, extending on to the back, distributed in a dermatomal pattern. There was associated limb hypertrophy and craniosynostosis. Nevus flammeus often referred to as the port-wine stain, is a vascular malformation composed of mature ectatic capillaries. This lesion occurs in approximately 0.3% of newborns. The flat, reddish blue nevus flammeus is present at birth. During childhood, the lesion lightens only minimally due to skin thickening and changes in pigment. In or following adolescence, the lesion may begin to darken and develop varicosities, nodules, or pyogenic granulomas. Nevus flammeus may be associated with Klippel-Trenaunay-Weber syndrome,  Sturge-Weber syndrome More Details, and ipsilateral glaucoma.

Klippel-Trenaunay-Weber syndrome is characterized by the overgrowth of soft tissue, bone, and all involved structures in an area of the body (especially an arm or leg) in which a nevus flammeus is present. In particular, discrepancies in leg length can occur, resulting in gait abnormalities and/or scoliosis. Pulsed-dye laser therapy can be used to lighten a nevus flammeus lesion, to reduce the risk of Klippel-Trenaunay-Weber syndrome and to minimize the deformities that can occur with progression of the lesion. Compression garments can help to minimize overgrowth, especially when the lesion is confined to an extremity.[5]

A single case of anal polyp was seen in our study, which was excised. Zagne and Fernandes [7] in a similar study found a case of nasal adnexal polyp. None of the previous Indian studies have mentioned the occurrence of anal polyp.

We had a single neonate with clinical features suggestive of Waardenburg syndrome. However, sensorineural deafness could not be evaluated by brain evoked auditory response as the baby was uncooperative. None of the earlier studies have reported such an occurrence.


  Conclusion Top


The hospital-based incidence of neonatal dermatoses was 98.5% with no sexual predilection. Mongolian spot, milia, sebaceous hyperplasia, erythema toxicum, and physiological scaling were the common physiological and transient dermatoses seen. A few pathological conditions such as Waardenburg syndrome and bathing trunk nevus were seen.

Genetic, environmental, racial, and various maternal and neonatal factors (maternal age, maternal blood group, consanguinity, regular antenatal checkup, and maturity of the baby) may influence the occurrence of certain skin lesions. Patterns of neonatal dermatoses may vary depending on racial and geographical factors also. Patterns may vary regionally, even within the same country, as evident in our study. Thus, the study of neonatal skin helps to differentiate benign transient lesions from pathological conditions. Correct diagnosis and counseling the parents may relieve the anxiety and mental trauma.

Declaration of Patient Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We thank Professor and Head, Department of Obstetrics and Gynecology; Professor and HOD, Department of Pediatrics for their cooperation in conducting this study. We also thank Dr. Girianna Gowda, MD and Shri. K.S. Sridhar for their help in statistical analysis

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

 
  References Top

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Monteagudo B, Labandeira J, León-Muiños E, Carballeira I, Cabanillas M, Suárez-Amor O, et al. Frequency of birthmarks and transient skin lesions in new-borns according to maternal factors (diseases, drugs, dietary supplements, and tobacco). Indian J Dermatol Venereol Leprol 2011;77:535.  Back to cited text no. 10
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Conlon JD, Drolet BA. Skin lesions in the neonate. Pediatr Clin North Am 2004;51:863-88.  Back to cited text no. 13
    
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Das PK, Nair SC, Harris VK, Rose D, Mammen JJ, Bose YN, et al. Distribution of ABO and Rh-D blood groups among blood donors in a tertiary care centre in South India. Trop Doct 2001;31:47-8.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
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