|Year : 2018 | Volume
| Issue : 1 | Page : 40-47
Study of physiological and pathological skin changes in neonates: An east indian perspective
Binodini Behera1, Yatra Kavadya1, Prasenjit Mohanty1, Dipanweeta Routray2, Subhra Ghosh3, Lina Das4
1 Department of Skin and VD, S.C.B. Medical College, Cuttack, Odisha, India
2 Department of Preventive and Social Medicine, S.C.B. Medical College, Cuttack, Odisha, India
3 Department of Obstetrics and Gynaecology, S.C.B. Medical College, Cuttack, Odisha, India
4 Department of Paediatrics, S.V.P. Post Graduate Institute of Paediatrics, Cuttack, Odisha, India
|Date of Web Publication||28-Dec-2017|
HIG 13, Sector 1, Shankar Nagar, Raipur - 492 007, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Background: Numerous dermatological conditions are prevalent in neonatal period, i.e., first 28 days of life with varied presentations ranging from transient self-limiting lesions to serious dermatosis requiring clinical attention. Due to lack of complete knowledge, it is distressing for both parents and treating physician. Objectives: This study was done in eastern part of India to record various dermatosis, and their prevalence compared with other part of country and find association between skin conditions and parameters, namely, sex, parity, gestational age, mode of delivery, and birth weight. Materials and Methods: This descriptive cross-sectional study was done in tertiary care hospital entailed recording of 400 neonates having any kind of dermatosis and statistically evaluated using Chi-square test (SPSS) and significance (P < 0.05). Results: Mongolian spot followed by sebaceous gland hyperplasia and epstein pearls were the common dermatologic findings. Physiological desquamation, acrocyanosis, and sebaceous gland hyperplasia were more prevalent in males and was statistically significant while erythema toxicum neonatorum significantly high in females. Epstein pearls, physiological scaling was also significantly high in term babies. Physiological scaling in cesarean patients and acrocyanosis in vaginal delivery was also significantly associated. Some atypical cases such as phakomatosis pigmentovascularis, plantar keratoderma, collodion baby, and congenital whorled hypermelanosis were also present in our study group. Conclusion: Physiological skin lesions are very common in neonates and appreciation of these lesions are important.
Keywords: Mongolian spot, neonatal dermatoses, neonatal skin
|How to cite this article:|
Behera B, Kavadya Y, Mohanty P, Routray D, Ghosh S, Das L. Study of physiological and pathological skin changes in neonates: An east indian perspective. Indian J Paediatr Dermatol 2018;19:40-7
|How to cite this URL:|
Behera B, Kavadya Y, Mohanty P, Routray D, Ghosh S, Das L. Study of physiological and pathological skin changes in neonates: An east indian perspective. Indian J Paediatr Dermatol [serial online] 2018 [cited 2019 Sep 19];19:40-7. Available from: http://www.ijpd.in/text.asp?2018/19/1/40/216943
| Introduction|| |
A neonate is a child in first 4 weeks of extrauterine life. After birth, skin undergoes a myriad of changes resulting in varied cutaneous manifestations ranging from benign to life-threatening ones. Some may resolve, some may persist with little change, and others are harbingers of systemic disease. These lesions perhaps are a matter of stress for the parents and for the attending physicians who are not aware about the lesions. An elaborate knowledge is required to distinguish between the benign conditions to promptly and accurately respond to these lesions and avoid unnecessary intervention. In addition, regional and racial variations present need to be addressed. This survey was conducted to study different skin lesions, their prevalence in neonates and to find their association with various maternal and neonatal factors. Similar studies are available in literature, but there is paucity of data from eastern part of India.
| Materials and Methods|| |
It was a hospital-based cross-sectional observational descriptive study done in the Department of Obstetrics and Gynecology and Skin and VD of our institute from April 2014 to April 2015. Permission was also obtained from Ethics Committee of our Institution before this study. Four hundred neonates with cutaneous manifestation either physiological, pathological or both were included in this study. The babies in intensive care unit (for prevention of any iatrogenic infection due to improper handling) and cases where mothers were not consenting were excluded. The gender, gestational age, birth weight, the mode of delivery, and significant maternal history were recorded in each case. All the neonates were examined by the same dermatologist. The entire skin, the mucous membranes and the nails were thoroughly examined in proper light by completely undressing the child. The diagnosis of the skin lesions was based on description elaborated in the text. Simple noninvasive procedures were done. No biopsies were performed, as parents did not consent. Statistical analysis: data were entered into Microsoft Excel 2007 and analyzed using SPSS version 21 (PASW Statistics for Windows, Chicago, IL, USA: SPSS 1OC). Chi-square test was used to see the statistical significance between two proportions and Fisher's exact test was used when cell frequency was <5. P < 0.05 was taken as statistically significant and P < 0.01 as highly statistically significant.
| Results|| |
A total of 400 newborns with cutaneous lesions were examined during the study. Of these, 224 were male and 176 were female infants. The babies were seen only once between day 1 and 28 (average day: 4.32 ± 3 standard deviation [SD]), the majority (89%) being examined within first 7 days of life. 86 were low birth babies and 314 babies being 2.5 kg or more. In the study group, 320 babies were term, 68 being pre-term, and 12 post-term. There were 307 primi and 93 multipara mothers, average age being 23.88 ± 2.5 SD. A total of 287 mothers delivered through cesarean section. Totally, 199 neonates have shown two dermatoses while 104 neonates had one. 812 different dermatoses was seen in 400 neonates. The neonatal skin lesions are categorized and shown in [Table 1]. Mongolian spot (42.5%) [Figure 1], Sebaceous gland hyperplasia (38.8%) [Figure 2], Epstein pearls (32.8%) were the common observation. We also had interesting cases of familial plantar keratoderma [Figure 3]a and [Figure 3]b, phakomatosis pigmentovascularis 2a [Figure 4]a and [Figure 4]b, congenital linear and whorled hypermelanosis [Figure 5], benign cutaneous hemangiomatosis [Figure 6], and collodion baby [Figure 7].
|Figure 1: Bluish-gray single oval macule of size 5–6 cm present over lumbosacral area|
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|Figure 2: Multiple yellowish pinpoint uniform papules present around nose|
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|Figure 3: (a) Diffuse thickening of bilateral planter aspect of feet and hands. (b) Localized yellowish thickening over plantar aspect of feet|
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|Figure 4: (a) Large bluish-grey pigmentation on the back, buttocks with port wine stains. (b) Nevus flammeus involving scalp, face, neck, trunk, scrotum, and flexors of thigh and arms along with mongolian spot present over lower limbs|
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|Figure 5: Hyperpigmented macules present in the form of streaks and whorls over trunk and extremities following line of blaschkos|
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|Figure 6: Few erythematous nodules of size 1–2 cm in diameter present diffusely over body|
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|Figure 7: Thickened parchment-like membrane enclosing baby with ectropian present|
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This study enabled to reveal 12 different associations. A significant association (P< 0.05) was seen in milia, acrocyanosis, sebaceous gland hyperplasia with male gender and erythema toxicum neonatorum (ETN) and epstein pearls with female [Table 2]. Regarding the gestational age, physiological scaling of newborn, sebaceous gland hyperplasia and epstein pearls had an association with term babies [Table 3]. Concerning mode of delivery, acrocyanosis was found having an association with vaginal delivery, and physiological desquamation was more in babies delivered by cesarean section [Table 4]. With respect to the birth weight, physiological jaundice was shown association with low birth weight [Table 5]. Physiological desquamation was seen more in primigravida mothers with significant association [Table 6].
| Discussion|| |
The present study presents a comprehensive analysis on the basis of observations made on 400 neonates for skin disorders and also on statistical analysis. Factors influencing pattern of cutaneous changes in neonates is heredity, race, gestational age, and maternal health in addition to other external factors such as hygiene, socioeconomic status, customs, and mode of delivery. Variations are also result of the different study period, inclusion and exclusion criteria and no well-defined guidelines to classify neonatal dermatoses.
This study was done in a tertiary hospital-based study done in eastern part of Odisha. The climate is perennially hot and humid with few shower sprinkles. Being a hospital-based study, cesarean sections are more in the population studied as compared to community population. Furthermore, the study group had more of below poverty line population and primi mothers. Unfortunately, biopsy could not be done in doubtful cases due to denial of consent from parents of the patients. The data have been compared to various Indian and foreign studies available in literature.
Physiologic desquamation (PD) was noted in 64 (16%) neonates which was identical to a study done by Dash et al., Nobbay and Chakrabarty  and Kulkarni and Singh. It was also reported to be 31.29% by Gokdemir et al., 40% by Sachdeva et al., 18.23% by Zagne and Fernandes  and 83% by Baruah et al. In our study, PD was noted most common in term neonates (92.2%) which is highly significant (P = 0.025) and consistent with the study of Sadana et al. and in contrast to other study  who found it more in postterm. We have also found a highly significant association with parity (P = 0.001) more in primi and mode of delivery (P = 0.002) being more in neonates delivered through cesarean sections which is not reported in other studies. In contrast to our studies, Sachdeva et al. found it more in babies of multiparous women.
Milia in previous studies have ranged from 1.4 to 93.1%.,,,,,,, In our study, it was found in 32 neonates (8%). It has shown a highly significant association with gender (P = 0.003) being more in males as reported by Zagne et al. This is in contrast to the observation made by Gokdemir et al. and Jain et al. who found it more in females. It was more in term and neonates with normal birth weight similar to other studies.,,
Epstein pearls were seen in 131 (33%) neonates, with the most common site being midline of palate similar to another Indian study. They occur commonly in 64%–89% of normal neonates and are common in whites explaining low incidence in our study. It was found to be significantly associated with gender (P = 0.04), being more common in females and also with gestational age (P = 0.04) term babies having more of it. Moosavi and Hosseini  has found it to be more in term babies similar to our study while Baruah et al. had found no relation with gestational age. Shajari et al. have found it more in males which is in contrast to our study.
The reported incidence of physiological jaundice of newborn varies from 3.5% to 20.6%.,, In our study, it was found in 11 (2.8%) which was found to be significantly associated with term pregnancy (P = 0.001) and low birth weight (P = 0.007). Association with low birth weight has also been observed by Sadana et al.
Sebaceous gland hyperplasia (SGH) was found in 155 (38.8%) neonates, being significantly associated with male gender (P = 0.001) and term babies. (P = 0.001). In other studies, the percentage varied from 23% to 50%. Jain et al. have found SGH more in males, preterm, vaginal delivery, and babies born to multipara. Sachdeva et al. also made a similar observation, i.e., finding the lesion to be more common among neonates born vaginally and those born to multiparous women. Irrespective of sex of the neonates, our findings were similar to those of Zagne and Fernandes  and Haveri and Inamadar  but in contrast to those of Gokdemir et al. Sebum secretion rates were higher in neonates compared to the pre-adolescent children. It is assumed that this sebaceous gland activity reflects benign proliferations in response to circulating hormones.
The incidence of ETN ranges from 1.3% to 40.8%.,,,,,,,,, In our study, it was found in 24 (6%) neonates. There was highly significant association with gender (P = 0.002), females being predominately affected. This finding was consistent with Zagne et al. and Sadana et al. while Hidano et al. noted equal sex distribution. In our study also, we have found ETN more in term neonates such as Haveri and Inamadar, Sachdeva et al., Baruah et al., and Dash et al., similar to Egyptian and Japanese study. We also found it to be more in normal weight baby. Sadana et al. has quoted statistical significance between normal birth weight and ETN. Like Gokdemir et al. and Zagne et al. we also found ETN more in babies delivered through cesarean section which is in contrast with Sadana et al.
Miniature puberty was noted in 19 (4.8%) neonates. Gokdemir et al., Jain et al. in their studies, have found miniature puberty in 43.5% and 71% of neonates, respectively.
Acrocyanosis was seen in 12 (3%) neonates in our study. We have found it to be highly significant with mode of delivery (P = 0.000) and slightly significant in male gender (P = 0.053). Zagne et al. also have found a significant association between acrocyanosis and neonates delivered vaginally. As these deliveries are usually slow and time taking, the compressive pressure exerted over the fetus while inside uterus and birth canal might explain the relationship.
Miliaria was noted in 83 (20.8%) of neonates in our study especially in summer season (month of March to July). This incidence was similar to a pattern observed in a study done by Nobbay and Chakrabarty (7%), Baruah et al. (13.2%), Dash et al. (24%) and Sachdeva et al. (20.6%). Miliaria crystallina was more common variant seen in 48 neonates in our study which was not similar to other studies. In other studies, miliaria rubra was more common. This variation may be attributed to climatic condition and practice of binding the babies in cloth for a long time in our areas. Common sites of involvement were over forehead, neck and trunk comparable to other studies. Like Dash et al., we also found predilection for term babies and those born by cesarean section but was not very significant statistically.
The incidence of Mongolian spots (MS) have been recorded ranging from 11.7% to 89% in previous studies.,,,,,, We observed MS to be the most common finding in our study in 170 neonates (42.5%) which is comparable to other Indian studies. As observed by Sachdeva et al., we found a higher incidence of Mongolian spots among neonates having higher birth weight and also those born to primipara. But Zagne et al., Sachdeva et al., Sadana et al. and Jain et al. in contrast have found it more in multipara. The most common site was lumbosacral with few atypical sites such as leg, hand, and neck.
Congenital melanocytic nevus was seen in 3 (1%) neonates comparable to 2% by Haveri and Inamadar. One neonate presented with an atypical presentation having a large dome-shaped plaque type nevus of 8–10 cm size over trunk area and multiple satellite lesions covering whole body [Figure 8]. Parents were counseled for biopsy, but they never turned up.
|Figure 8: Hyperpigmented thicked plaque of size 6–8 cm present over abdomen area with multiple satellite lesions|
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The incidence of Salmon patch in the present study was 10%. It was 22% in the Japanese study  and 28% in an Indian study. The most common site of occurrence in the present study was eyelids. No gender predilection was seen, in contrast to female preponderance found in the earlier observations made by Zagne and Fernandes  and Hidano et al. Sachdeva et al. in their study have observed salmon patch to occur more frequently among neonates with a higher birth weight which is similar to our findings. We also found the lesion being more common in term neonates which has also been reported by Jain et al.
Hemangiomas were seen in 5 neonates (1%), comprising 1 postterm, and 4 mature neonates. All the 4 cases were female neonates. Female preponderance has also been mentioned in the ratio of 1:3.
One interesting case of phakomatosis pigmentovascularis IIa was seen in our study. A 4-day-old neonate had bilateral nevus flammeus involving the scalp, face, neck, trunk, upper part of the back, scrotum, and the flexor sides of arms and thighs. Large, bluish-gray pigmentation was also observed on the abdominal area, back, buttocks, legs, and the extensor sides of the arms.
Napkin dermatitis has been seen in 0.3%–18.9% cases.,,,,, There was only one case in our study group (0.3%). The possible explanation is that napkin dermatitis is more common in 7–11 months of age while our study was confined to 1 month only.
Cradle cap in our study was seen in 8 (2%) neonates. Previous reported incidence is 0. 3%–4.4%.,,,,, The incidence was seen more in term babies as observed by Sadana et al. and more in normal birth weight as seen by El-Moneim et al.
Bacterial infections were in seen 14 neonates (4%). Twelve cases of impetigo were present. Nanda et al. have found it to be 11% while Nobbay and Chakrabarty  reported skin infections in 7.8%. Higher incidence in Indian studies can be justified because of hot and humid climate, poor hygiene, and overcrowding in our hospitals.
Fungal infections were observed in 8 (2.1%) neonates and oral candidiasis was seen in 7 of the studied neonates (1.8%). Our results were in contrast to the finding of Ferahbas et al. who showed a significant association between candidiasis and maturity (more in preterm). In our study, it was more in term baby. One case of tinea was found in our study whose mother had same lesions all over her body.
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.
We would like to thank Dr. Madan Mohan Sahoo, Associate Professor, Orthopaedics, S.C.B. Medical College, Cuttack for technical help.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]