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ORIGINAL ARTICLE
Year : 2018  |  Volume : 19  |  Issue : 2  |  Page : 124-129

A study of dermatoses in the early neonatal period from a tertiary care hospital in North West Punjab


1 Department of Dermatology, Christian Medical College, Ludhiana, Punjab, India
2 Department of Pediatrics, Christian Medical College, Ludhiana, Punjab, India

Date of Web Publication26-Mar-2018

Correspondence Address:
Shiti Bose
House No. 74, Anuj Vihar, Shankar Vihar, Dhaula Kuan, New Delhi - 110 010
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_58_17

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  Abstract 


Background: Neonatal life, as defined by the World Health Organization, constitutes the first 28 days of extrauterine life. The transition of neonatal skin from an aqueous to an air-dominant environment results in various changes, both physiological and pathological. Aims: This study was designed to find the prevalence and pattern of various physiological and pathological dermatoses as well as its relation to maternal and neonatal factors in the early neonatal period. Materials and Methods: This prospective study was done on 505 live born neonates at Christian Medical College and Hospital, Ludhiana. All consecutive live born babies and those presenting for follow-up within 7 days of birth were considered. Results: Out of 505 neonates that were examined, 284 (56.24%) were males and 221 (43.76%) were females. Physiological skin changes were seen in 460 (91.09%), the most common being physiological desquamation in 211 (41.78%) neonates followed by Milia in 199 (39.41%). Pathological changes were seen in 102 (20.20%) neonates of whom one had aplasia cutis congenita. The most common developmental abnormality was accessory nipple in 6 (1.19%) neonates. Icterus was most often seen in neonates delivered by normal vaginal delivery 134 (56.54%). Milia was more often seen in babies of multiparous mothers, 135 (67.84%) as compared to primiparous mothers. Conclusion: A good knowledge of neonatal dermatoses helps allay concerns in parents and treating physicians thereby avoiding diagnostic and therapeutic procedures, which may not be required, especially as most of the early neonatal dermatoses are transient in nature.

Keywords: Early neonatal period, neonatal dermatoses, physiological skin changes


How to cite this article:
Bose S, Thomas EA, Bhatia A, Sohi I. A study of dermatoses in the early neonatal period from a tertiary care hospital in North West Punjab. Indian J Paediatr Dermatol 2018;19:124-9

How to cite this URL:
Bose S, Thomas EA, Bhatia A, Sohi I. A study of dermatoses in the early neonatal period from a tertiary care hospital in North West Punjab. Indian J Paediatr Dermatol [serial online] 2018 [cited 2019 Dec 9];19:124-9. Available from: http://www.ijpd.in/text.asp?2018/19/2/124/217482




  Introduction Top


Neonatal life, as defined by the World Health Organization, constitutes the first 28 days of extrauterine life.[1]

The transition of neonatal skin from an aqueous to an air-dominant environment results in various changes, both physiological and pathological. Skin, oral mucosa, genitalia, hair, and nails have been found to be affected nearly universally in up to 99.3% neonates.[2]

The physiological changes are usually transient and limited to the first several days or weeks of life unlike pathological changes.[3]

Various maternal factors such as age, maternal illnesses during pregnancy, and mode of delivery also contribute to cutaneous findings in neonates.[4]

It is important to differentiate between benign and pathological skin lesions in newborn as a physiological skin change would require no therapy but a pathological manifestation needs to be thoroughly investigated and treated.[2]


  Materials and Methods Top


This prospective study was done from January 1, 2014, to December 31, 2014, at Christian Medical College and Hospital and consecutive live born babies and those presenting for follow-up within 7 days of birth to neonatal outpatient department were examined for any cutaneous manifestations. A total of 505 neonates were examined. After taking an informed consent from the mother/guardian, the first examination of the neonate was done within 24–48 h of birth and the second examination was done within 5–7 days of birth. Detailed maternal history was also noted.

The baseline demographics of the study collected were maternal factors such as age, mode of delivery, illnesses and pregnancy-associated complications and neonatal factors such as gender, gestational age, and birth weight.

Statistical analysis

Categorical variables were presented in number and percentage (%), and continuous variables were presented as mean ± standard deviation and median. Qualitative variable was compared using Chi-square test/Fisher's exact test. P < 0.05 was considered statistically significant. The data were entered into MS Excel spreadsheet, and analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0, IBM, United States of America, Armonk, New York.


  Results Top


Out of 505 neonates that were examined, 284 (56.24%) were males and 221 (43.76%) were females. Most of the newborns, 440 (87.13%) were appropriate for gestational age (AGA), whereas 34 (6.73%) were small for gestational age (SGA) and 31 (6.14%) were large for gestational age (LGA).

One hundred and ninety-three (38.22%) mothers were primiparous whereas the remaining were multiparous. Three hundred and ninety-nine (79.81%) were in the age group of 21–30 years, 92 (18.22%) were more than 30 years, and 14 (2.77%) were 20 years or less in age. The most common mode of delivery was normal vaginal delivery in 244 (48.32%) followed by cesarean in 237 (46.93%) and instrumental delivery in 24 (4.75%).

Physiological skin changes were seen in 460 (91.09%) neonates, and 355 (70.30%) had more than one transient cutaneous manifestation. Only 29 (5.74%) had no cutaneous findings. Pathological skin changes were noted in 102 (20.20%), out of which 21 (4.16%) had more than one pathological finding. [Table 1] shows a list of transient cutaneous manifestations in neonates.
Table 1: Prevalence of transient skin disorders in neonates (n=505)

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The most common transient change was physiological desquamation in 211 (41.78%) neonates followed by Milia in 199 (39.41%) [Table 1].

One (0.20%) baby had congenital miliaria crystallina. [Figure 1] and [Figure 2] show the physiological findings of Epstein's pearls and Bohn's pearls, respectively.
Figure 1: Epstein's pearl

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Figure 2: Bohn's Nodule

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Icterus was seen in 237 (46.93%) neonates which was the most common color change seen, and the most common nevi was Mongolian spots (MSs) in 196 (38.81%). A total of 187 (37.03%) neonates had it in the natal or caudal lumbar region whereas 9 (0.02%) neonates had aberrant MSs, involving the thigh, knee, unilateral arm, and upper back.

Pathological skin changes were seen in 102 neonates of whom one had aplasia cutis congenita (ACC) [Figure 3], and 2 had congenital melanocytic nevi (0.40%).
Figure 3: Aplasia cutis congenita

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Developmental changes were seen in 44 (8.71%) neonates, of which the most common was accessory nipple in 6 (1.19%). [Table 2] shows a list of congenital disorders and genodermatoses.
Table 2: Congenital disorders (including developmental disorders) and genodermatoses

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Among the acquired infections, dacryocystitis was the most common in 7 (1.39%) neonates. One neonate had bullous impetigo [Figure 4].
Figure 4: Bullous impetigo

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Perianal dermatitis was the most common dermatitis among neonates, seen in 4 (0.79%), followed by diaper dermatitis in 1 (0.20%) and contact dermatitis in 1 (0.20%).

The most common injury seen during delivery was caput succedaneum in 16 (3.17%) neonates. Among other injuries, 3 (0.59%) had forceps-induced injuries including abrasion and a small laceration over the parietal region, and 1 (0.20%) had fracture humerus.

Most of the neonatal dermatoses were observed more often in male neonates as compared to females except for acrocyanosis and vernix caseosa which was more common in females.

Hypertrichosis lanuginosa had a significant positive correlation with the birth weight category; it was more common in LGA neonates (P = 0.011). The relation of transient skin disorders to sex and birth weight of the neonate has been shown in [Table 3].
Table 3: Relation of transient skin disorders to sex and birth weight of the neonate

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Erythema toxicum neonatorum was significantly more common in term neonates weighing more than 2.5 kg.

Icterus was most often seen in neonates delivered by normal vaginal delivery in 134 (56.54%) with a P value of 0.002. The relation of transient skin changes to the mode of delivery is mentioned in [Table 4].
Table 4: Relation of transient skin disorders to mode of delivery and parity of mothers

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Milia were more often seen in babies of multiparous mothers, 135 (67.84%) as compared to primiparous mothers (P = 0.024) [Table 4].

There was a significant positive correlation between maternal diabetes mellitus and the appearance of sebaceous hyperplasia in neonates (P = 0.018), hypertensive mothers, and cutis marmorata (P = 0.029) in neonates, mothers suffering from depression, and neonates with acrocyanosis (P = 0.047) [Table 5].
Table 5: Relation of the transient skin disorders to maternal diseases

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Among mothers who were on antihypertensive agents, a significant number had neonates with sebaceous hyperplasia in 17 (38.64%) with a P = 0.013.


  Discussion Top


The present study gives a comprehensive analysis of the various types of neonatal dermatoses along with its association with neonatal as well as maternal factors.

The prevalence of neonatal dermatoses has varied in different studies from 74.6% to 100%.[5],[6]

In our study, the prevalence of neonatal dermatoses was 94.26%.

Physiological cutaneous changes were seen in 91.09% neonates and pathological skin changes in 20.20% neonates. Only 5.74% neonates had no skin changes at all.

The most common transient skin change noted in our study was physiological desquamation, in 211 (41.78%) neonates. It was observed more in males (60%), AGA term neonates weighing more than 2.5 kg, delivered by normal vaginal delivery and in multiparous mothers more often and in mothers in the age group 21–30 years. In other studies, the incidence varies from 1.9–87.7%.[7],[8] These variations could be explained by the variations in time of examining the newborns and the number of times they were examined.[4],[8] The pathophysiology of neonatal desquamation is unknown. According to Serdaroglu and Cakil, postmaturity in the neonate leads to increased desquamation.[9] Another hypothesis suggested that desquamation may be due to loss of vernix caseosa leading to the poor barrier function of neonatal skin leading to transepidermal water loss which is responsible for dehydration of the neonatal epidermis during the first few days of life.[10] A study by Monteagudo et al. suggests that postterm neonates and those born by vaginal delivery have less of the body surface covered by vernix and hence a higher chance of developing physiological desquamation.[11]

Milia were the second most common transient physiological skin change, seen in 199 (39.41%) neonates. In our study, a higher incidence was observed in males, term neonates with birth weight <2.5 kg, SGA, and those born to multiparous mothers delivered by cesarean section.

Epstein's pearls were present in 191 (37.82%) neonates in our study. These are microkeratocysts located on the palatal raphe, whereas Bohn's cysts are located on the alveolar ridges. Studies suggest that these cysts are a result of imprisonment of persistent epithelial cells in the place of fusion of alveolar processes.[12] In our study, Epstein's pearls were more common in term AGA neonates weighing more than 2.5 kg. It is important to know that these lesions are transient and do not require any intervention.

MSs were seen in 196 (38.81%), and it was the most common nevi seen in our study. It was seen more in male neonates, LGA, born by cesarean section, and more often seen in babies born to mothers who were anemic.

In our study, 1 (0.20%) baby had congenital miliaria crystallina. This was a very rare finding, as only 4 reports of congenital miliaria crystallina have been reported so far.[13],[14],[15],[16] A lack of maturation of the sweat duct during the first few days following birth results in miliaria crystallina, but no definitive cause has been found so far, for congenital occurrence of the same. It usually follows maternal illness in the form of fever in the prenatal period or chorioamnionitis [15] although in our study no such correlation was seen. A possible explanation for the development of congenital miliaria crystallina could be in utero obstruction of sweat glands.[15]

Cutis marmorata was seen in 33 (6.53%) neonates, more in preterms weighing <2.5 kg and AGA babies. In our study, a significant positive correlation of cutis marmorata was seen in babies born to hypertensive mothers. All the lesions resolved on rewarming suggesting that it was a transient finding, an exaggerated vasomotor response to hypothermia due to immaturity of the autonomic nervous system, rather than the pathological cutis marmorata telangiectatica congenita, in which the mottled pattern often persists, even on rewarming the baby.

Acrocyanosis was seen in 8 (1.58%) neonates in our study, weighing <2.5 kg, preterm, and LGA born to mothers by cesarean section. A higher incidence of acrocyanosis in cesarean sections in our study can be due to preexisting fetal compromise as in meconium aspiration. It was also seen in neonates born to hypothyroid mothers and mothers suffering from depression and no such association has been reported so far.

The incidence of acrocyanosis in neonates of mothers having depression could be explained by the intake of tricyclic antidepressants such as imipramine and desipramine, by the mother as shown in certain other studies.[16],[17]

In our study, pathological skin changes were seen in 102 (20.20%) neonates.

In our study, 1 (0.20%) neonate had ACC localized to the scalp. The same neonate also had ectopic MSs located over the ankle. A CT scan revealed an underlying bony defect (partial agenesis of parietal bone), but clinical examinations showed no neurological impairment. There were no other organ abnormalities and routine metabolic and hematological laboratory panels were normal. A maternal history showed that the mother suffered from multiple sclerosis and hence was on oral steroids and also received a single dose of intravenous immunoglobulin (IVIG) and Vitamin B12 supplements during the first trimester of pregnancy.

There have been reports of ACC in association with maternal varicella infection [18] and maternal intake of methimazole, neomercazole, and azathioprine.[19],[20] Association of ACC with maternal multiple sclerosis, intake of steroids, and IVIG have not been reported so far.

In our study, caput succedaneum was the most common injury during delivery in 16 (3.17%) neonates. It was more often seen in neonates born by normal vaginal delivery in 14 (2.77%), followed by 1 (0.20%) each in those delivered by cesarean section and manipulative deliveries. In caput succedaneum, a role of trauma during vaginal delivery has been considered.

In our study, skin lesions were seen more often in males except vernix caseosa and acrocyanosis where it was common in female neonates. According to Das and Maiti, primary acrocyanosis is more common in females due to low body mass index in females as compared to males.

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.


  Conclusion: Top


This Study Was Aimed at Finding the Prevalence of Dermatoses during the Early Neonatal Period and Its Relation to Neonatal and Maternal Factors. the Physiological Cutaneous Changes (91.09%) Were More Commonly Observed as Compared to the Pathological Changes (20.20%). as a Larger Number of Neonates Present With Transient, Physiological Cutaneous Changes, it Is Very Important for the Dermatologist and Pediatrician to Have a Thorough Knowledge of the Same. These Transient Dermatoses Should Be Differentiated from More Serious Pathological Skin Conditions in Order to Avoid Unnecessary Therapy to Neonates and to Reassure Parents About the Good Prognosis of These Skin Manifestations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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