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Year : 2022  |  Volume : 23  |  Issue : 1  |  Page : 43-48

A clinical study of physiological cutaneous manifestations in early neonates at a tertiary care center in western Rajasthan

1 Department of Dermatology, Sardar Patel Medical College, Bikaner, Rajasthan, India
2 Department of Skin and VD, Sardar Patel Medical College, Bikaner, Rajasthan, India

Date of Submission09-Mar-2019
Date of Decision18-Apr-2020
Date of Acceptance01-Jun-2021
Date of Web Publication31-Dec-2021

Correspondence Address:
Divya Sharma
Department of Dermatology, Sardar Patel Medical College, Bikaner, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpd.IJPD_28_19

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Introduction: The rapidly adapting neonatal skin, being anatomically and physiologically distinct from an adult, may exhibit a variety of entities, ranging from mild self-limiting to the severe life-threatening ones. The transition of neonatal skin from an aqueous to an air-dominant environment results in various changes, both physiological and pathological. Physiological and pathological dermatoses should be differentiated to avoid unnecessary treatment and psychological distress to parents. The present study was carried out to determine prevalence and patterns of physiological cutaneous manifestations among early neonates in western Rajasthan. Materials and Methods: This hospital-based, descriptive, observational study was carried at a tertiary care hospital over a period of 1 year. After due informed consent, total of 5000 early neonates delivered during this time were included in the study. A detailed history was taken and dermatological examination of each neonate was carried out. Laboratory procedures were performed to confirm diagnosis if required. Data were collected in a predesigned pro forma. Results: Out of 5000 newborns, 64.96% were male and 35.04% female. Ninety-two percentage had physiological changes and 21% had pathological changes. The physiological skin changes observed in order of frequency were sebaceous hyperplasia (65.32%), milia (51.12%), physiological desquamation (41.02%), vernix (35%), and physiological jaundice (9.32%). Cutis marmorata, harlequin skin changes, and lanugo hair were seen more in low-birth weight and preterm neonates. Conclusion: Most of the early neonatal dermatoses are physiological and transient in nature. Hence, it is important to identify and differentiate them from other serious conditions, thereby avoiding unnecessary diagnostic and therapeutic procedures and provide reassurance to overenthusiastic dermatologists, pediatricians, and parents.

Keywords: Cutis marmorata, milia, neonate dermatoses, physiological changes, sebaceous hyperplasia

How to cite this article:
Choudhary P, Mehta RD, Ghiya BC, Sharma D. A clinical study of physiological cutaneous manifestations in early neonates at a tertiary care center in western Rajasthan. Indian J Paediatr Dermatol 2022;23:43-8

How to cite this URL:
Choudhary P, Mehta RD, Ghiya BC, Sharma D. A clinical study of physiological cutaneous manifestations in early neonates at a tertiary care center in western Rajasthan. Indian J Paediatr Dermatol [serial online] 2022 [cited 2022 May 20];23:43-8. Available from: https://www.ijpd.in/text.asp?2022/23/1/43/334674

  Introduction Top

Neonatal skin is distinct, in terms of permeability, barrier function, absorption, and temperature regulation compared to an adult skin. It can present with a vast range of conditions owing to the dramatic challenge presented to it, on transition from an aqueous atmosphere to a dry one. Dermatoses are quite frequent in neonates; these are documented from 96% to 99.3% of all neonates in various studies published worldwide.[1],[2],[3],[4]

Neonatal dermatoses can be classified as physiological, transient, genodermatoses, acquired, and iatrogenic.[5] Regional, religious, maternal factors, and mode of delivery are known to contribute to cutaneous findings in neonates.[6] The physiological changes are usually limited to the first several days or weeks of life unlike pathological changes.[4] Majority of the neonatal cutaneous lesions are usually physiological, transient, and self-limited and thus require no treatment.[6],[7]

These lesions perhaps are a matter of concern for the parents and for the attending physicians if they are not aware of the usual physiological manifestations. Hence, it is important to be aware of the innocent physiological skin lesions and differentiate these from other serious conditions, which will help to avoid the unnecessary therapy to the neonates and also reassure parents of good prognosis of these manifestations.

This study was conducted to assess prevalence and pattern of different physiological skin lesions, in early neonatal period. Similar studies are available in literature, but there is a paucity of data from Western part of India.

  Materials and Methods Top

This hospital-based, descriptive study was conducted in the period of March 2016 to February 2017. Five thousand early neonates delivered in the obstetrics and gynecology department and admitted in pediatric nursery irrespective of gestational age, sex, and mode of delivery were included in the study, whereas babies born outside the hospital and mothers who were unwilling to give consent for examination were excluded.

Ethical permission was duly obtained from the institutional ethics and research board (Approval number No: S. No. 5/F ([Acad] SPMC/2016/1068 Dated10/3/16). After informed consent from the guardians, detailed history was recorded including sex, birth weight of baby, age of mother, parity, history of consanguinity, mode of delivery, any maternal illness, or parental skin diseases. The neonates were thoroughly examined in daylight by completely undressing the child and all the cutaneous findings were recorded in approved pro forma with photographic evidence. The examinations were performed by postgraduate student and post-MD colleagues (senior residents). Moreover, final evaluation was done by senior faculty from the department of dermatology and pediatric medicine. Assessment was done within 7 days of birth.

Simple investigations such as examination of scrapings for Gram staining, KOH smear, and Tzanck smear were performed whenever required. Skin biopsy was done in few cases of milia, sebaceous hyperplasia, superficial cutaneous desquamation, and Epstein pearls, where parents insisted and/or consented for histopathological examination to rule out any pathological variant or systemic conditions, despite reassuring these to be physiological changes.

Statistical analysis was performed with the SPSS, trial version 23 for Windows statistical software package (SPSS Inc., Chicago, Il, USA) and primer. The categorical data were presented as numbers and percentage and analysis between skin lesions and different maternal or neonatal factors were calculated using Chi-square test and Fisher's exact test. P < 0.05 was considered statistically significant.

  Results Top

Out of 5000 early neonates who were examined, 3248 (64.96%) were male and 1752 (35.04%) were female. Physiological skin changes were seen in 4621 (92.42%) neonates, and 3822 (76.44%) had more than one physiological manifestation.

The most common physiological change was sebaceous hyperplasia [Figure 1] in 3260 (65.32%) neonates, followed by milia [Figure 2] in 2556 (51.12%), physiological superficial cutaneous desquamation [Figure 3] in 2051 (41.02%), and vernix caseosa in 1750 (35%) neonates [Table 1].
Figure 1: Sebaceous hyperplasia

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Figure 2: Milia

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Figure 3: Physiological superficial desquamation

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Table 1: Prevalence of physiological skin changes in neonates

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All physiological skin changes were noted more common in male neonates, except vernix caseosa in 984 (56.22%) female neonates as compared to male, i.e., 766 (43.77%) [Table 2].
Table 2: Relation of neonatal dermatoses with sex

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Out of 5000 neonates, 1856 (37.12%) were low-birth-weight babies (<2.5 kg) and 3144 (62.88%) were normal-weight babies (>2.5 kg). We found a significantly higher incidence of vernix caseosa (P = 0.001), sebaceous hyperplasia (P = 0.001), milia (P = 0.001), superficial cutaneous desquamation (P = 0.001), and Epstein pearls (P = 0.001), in babies with weight more than 2.5 kg as compared to low-birth-weight neonates. Harlequin skin changes (P = 0.001), cutis marmorata (P = 0.001), and lanugo hair (P = 0.001) occurred significantly more among low-birth-weight neonates [Table 3].
Table 3: Relation of neonatal dermatoses with weight

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Out of 5000 neonates observed, 1522 mothers delivered (30.44%) pre-term, 3368 (67.36%) were on term, and 110 (2.2%) were postterm neonates. Harlequin skin changes, cutis marmorata [Figure 4], and lanugo hair were more common in preterm neonates, whereas other physiological changes were more in term neonates.
Figure 4: Cutis mamorata

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One thousand nine hundred and eleven (38.22%) were of primiparous mothers, whereas the remaining were of multiparous. All physiological cutaneous manifestations as milia (72.61%), sebaceous hyperplasia (58.94%), vernix (51.31%), and physiological superficial desquamation (75.19%) were significantly more prevalent among multipara mothers as compared to primipara mothers (P = 0.001) [Table 4].
Table 4: Relation of neonatal dermatoses with parity

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Normal vaginal delivery (49.54%) was the most common mode of delivery, followed by cesarean section (44.22%) and instrumental delivery (6.24%) of the mothers under study. Physiological conditions were more frequent in neonates delivered with normal vaginal delivery as compared to babies born by cesarean or instrument assisted vaginal delivery (P < 0.05) as shown in [Table 5].
Table 5: Relation of neonatal dermatoses with mode of delivery

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Among mothers who had diabetes, the appearance of sebaceous hyperplasia compared to other physiological changes was statistically significant (P = 0.001). Superficial cutaneous desquamation was seen significantly more (P = 0.001) among neonates born to hypothyroid and anemic mothers as compared to babies born to mothers who had no comorbidities [Table 6].
Table 6: Relation of neonatal dermatoses with maternal illness

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  Discussion Top

The appreciation of physiological changes and their differentiation from pathological changes of neonate is critical. The pattern of neonatal dermatoses varies by place and depends on various maternal and neonatal factors such as gestational age, maternal health, and mode of delivery.[8]

Neonatal skin can present with a vast range of conditions as the prevalence of dermatoses varies in different studies between 79.4% and 100%.[9] Various studies have shown the prevalence of physiological changes among neonates ranging from 57% to 100%;[1],[10] whereas in our study, physiological skin changes were seen in 92.42% of neonates. These differences in the results may be related to variations in study methods, environmental, and racial factors.

The most common physiological change in our study was sebaceous hyperplasia, noted in 65.32% of neonates. The most common site of sebaceous hyperplasia was nose. Sebum secretion rates are higher in neonates compared with preadolescent children. It is assumed that this sebaceous gland activity reflects the stimulation by placentally transferred maternal androgen, particularly by dehydroepiandrosterone.[11]In other studies, the incidence varies from 68.33% to 89.4%.[4],[7] It was seen more commonly in full-term neonates weighing more than 2.5 kg, delivered by normal vaginal delivery, and multiparous mothers more often, similar to other studies.[6],[12],[13] Similar to our study, Haveri and Inamadar[4] reported that sebaceous hyperplasia was more common in term neonates (88.25%).

Milia was the second most common physiological finding, seen in 51.12% of neonates. In our study, a higher incidence was seen in term male neonates, weighing more than 2.5 kg, which has also been noted by other workers.[6],[12] The most common site involved was tip of nose (66.51%), followed by cheeks (19.56%), forehead (7.46%%), chin (4.4%%), and philtrum (2.2%). Our findings were comparable to Baruch et al.'s[14] study where tip of nose (96.2%) was the most common site followed by alae nasi (62.3%), cheeks and nasolabial folds (31.8%), forehead (21.9%), chin (7.4%), and philtrum (5.3%). The incidence of milia varied from 9.92% to 94.8% in other studies.[15],[16] A study by Jain et al.[7] showed a higher prevalence of milia in babies born by cesarean section and in female babies although other studies showed a higher prevalence of the same in males.[2],[17]

Superficial cutaneous desquamation in previous studies has ranged from 1.9% to 87.7%.[1],[10],[12],[18],[19],[20] In our study, it was noted in 41.02% of neonates. The variations in prevalence are mainly because the duration of observation varies in all the studies. It was noted more in males (54.07%) and in whom who were weighing more than 2.5 kg. It has been suggested that desquamation may be related to the loss of the vernix caseosa and poor barrier function of neonatal skin which might allow transepidermal water loss with subsequent dehydration of the stratum corneum during the first few days of life.[2]

In our study, cutis marmorata and harlequin skin changes were seen in 103 (2.06%) and 53 (1.06%) neonates. We found these to be more in preterms weighing <2.5 kg, in males and those born to multiparous mothers by normal vaginal delivery. Cutis marmorata is considered to be an exaggerated vasomotor response to hypothermia; it is more commonly seen in preterms due to immature autonomic nervous system of preterm neonates, which resolves on rewarming.[21] In other studies, the incidence of cutis marmorata was 1%–5.91%.[12],[22] In a study by Nobbay and Chakrabarty,[10] a higher incidence (43.6%) of cutis marmorata was noted.

We found a lower incidence lanugo (1.94%), in contrast to Sachdeva et al.,[6] and Nobbay and Chakrabarty,[10] who found an incidence of 14.4% and 14.6%, respectively. Languo was noted in term neonates weighing more than 2.5 kg similar to Sadana et al.'s study.[23]

All physiological skin changes were noted more common in male neonates except vernix caseosa in 984 (56.22%) female neonates. The prevalence of vernix caseosa has been similarly reported more often in females than males in other studies by Haveri and Inamadar[4] and Ekiz et al.[17]

All cutaneous manifestations as milia (72.61%), sebaceous hyperplasia (58.94%), vernix (51.31%), and superficial cutaneous desquamation (75.19%) were noted more in multipara mothers, which was comparable to the study by Sadana et al.[23] and Zagne and Fernandes[22]

The present study gives a comprehensive analysis of physiological changes in early neonates. It might also help assess the changing trends of early neonatal dermatoses. There are few limitations of this study. This study was done only at one center with limited number of cases, because of time limit given. Histopathological evidence was undertaken in limited cases whom parents consented for the biopsy.

  Conclusion Top

This study enabled the characterization of early neonatal physiological changes and its relation to neonatal and maternal factors. It is important for dermatologist and pediatrician to have a thorough knowledge of the same as most of physiological conditions are self-limiting, requiring no treatment. There is also a great need for parental education and counseling about these common variants to allay unnecessary therapy to neonates, unnecessary parental concern, and anxiety associated with these clinical conditions.

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Conflicts of interest

There are no conflicts of interest.

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Haveri FT, Inamadar AC. A cross-sectional prospective study of cutaneous lesions in newborn. ISRN Dermatol 2014;2014:360590.  Back to cited text no. 4
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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


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