Transient Cutaneous Alterations of the Newborn Authors: Catarina Queirós,1 Mafalda Casinhas Santos,2 Rita Pimenta,1 Cristina Tapadinhas,1 Paulo Filipe1,3 1. Serviço de Dermatologia, Hospital de Santa Maria, Centro Hospitalar e Universitário de Lisboa Norte, Lisbon, Portugal 2. Serviço de Pediatria, Hospital de Vila Franca de Xira, Lisbon, Portugal 3. Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal *Correspondence to [email protected] Disclosure: The authors have declared no conflicts of interest. Received: 27.06.20 Accepted: 17.12.20 Keywords: Common rashes, cutaneous alterations, newborn, skin. Citation: EMJ. 2021;6[1]:97-106. Abstract Neonatal cutaneous alterations are common, usually appearing at birth or during the first few days of life. Most of these conditions are physiological, benign, and transient, arising from a combination of immaturity of the newborn skin with environmental factors. Nonetheless, some of them may eventually be a clue to underlying disorders. Physicians should therefore be aware of these clinical manifestations so that parents can be reassured and, when necessary, complementary investigations can be undertaken. INTRODUCTION a cause of concern to parents, who need reassurance about its nature. At birth, the skin of the newborn suddenly comes In this paper, several common cutaneous into contact with the extrauterine world: a dry and alterations observed in newborn skin are 1 aerobic environment. Newborn skin is 40–60% reviewed. In the first part, physiological changes thicker than adult skin, with weaker intercellular are covered, including traumatic, vascular, 2 attachment and decreased production of sweat. pigmentary, and hormonal conditions. In the Newborn skin is therefore more vulnerable, second part, a review of the most common rashes although structurally similar to adult skin, and of the newborn is undertaken. Although not trauma associated with delivery leaves its marks typically apparent during the neonatal period, 3 on it. Moreover, newborn skin must rapidly infantile acropustulosis and eosinophilic pustular adapt and mature to provide protection against folliculitis are included as these are important in infection, toxins, changes in temperature, and the differential diagnosis of other conditions. transepidermal water loss, which poses an additional stress.1 PHYSIOLOGICAL ALTERATIONS Because of these factors, cutaneous alterations 3 are relatively common in the neonatal period. Vernix Caseosa Most of these conditions are physiological, benign, and transient, thus do not require The vernix caseosa is a protective layer which therapy.4 Nevertheless, they are frequently covers neonatal skin at birth (Figure 1). It is a Creative Commons Attribution-Non Commercial 4.0 March 2021 • EMJ 97 complex membranous substance comprising easily, leading to linear or round erosions. Lesions 80% water, 10% protein, and 10% lipids, which are present at birth and are located mainly on the include barrier lipids such as ceramides, free forearm, wrist, and hand. Although frequently fatty acids, phospholipids, and cholesterol, partly solitary, blisters can be multiple and bilateral.6 synthesised by fetal sebaceous glands during the Diagnosis of congenital sucking blisters is one last trimester of pregnancy.5 In its composition of exclusion. The absence of lesions in other there are also shed lanugo hair and desquamated body regions, the timing of onset, and the rapid cells. In utero, the vernix protects neonatal skin resolution of the blisters, in combination with the against amniotic fluid.1 During transition to an otherwise well appearance of the neonate, are extrauterine environment, the vernix has several highly suggestive of this condition.7 Differential important functions including lubrication of diagnosis of sucking blisters includes congenital the birth canal during parturition, prevention or neonatal herpes simplex virus infection, of water loss, and temperature regulation. fetal or neonatal varicella, bullous impetigo, It is also implicated in the development of epidermolysis bullosa, congenital syphilis, innate immunity and facilitates reduction of or congenital candidiasis, among other rarer skin pH to the ideal range for optimal skin entities.6 Sucking blisters resolve spontaneously 1,5 function; therefore, the vernix should be left as in days to weeks without sequelae, and therefore undisturbed as possible. Gentle bathing or dry no specific therapy is needed.6 wiping does not significantly disrupt this layer, and should therefore be the procedures of choice Caput Succedaneum and 1 for newborns’ hygiene. Cephalohaematoma TRAUMATIC LESIONS Caput succedaneum refers to a collection of oedematous fluid above the periosteum, between the outermost layer of the scalp and Sucking Blisters the subcutaneous tissue. It is a common lesion Sucking blisters are estimated to occur in 1:250 seen at birth, and results from the high pressure live births and result from vigorous sucking by exerted on the infant’s head by the vaginal walls the infant during fetal life. Clinically, flaccid bullae and uterus as the head passes through the on a noninflamed base are seen, which rupture narrowed cervix during labour.8 Figure 1: Vernix caseosa covering the skin of a newborn. 98 EMJ • March 2021 EMJ Although caput succedaneum may occur mouth and the extremities. It is caused by benign in the absence of risk factors, incidence vasomotor changes that result in peripheral increases in difficult or prolonged labours, with vasoconstriction and increased tissue oxygen premature rupture of the amniotic membranes, extraction, attributed to peripheral arteriole in primigravidae, and in instrument-assisted hypertonia. Acrocyanosis is a benign condition deliveries. This condition is evident immediately and may persist for 24 to 48 hours. After this after delivery and gradually decreases in period, it may occasionally recur in the context size thereafter.9 On physical examination, it of cold exposure or crying.11 Acrocyanosis must is generally 1–2 cm in depth and has a soft, be distinguished from central cyanosis. This boggy feel with irregular margins. Petechiae, is defined as a dusky appearance of the body purpura, and an ecchymotic appearance may and the mucous membranes and is always 8 be present. concerning beyond the first 10 minutes of life. Cephalohaematoma is a subperiosteal Abnormalities in ventilation, congenital heart accumulation of blood, which occurs abnormalities, and haemoglobinopathies are 11 infrequently, with an incidence of 0.4–2.5% of all amongst the main causes of central cyanosis. live births. It is more common in primigravidae, Cutis Marmorata in infants with higher percentiles, and following instrument-assisted deliveries or prolonged, Cutis marmorata is a benign entity characterised difficult labour and, for unknown reasons, occurs by the appearance of a reticulated or livedoid twice as often in males as in females. Because purplish mottling of the skin, related to of the slow nature of subperiostial bleeding, physiological capillary and venular vasomotion cephalohaematomas are not usually present in the setting of cold exposure.12 Cutis at birth but develop hours or even days after marmorata seems to be associated with lower delivery.9 As the bleeding continues and blood gestational age and birth weight, which may occupies the subperiosteal space, pressure acts be associated with the greater vulnerability of as a tamponade to stop further bleeding. A firm, these neonates, who are therefore more likely enlarged unilateral or bilateral bump covering to present with vasomotor instability.3 This one or more bones of the scalp characterises condition must be distinguished from cutis this lesion. Unlike caput succedaneum, marmorata telangiectatica congenita, which 8 cephalohaematomas do not cross suture lines. is characterised by a fixed vascular change Cephalohaematoma and capput succedaneum associated with subtle dermal atrophy. This must be distinguished from subgaleal entity may be associated with limb length haematomas, which, unlike the former conditions, discrepancy, vascular, osseous, ocular, and can be life-threatening. Neonatal subgaleal neurologic malformations.12 haematomas are usually associated with vacuum extraction deliveries, although they have also Harlequin Colour Change been reported in deliveries without instrument Harlequin colour change presents as erythema 10 use. Observation is the primary treatment in one half (the dependent side) and pallor in for both uncomplicated caput succedaneum the other half of the body, usually lasting for and cephalohaematoma. Resolution of caput several minutes. This condition presents in the succedaneum is generally spontaneous and first 3 weeks of life, commonly between Day 2 occurs within the first few days following birth. A and Day 5.11,12 Although it has been observed in cephalohaematoma may take longer to resolve, neonates after the administration of anaesthetic 8 but most cases do so within 2 to 6 weeks of life. agents and alprostadil, harlequin colour change may also occur in healthy neonates in the VASCULAR PHENOMENON absence of medication. This phenomenon may occur as a result of changes in vascular tone, Acrocyanosis although it still remains unexplained. Harlequin color change is a benign and transient feature; Acrocyanosis is often seen in healthy newborns therefore, no treatment is necessary.13 during the first hours of life and refers to the occurrence of peripheral cyanosis around the Creative Commons Attribution-Non