STUDY OF SPECTRUM OF DERMATOLOGICAL MANIFESTATIONS IN NEONATES This dissertation is submitted to THE TAMILNADU DR.M.G.R. MEDICAL UNIVERSITY In partial fulfillment of the requirement of the award for the degree of M.D DEGREE IN DERMATOLOGY, VENEREOLOGY AND LEPROSY BRANCH XX GOVERNMENT STANLEY MEDICAL COLLEGE CHENNAI – 600001 MAY 2020 DECLARATION BY THE CANDIDATE I, Dr. STACY ANN MARBANIANG solemnly declare that the dissertation titled “STUDY OF SPECTRUM OF DERMATOLOGICAL MANIFESTATIONS IN NEONATES” is a bonafide work done by me at the Department of Dermatology, Venereology and Leprosy, Government Stanley Medical College and Hospital during 2017 – 2020 under the guidance of my guide, Prof. Dr. V. ANANDAN, M.D (Dermatology) and under the supervision of my HOD, Prof. Dr. PARIMALAM KUMAR, M.D,D.D.,Dip.,N.B., MNAMS.,FIAD.,FRCP. The dissertation is submitted to THE TAMILNADU DR.M.G.R. MEDICAL UNIVERSITY towards the partial fulfillment of requirement for the award of M.D Degree in DERMATOLOGY, VENEREOLGY and LEPROSY (BRANCH XX) Place: Date: Signature of the candidate: CERTIFICATE BY THE INSTITUTE Certified that this dissertation entitled “STUDY OF SPECTRUM OF DERMATOLOGICAL MANIFESTATIONS IN NEONATES” is a bonafide work done by Dr. STACY ANN MARBANIANG, post graduate student of the Department of Dermatology, Venereology, Leprosy, Government Stanley Medical College and Hospital, Chennai – 600001 during the academic year 2017 – 2020 for the partial fulfillment of university rules and regulation for the award of M.D Degree in DERMATOLOGY, VENEREOLOGYAND LEPROSY (BRANCH XX). This work has not been submitted previously for the award of any degree. Dr. PARIMALAM KUMAR Dr. R. SHANTHI MALAR M.D., D.D., Dip.N.B., MNAMS.,FIAD.,FRCP., MD, DA Professor and Head of Department Dean, Department of Dermatology Govt. Stanley Medical College, Govt. Stanley Medical College Chennai-600 001. Chennai-600 001 Dr. V. ANANDAN, M.D (Dermatology )(GUIDE) Professor, Department of Dermatology, Govt. Stanley Medical College, Chennai-600 001. CERTIFICATE BY THE HEAD OF THE DEPARTMENT Certified that this dissertation entitled “STUDY OF SPECTRUM OF DERMATOLOGICAL MANIFESTATIONS IN NEONATES” is a bonafide work done by Dr. STACY ANN MARBANIANG, post graduate student of the Department of Dermatology, Venereology, Leprosy, Government Stanley Medical College and Hospital, Chennai – 600001 during the academic year 2017 – 2020 for the partial fulfillment of university rules and regulation for the award of M.D Degree in DERMATOLOGY, VENEREOLOGY AND LEPROSY (BRANCH XX). This work has not been submitted previously for the award of any degree. Dr. PARIMALAM KUMAR, M.D.,D.D.,Dip.N.B.,MNAMS.,FIAD.,FRCP., Professor and Head of Department, Department of Dermatology, Govt. Stanley Medical College, Chennai-600 001 CERTIFICATE BY GUIDE Certified that this dissertation entitled “STUDY OF SPECTRUM OF DERMATOLOGICAL MANIFESTATIONS IN NEONATES” is a bonafide work done by Dr. STACY ANN MARBANIANG , post graduate student of the Department of Dermatology, Venereology, Leprosy, Government Stanley Medical College and Hospital, Chennai – 600001 during the academic year 2017 – 2020 for the partial fulfillment of university rules and regulation for the award of M.D Degree in DERMATOLOGY, VENEREOLOGY AND LEPROSY (BRANCH XX). This work has not been submitted previously for the award of any degree. Dr. V. ANANDAN, M.D (Dermatology), Professor, Department of Dermatology, Govt. Stanley Medical College, Chennai-600 001. ACKNOWLEDGEMENT It is with immense pleasure and gratitude that I thank Dr. SHANTHI MALAR. M.D., D.A., Dean, GOVERNMENT STANLEY MEDICAL COLLEGE for bestowing me the permission and privilege of presenting this study and for enabling me to avail the institutional facilities. I am gratefully indebted to Prof. Dr. PARIMALAM KUMAR, M.D., D.D., Dip.N.B., MNAMS., FIAD.,FRCP., Professor and Head of Department of Dermatology and Leprosy for her invaluable guidance and motivation. I would like to express my sincere and heartfelt thanks to Prof. Dr. V. ANANDAN M.D., (Dermatology), for his guidance and encouragement. I express my deep sense of gratitude to Dr. N. SARAVANAN Professor and Head of Department of Venereology, Dr. ARUN KUMAR, M.D., former professor, Department of Venereology, for their constant support and motivation. I am grateful to Dr. P. SARADHA, M.D DVL.,Associate Professor of Venereology for her support and inspiration. Words will not suffice the gratitude I owe to my beloved co-guide Dr. MANI SURYA KUMAR, M.D (DVL)., Assistant professor, Department of Dermatology, for his guidance and endless patience in moulding of the study. All our Assistant professors, Department of Dermatology, Dr. SOWMIYA, M.D (DVL), Dr NITHYAGAYATHRI DEVI M.D(DVL), Dr. MOHANASUDARI, M.D(DVL). Dr.V.SENTHILKUMAR D.V,DNB(Derm)., Dr.SARASWATHI,M.D(DVL), Dr.N.S.JAYANTHIM.D(DVL), Dr. ANBULAKSHMI.J DDVL., are thanked for their enthusiasm in motivating me with their efforts to materialize this study. I am inclined to thank Dr. KAYALVIZHI, M.D(DVL), Dr. SARAN KUMAR, M.D (DVL), Dr. SYED IQBAL, M.D (DVL), Assistant professors, Department of Venereology for their help and suggestions. I would like to take this opportunity to thank Professor DR. KALAIVANI , Medical Superintendent RSRM , Chennai for allowing me to conduct my study in her Department. .I would also like to express my gratitude to Professor DR. P. RAVICHANDRAN Head of Department of Paediatrics and Professor DR. MANIMEGALAI incharge of NICU for allowing me to conduct the study in their Department. I also express my thankfulness to my batch mates and my beloved juniors for having helped me in constructing this study. I duly acknowledge the paramedical staffs and my colleagues for their help and favours. I also wholeheartedly thank my parents and my family members who constantly made me aware of the values of this noble profession. A sincere thanks to all my patients for their cooperation & participation in this study. Last but not least I thank the Almighty God, whose blessings are always with me. CONTENTS S.NO. TITLE PAGE NO. 1. INTRODUCTION 1 2. REVIEW OF LITERATURE 2-37 3. AIMS AND OBJECTIVES 38 4. MATERIALS AND METHODS 39-42 5. RESULTS 43--54 6. DISCUSSION 55-61 7. CLINICAL PHOTOGRAPHS 62-73 8. SUMMARY 74-77 9. CONCLUSION 78-80 10. BIBLIOGRAPHY ANNEXURE PROFORMA PATIENT CONSENT FORM ETHICAL COMMITTEE APPROVAL PLAGIARISM APPROVAL KEY TO MASTERCHART MASTER CHART STUDY OF SPECTRUM OF DERMATOLOGICAL MANIFESTATIONS IN NEONATES INTRODUCTION INTRODUCTION Neonatal period is defined by the World Health Organisation (WHO) as the period of less than 28 days after birth. Hence Neonatal Dermatology includes the spectrum of cutaneous manifestations occurring during these first four weeks of life. Skin changes are common in neonates and often cause anxiety and serious concern to the parents. Although most are benign and self-limited some may require further work- up in order to rule out a serious condition . Many factors may influence the pattern of dermatoses in newborns like environmental ,maternal , regional and racial factors .Therefore a thorough understanding of the physiologic characteristics and peculiarities of neonatal skin is important. Neonatal dermatoses can be classified as : 1) Transient benign skin disorders 2) Developmental abnormalities 3) Acquired skin disorders. 4) Iatrogenic and traumatic disorders. There are very few published literature on neonatal dermatoses in our country. 1 REVIEW OF LITERATURE 2 REVIEW OF LITERATURE DEVELOPMENT OF SKIN The skin arises by the juxtaposition of two major embryological elements: the prospective epidermis that originates from a surface area of the early gastrula, and the prospective mesoderm that comes into contact with the inner surface of the epidermis during gastrulation. The mesoderm provides the dermis and is also essential for inducing differentiation of the epidermal structures, such as the hair follicle. The melanocytes are derived from the neural crest. After gastrulation a single-layered neuroectoderm lies on the surface of the embryo. Depending upon the molecular signal it receives this layer will go on to form the nervous system or the skin epithelium . Development of the epidermis starts at the third week of life . Initially a basal layer of cuboidal cells overlying the mesoderm or future dermis is seen. By the fifth week, a secondary layer of squamous, non-keratinizing, cuboidal cells, known as periderm or epitrichium, develops atop the basal layer. This periderm eventually sloughs 3 off to become a component of a waxy substance called vernix caseosa which serves to protect the fetus from bacterial and environmental insults. ANATOMY Vernix caseosa- It is a greasy, yellow-white substance which is found to coat the skin of a newborn and persists for the first several days of postnatal life. Vernix means “ to varnish” and “caseous” means cheesy nature. Vernix consists of water (81%), lipid (9%), and proteins (10%). Cholesterol esters , wax esters, ceramides ,squalene, cholesterol, triglycerides, free fatty acids are the major lipid composition.1 The development of vernix caseosa proceeds in a cephalocaudal manner and is the result of an orderly progression of epithelial maturation.2 At birth, vernix may cover the entire skin surface or only confined to body folds. It may be absent in very low birth weight and premature infants. Hence they lack the protective function of vernix caseosa. The functions of vernix includes formation of an epidermal barrier in utero to facilitate epidermal growth underneath it , minimises friction of fetal parts during delivery, antimicrobial cover against the bacteriologically rich environment of the mother's genital tract3 . 4 It also prevents loss of fluids and electrolytes or TEWL (Trans Epidermal Water Loss). In addition it also has anti-oxidant 4 ,moisteurising 5, temperature regulation and wound healing properties. 6 The colour of the vernix at birth may reflect intra-uterine problems . For example, it appears golden yellow in hemolytic disease of newborn .Human skin consists of three layers: epidermis, dermis, and subcutaneous fat.