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Survey of skin disorders in newborns: Clinical observation in Rohilkhand region.

INTRODUCTION: Neonatal skin provides physical protection and assists in fluid balance, immunosurveillance and thermoregulation, thus playing a vital role in the newborn's transition from an aqueous to an air-dominant environment. A large number of changes from transient physiological to grossly pathological lesions are seen in the skin of a neonate. (1) The majority of the disorders in the newborn are physiological, transient and self-limited and require no therapy. (2) Thus, a working knowledge of both normal and abnormal cutaneous lesions of the neonate is required to determine which skin lesions require early intervention.

Several studies have documented differences in dermatological findings in neonates of various racial groups. For example, the incidence of dermal melanosis is more common in black, Native American, Asian and Hispanic populations. (3) Another study showed a higher prevalence of birthmarks in the Jewish than in the Arab Israeli population. (4)

In this study in Bareilly in northern India we recorded skin disorders in neonates during the first 5 days after birth. Our aim was to prospectively study the rate of skin disorders in a large group of Egyptian newborns, and their relation to sex, birth weight, sociodemographic factors and maternal pathophysiological variables. We also aimed to compare the findings with other studies from the literature among different racial and ethnic groups.

METHODS:

Sample and Setting: This was descriptive prospective cohort study design in the neonatal unit at SRMS institute of medical sciences hospital. It is a tertiary referral unit that serves around 5 million inhabitants living in Rohilkhand region of Uttar Pradesh in India. The nursery capacity is 33 places. Out born admissions represent about 75% of admissions to the nursery.

A total of 600 newborns in SRMSIMS hospital nursery during June 2013 to May 2014 were examined for skin problems. Consecutively admitted newborns over the period of the study were recruited if they were admitted in the first 5 days of life. During the study period 708 newborns were admitted. Of these 108 were excluded, due to age at admission above 5 days (n = 66), unavailability of the dermatologist before reaching 5 days of age (n=31) or death before the dermatologist examination (n = 11).

Data Collection: Each neonate was examined daily for 5 days after birth by the same examiner who was a consultant dermatologist. Using the International statistical classification of diseases and related health problems, version 10 (ICD 10), (5) all dermatological findings were noted. Fungal skin infections were confirmed by Wood light examination. Sex, birth weight and age in hours at the time of first examination were recorded. The examiner was blind to the socio demographic, maternal or neonatal factors related to each neonate before or during clinical examination.

Relevant history was recorded, especially age of the mother, occupational, income and educational status, and rural or urban background of the parents. Parity of the mother, history of abortion, maternal illness or maternal smoking (passive and active) during pregnancy and the mode of delivery were noted.

The relationship between the frequency of lesions and various maternal and neonatal variables was studied. A comparison was made between low birth weight (LBW) (<2500 g) and normal birth weight (NBW) (> 2500 g) neonates.

Ethical Considerations: Approval of SRMSIMS research ethics committee was sought before the start of the study. Written approval from the parents of each neonate was taken before the start of the clinical examination.

Statistical Analysis: Data management and computations of descriptive statistics and prevalence were performed using SPSS for Windows, version 10. The chi- squared test was used to determine the significance of the association between the variables. Also, odds ratios (OR) at 95% confidence interval (CI) were calculated to determine the strength of association. There were no missing data.

RESULT: Of 600 newborns, 240 (40.0%) had 1 or more skin disorder at birth or that appeared during the first 5 days after birth.

Description of Skin Disorders: Birthmarks represented 100 (16.7%) of the skin manifestations in the studied neonates. Pigmented naevi were the most common, with mongolian spots in 11.7% of neonates, followed by congenital melanocytic naevi (2.7%). Vascular naevi included naevus simplex (1.3%) and naevus flammeus (1.0%) (Table 1).

Infections were the next most common type of skin disorder. Fungal skin infections were the most frequently observed pathological non-naevus skin disorder; 80 (13.3%) of the examined neonates had either oral moniliasis, fungal infection in the napkin area or candidal intertrigo. Fungal infection was more frequent in NBW infants (7.8%) than in LBW infants (5.5%) (Table 2).

Bacterial infections were found in 1.3% of neonates and were more common in LBW (0.8%) than in NBW (0.5%) (Table 2).

Among skin disorders classified as physiological, desquamation was seen in 13.3% of neonates and congenital hypertrichosis lanuginosa in 11.7% (57.1% of them were delivered by normal vaginal delivery and 80% of them were from non-smoking mothers). Infantile seborrhoeic dermatitis was found in 4.0% of neonates, cutis marmorata in 5.3% and milia in 3.0%. Among eczematous skin changes contact dermatitis had a frequency of 4.0% (65% of them were from nonsmoker mothers).

Contact dermatitis was more common in LBW neonates (79.2%) (Table 2). In the category of transient non-infective skin diseases 1.7% of neonates had miliaria rubra and 1.3% erythema toxicum neonatorum. Both of these were common in NBW neonates (90.0% and 62.5% respectively) (Table2), but neither was related to maternal age or to maternal smoking. Among developmental skin defects congenital fossae were the most common (4.3%), followed by accessory tragi (3.5%). Among the other types of skin changes, bronze baby syndrome and epidermolysis bullosa were found in 2.7% and 2.0% respectively of our sample.

Characteristics of neonates with skin disorders our analysis showed no major differences in the rate of skin disorders between the sexes: 121 cases were in males (50.4%) and 119 in females (49.6%). Skin disorders were found in 151 newborns (62.9%) of multigravida mothers and 89 (37.1%) of primigravida mothers. More than half of mothers (129, 53.8%) were in the age group 21-25 years, 57 (23.8%) were aged < 20 years old and 54 (22.5%) were aged 26-40 years.

Analysis of the characteristics of neonates with infectious skin lesions versus those with noninfectious skin lesion are summarized in Table 3. A significant positive association was found between infectious skin changes and normal birth weight of the newborns, with low birth weight infants less likely to have skin disorders (OR = 0.3, 95%.CI: 0.2-0.5, P < 0.001). Fungal infections were more frequent in NBW neonates (58.8%) while bacterial infections were more frequent in LBW (62.5%) (Table 2).

No significant association was found between maternal smoking and infectious skin changes in neonates. Mothers living in rural areas were more likely to have newborns with infectious skin lesions (OR = 2.6, 95% CI: 1.6-4.2, P < 0.001); 87.5% of neonates with bacterial Infections and 66.2% of neonates with fungal infections were resident in rural areas. Analysis of the characteristics of neonates with and without birthmarks are summarized in Table 4.

Birthmarks were significantly more common in full-term infants with normal birth weight compared with low birth weight infants (OR = 0.1, 95% CI: 0.07-0.24, P< 0.001). Mongolian spots and naeveus fllammeus were more frequent in NBW neonates. Congenital melanocytic naevi and naeveus simplex were more common in LBW (Table 2). Sex did not increase the risk for birthmarks (P = 0.5) but living in a rural area increased the risk of birthmarks in newborns (OR = 2.5, 95% CI: 1.5-3.9, P < 0.001).

DISCUSSION: Several studies report that skin changes in neonates are common. (1,3,4) For example, the frequency of cutaneous lesions in German neonates was 59.7% and in another study on neonates was 94.8%. (6,7) In our study 40.0% of the examined neonates had one or more skin disorder (excluding jaundice, cyanosis, spina bifida and scalp hematoma) The rate of birthmarks in our study was only 16.7%. Other studies reported higher rate of birthmarks in neonates. In the Islamic Republic of Iran the incidence of birthmarks varied from 26.2% to 71.3%. (6)

In Israeli neonates of Arab origin the incidence of birthmarks was reported to be 49.7% while in those of Jewish origin the incidence was 50.3%. (4) Another study in India showed the incidence of birthmarks was to be 69%. (7) Melanocytic (pigmented) birthmarks were more frequent than vascular ones in our study and the most common pigmented birthmarks were Mongolian spots in 70 neonates, a frequency of 11.7%. The rate of mongolian spots was higher in NBW neonates. Congenital melanocytic naevi were the second most common pigmented birthmarks with a frequency of 2.7% and their incidence was higher in LBW neonates. No haemangiomas were recorded in our study.

Vascular birthmarks such as naevus flammeus and haemangiomas were the most common birthmarks in German neonates with a frequency of 37.2%. (8) Pigmented birthmarks were also the most frequent skin manifestation in Iranian neonates with a frequency of mongolian blue spots of 71.3%, while salmon patches were less frequent (26.2%) and haemangiomas were the least frequent (1.3%). (6)

In Taiwan, mongolian blue spots were the most common birth marks with a frequency of 61.6%, followed by salmon patches 27.8%. Haemangiomas and congenital naevi were found in only 0.2% and 0.6% of neonates respectively. (9) Similarly, mongolian spots and salmon patches were the most common birthmarks in Chinese neonates with a frequency of 86.3% and 22.6% respectively, while port wine patch, salmon patches and congenital naevi were the least frequent. (10)

Our results suggest that the prevalence of birthmarks in North Indian neonates is similar to its prevalence reported by others in non-white infants (Arabs, Africans and other Asian countries).Fungal skin infection was the most frequently observed pathologic non-naevous neonatal skin disorder in our study; 80 (13.3%) of the examined neonates had either oral moniliasis, fungal infection in the napkin area or candidal intertrigo.

The incidence of fungal skin infection in our study was greater than that observed in other studies where it ranged from 2% to 7%A 2, 5-7 Interestingly, it was more common in neonates with NBW than in LBW neonates. Besides, fungal skin infection was related to residence in a rural area (in 63% of fungal-infected neonates the mother resided in a rural area), but it had no relationship to maternal antibiotic therapy before delivery (in 68.4% of fungal-infected neonates the mother did not receive antibiotics before delivery).

Physiological skin changes were also among the more frequent skin manifestations in our studied neonates, with skin desquamation the most common (13.3%). It was more common in males than females and among term babies. The incidence of skin desquamation in other studies varied from 7.2% to 83%. (11,12) These variations may be attributed to the fact that the babies in other studies were followed up for more than 5 days. Congenital hypertrichosis lanuginose (lanugo hair) was seen in 70 cases (11.7%), a finding that is comparable to the incidence in other studies. (8, 9, 11)

Developmental skin defects were common in our study. The incidence is different from other studies where there was a lower incidence of skin tragi (1.3%) (8) and higher incidence of hirsutism. (7)

Transient non-infective skin diseases were uncommon in our study. The most frequent was miliaria rubra with a frequency of 1.7%, followed by erythema toxicum neonatorum with a frequency of 1.3%. These showed no relation to maternal factors but they were common in full term neonates and in neonates with birth weight > 2500g. This incidence was lower than other studies where the incidence of erythema toxicum neonatorum varied between 11.1% and 33.7% and miliaria rubra between 1.3% and 20.6%. (7, 8, 11) This observation of variation in incidence related to racial differences was different from the literature which showed these disorders are common in Asian races than Caucasian or Arab races. (2) Previous studies found racial variations in skin changes in newborns.

Salmon patches and mongolian spots were the most common birthmarks in non-white Asian and Arab neonates while congenital naevi were common in white and European neonates. (68-10) Similarly, erythema toxicum was the most common non-birthmark skin change in non-white Asian neonates but was the least frequent in European (German) neonates. (6, 8) Our results support these racial variations although the frequencies are lower.

Infantile seborrhoeic dermatitis (cradle cap) was seen in 24 cases (4.0%) in our study. In Germany it was 8.2%, (8) in Italy 10.7% (11) and in Taiwan it was 6.1%. (9) This low incidence, as compared with other studies, may be due to small sample size in our study. (8,9,11) Its incidence was low in LBW neonates. Cutis marmorata was seen in 32 cases (5.3%) in our study and most of the cases were of LBW. This incidence was comparable to that reported in other studies. (6,9,13)

Milia were seen in 18 neonates (3.0%) in this study. It was common in term babies and had no relation to maternal factors. This rate was lower than reported in other study in India (8.3%), (13) the Islamic Republic of Iran (6.2%) (6) and Taiwan (4.5%). (9) Eczematous skin eruption was common in our study, with a frequency of contact dermatitis of 4.0%. This was more common in LBW neonates and was related to maternal passive smoking.

DOI: 10.14260/jemds/2014/2918

REFERENCES:

(1.) O'Connor NR, McLaughlin MR, Ham P. Newborn skin: Part I. Common rashes. American Family Physician, 2008, 77: 47-52.

(2.) Atherton J. The neonate. In: Rook A, Wilkinson S, Ebling G, eds. Textbook of dermatology, 6th ed. Oxford, Blackwell Science, 1998: 449-518.

(3.) Jacobs AH, Walton RG. The incidence of birthmarks in the neonate. Pediatrics, 1976, 58: 218-222.

(4.) Kahana M et al. The incidence of birthmarks in Israeli neonates. International Journal of Dermatology, 1995, 34:704-706.

(5.) International statistical classification of diseases and health related problems, 10th revision. Volume 2. Geneva, World Health Organization, 1993.

(6.) Moosavi Z, Hosseini T. One-year survey of cutaneous lesions in 1000 consecutive Iranian newborns. Pediatric Dermatology, 2006, 23: 61-63

(7.) Sachdeva M et al. Cutaneous lesions in new born. Indian Journal of Dermatology, Venereology and Leprology, 2002, 68: 334-337.

(8.) Lorenz S et al. Hautver and erungenbei Neugeborenen in den ersten 5 Lebenstagen [Skin changes in newborn infants in the first 5 days of life]. Der Hautarzt, 2000, 51: 396-400.

(9.) Shih IH et al. A birthmark survey in 500 newborns: clinical observation in two northern Taiwan medical center nurseries. Chang Gung Medical Journal, 2007, 30: 220-225.

(10.) Tsai FJ, Tsai CH. Birthmarks and congenital skin lesions in Chinese newborns. Journal of the Formosan Medical Association, 1993, 92: 838-841.

(11.) Boccardi D et al. Birthmarks and transient skin lesions in new borns and their relationship to maternal factors: a preliminary report from northern Italy. Dermatology (Basel, Switzerland), 2007, 215: 53-58.

(12.) Dash K et al. Clinicoepidemiological study of cutaneous manifestations in the neonate. Indian Journal of Dermatology, Venereology and Leprology, 2000, 66: 26-28.

(13.) Mishra PC, Mathur GP, Mathur S. Normal anatomic variants in the newborn. Indian Pediatrics, 1992, 22: 39-42.

Piyush Upadhyay [1], Tushar Sinha [2]

AUTHORS:

[1.] Piyush Upadhyay

[2.] Tushar Sinha

PARTICULARS OF CONTRIBUTORS:

[1.] Assistant Professor, Department of Paediatrics, SRMSIMS.

[2.] Junior Resident, Department of Paediatrics, SRMSIMS.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Piyush Upadhyay, F-229, SRMSIMS, Bhojipura, Bareilly, U. P. Email: piyushdrpeds.com@gmail.com

Date of Submission: 26/06/2014.

Date of Peer Review: 27/06/2014.

Date of Acceptance: 30/06/2014.

Date of Publishing: 03/07/2014.
Table 1: Types of skin disorders found in a sample of neonates (n =
600) in India

Skin disorder                                            No.    %

Pigmented birthmarks

  Mongolian spots                                        70    11.7
  Congenital melanocytic naevi                           16    2.7

Vascular birthmarks

  Naevus simplex (salmon patches)                         8    1.3
  Naevus flammeus (portwine patches)                      6    1.0

Infections

  Fungal                                                 80    13.3
  Bacterial                                               8    1.3

Eczema

  Contact allergic dermatitis                            24    4.0
  Perianal dermatitis (non-infected)                      4    0.7
  Infantile seborrhoeic dermatitis (cradle cap)          24    4.0

Transient non-infective skin diseases

  Miliaria rubra (prickly heat)                          10    1.7
  Erythema toxicum                                        8    1.3
  Miliaria pustulosa                                      7    1.2

Physiological skin changes

  Desquamation                                           80    13.3
  Congenital hypertrichosis lanuginosa (lanugo hair)/
  Hirsuitism                                             74    12.4
  Cutis marmorata                                        32    5.3
  Milia                                                  18    3.0
  Developmental skin defects
  Congenital fossae (skin dimples)                       26    4.3
  Accessory tragus (skin tags)                           21    3.5
  Other
  Bronze discoloration (after phototherapy)              16    2.7
  Epidermolysis bullosa                                  12    2.0
  Disseminated intravascular coagulation                  9    1.5
  Thrombophlebitis                                        7    1.2
  Purpura fulminans                                       4    0.7
  Collodion baby                                          3    0.5
  Ichthyosis                                              1    0.2

Table 2: Frequency of skin disorders in normal birth weight and low
birth weight

neonates

Skin lesion                                             Neonatal
                                                       birth weight

                                                          Normal

                                                       No.     %

Pigmented birthmarks

  Mongolian spots                                      69    98.6
  Congenital melanocytic naevi                          7    43.8

Vascular birthmarks

  Naevous simplex (salmon patches)                      3    37.5
  Naevous flammeus (portwine patches)                   5    83.3

Infections

  Bacterial                                             3    37.5
  Fungal                                               47    58.8

Eczema

  Infantile seborrhoeic dermatitis (cradle cap)        17    70.8
  Contact allergic dermatitis                           5    20.8

Transient non-infective skin diseases

  Miliaria rubra                                        9    90.0
  Erythema toxicum neonatorum                           5    62.5

Physiological changes

  Desquamation                                         53    66.2
  Congenital hypertrichosis lanuginose (lanugo hair)   41    55.4
  Cutis marmorata                                       4    12.5
  Milia                                                13    72.2

Other

  Bronze discoloration                                 16    100.0
  Epidermolysis bullosa                                 4    33.3

Skin lesion                                            Neonatal birth
                                                          weight

                                                            Low

                                                       No.      %

Pigmented birthmarks

  Mongolian spots                                       1      1.4
  Congenital melanocytic naevi                          9     56.2

Vascular birthmarks

  Naevous simplex (salmon patches)                      5     62.5
  Naevous flammeus (portwine patches)                   1     16.7

Infections

  Bacterial                                             5     62.5
  Fungal                                                33    41.2

Eczema

  Infantile seborrhoeic dermatitis (cradle cap)         7     29.2
  Contact allergic dermatitis                           19    79.2

Transient non-infective skin diseases

  Miliaria rubra                                        1     10.0
  Erythema toxicum neonatorum                           3     37.5

Physiological changes

  Desquamation                                          27    33.8
  Congenital hypertrichosis lanuginose (lanugo hair)    33    44.6
  Cutis marmorata                                       28    87.5
  Milia                                                 5     27.8

Other

  Bronze discoloration                                  0      0.0
  Epidermolysis bullosa                                 8     66.7

Table 3: Comparison of characteristics in neonates with infectious
skin lesions versus non-infectious lesions

Characteristic                Infectious skin lesion

                                Yes           No

                              (n = 88)   (n = 384)

                        No.   %          No.   %
Neonatal birth weight

Low                     38    43.2       280   72.9
Normal                  50    56.8       104   27.1

Maternal smoking

Yes                     40    45.5       305   79.4
No                      48    54.5       79    20.6

Maternal residency

Rural                   60    68.2       174   45.3
Urban                   28    31.8       210   54.7

Characteristic           OR (95% CI)    P-value

Neonatal birth weight

Low                          --
Normal                  0.3 (0.2-0.5)   < 0.001

Maternal smoking

Yes                          --
No                      0.2 (0.1-0.4)   < 0.001

Maternal residency

Rural                        --
Urban                   2.6 (1.6-4.2)   < 0.001

Table 4: Comparison of characteristics in neonates with birthmarks
(pigmented and vascular) versus non-birthmark skin lesions

Characteristic                Birthmarks

                             Yes          No

                         (n = 100)    (n = 498)

                        No.    %     No.    %
Neonatal birth weight

Low                     16    16.0   290   58.2
Normal                  84    84.0   208   41.8

Sex

Male                    54    54.0   287   57.6
Female                  46    46.0   211   42.4

Maternal residency

Rural                   70    70.0   243   48.8
Urban                   30    30.0   255   51.2

Characteristic            OR (95% CI)     P-value

Neonatal birth weight

Low                           --
Normal                  0.1 (0.07-0.24)   < 0.001

Sex

Male                          --
Female                   0.9 (0.6-1.3)      0.5

Maternal residency

Rural                         --
Urban                    2.5 (1.5-3.9)    < 0.001

OR = odds ratio; CI = confidence interval.
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Title Annotation:ORIGINAL ARTICLE
Author:Upadhyay, Piyush; Sinha, Tushar
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Jul 7, 2014
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