Newborn period is generally taken as the first 4 weeks of extra uterine life. The skin of newborn present with variety of lesions which may be transient, physiological or pathological and at times distinction between a pathological and physiological reaction is indistinct. But the majority of neonatal skin lesions are transient and self-limiting. However these conditions often are a cause of anxiety in parents. Hence a treating dermatologist should be aware of this wide variety of physiological and pathological conditions affecting new born skin.

All new-borns born in department of obstetrics and gynaecology, irrespective of gestational age and mode of delivery in one year were considered for study. Data was collected regarding the maternal age, gestational age, and maternal illness from mother. An informed consent was taken from mother. Each new born was examined till their stay in the hospital with careful examination of the entire skin surface including palms, soles, nails, genitalia and scalp under good light. The new-borns were classified according to maturity as preterm, term and post term. Newborns were classified into two groups’ i.e. Weighing less than 2.5 kgs and greater than and equal to 2.5 kgs and mode of delivery of new-borns were recorded. The statistical software namely SPSS 11.0 and Systat 8.0 were used for the analysis of data.

1427 Newborns born in one year were examined for skin lesions. Out of them 1313 (92.01%) newborns had skin lesions. The rest 114 (7.99%) newborns did not have any lesions. 743 were male and 684 were females. 678 (91.25%) males and 635 (92.83%) females had skin lesions. Out of 1313 new-borns 363 (27.65%) new-borns had single lesion and 950 (72.35%) had multiple skin lesions.

Incidence of skin lesions in relation to maternal age and maturity is given in Tables 1 and 2. There was no statistically significant difference in the number of babies having skin lesions in relation to maternal age and maturity of the baby. However there was difference in pattern of lesions with respect to maturity of babies.

Table 1: Incidence of skin lesions in relation to maternal age.

Table 2: Incidence of lesions in relation to gestational age.

Incidence of lesions in relation to gestational age of the baby is given in Table 2.

Out of 1427 mothers in the study group, 352 (24.67%) had some or the other illnesses during their pregnancy and 1075 (75.33%) were healthy mothers. Incidence of skin lesions in these group is given in Table 3.

Table 3: Incidence of skin lesions in relation to presence or absence of maternal illness.

Though there was no statistically significant difference in the incidence of skin lesions in both groups, some skin findings like congenital dermal melanocytosis (Mongolian spots), cutis marmorata were found more in babies born to mothers with illness during pregnancy.

Out of 1427 deliveries 816 (57.18%) were vaginal deliveries, among them 737 were normal, 32 were forceps assisted and 47 vacuum assisted. Skin lesions in these groups are given in Table 4. Though there was slight increase in the incidence of lesions in instrumental delivery it was not statistically significant.

Table 4: Incidence of skin lesions in relation to mode of delivery.

Out of 1427 new-borns 311 were low birth weight babies with 283 (91%) having skin lesions. 1116 babies were of normal weight out of them 1030 (92.29%) were having skin lesions. The various cutaneous lesions in relation to maternal illness, mode of delivery, maturity, birth weight and sex are given in Tables 5 and 6.

Table 5: The various cutaneous lesions in relation to maternal illness, mode of delivery and maturity.

Table 6: The various cutaneous lesions in relation to birth weight and sex.

Congenital dermal melanocytosis or Mongolian spots were the most common cutaneous finding in the present study with the incidence of 74.6%. There was statistically significant (p<0.05) increase in the incidence (88.07%) of Congenital dermal melanocytosis in babies born to mothers with maternal illness during pregnancy.

Increased incidence of lanugo hairs were observed in babies born to mothers with maternal illness during pregnancy which was statistically significant.

Statistically significant increase in the incidence of cutis marmorata was observed in preterm, low birth babies and also babies born to mothers with maternal illness during pregnancy.

Physiologic desquamation and pigmented nevus were found more commonly (p<.05) in post term babies. Perianal dermatitis was more commonly seen in babies with low birth weight.

The prevalence of dermatoses in the newborn varies between 79.4% and 100% [1,2]. According to Ahsan et al. in their study involving 1000 neonates the overall incidence of skin lesions was 94% [3]. According to a study done by Baruah et al. in a south Indian city the incidence of cutaneous lesions was 93%. In the present study total of 1427 neonates were enrolled for the study. Among them 1313 i.e. 92.01% of them had skin manifestation.

In the present study 352 (24.57%) neonates had maternal illness during pregnancy. The significant illnesses were hypertension (154), anaemia (37), diabetes mellitus (35), UTI (24), vaginitis (23), heart disease (15), asthma (14), reproductive tract infections (13), and other miscellaneous conditions.

In the present study 51.65% had normal delivery, 5.53% had instrumental assisted delivery and 42.82% had caesarean section. Out of these 91.3%, 93.67% and 92.96% had skin lesions respectively.

In a study by Nanda et al. [4] it was 58.18%, 16.60, and 25.22% for normal delivery; instrumental assisted delivery and caesarean section respectively. This study is comparable to Nanda et al. study where there is increased incidence of skin lesions in caesarean section group. Kulkarni et al. in their study found skin lesions in 86.9% of full term, 8.6% of preterm and 5% in post term new-borns [5]. In our study also 85.3% of full term, 11.5% of preterm and 3.1% in post term new-born’s had skin lesions.

Nobby et al. [6] found an incidence of skin lesion in 52.4% of males and 47.6% of female new-borns whereas Baruah et al. found incidence of skin lesions to be 55% and 45% for male and females respectively. The present study also showed 51.64% and 48.36 % had skin lesions in males and females respectively. The incidence of Mongolian spot in various study are Sachdeva et al. [7] 60.2%, Mishra et al. [8] 72%, Sareli et al. [9] 81.5% in blacks. According to sachdeva et al. mangolian spots were seen more commonly in males and more among term babies. A higher incidence was observed in multipara and in babies with more birth weight. There was no relation to maternal illness or mode of delivery [7].

In our study the incidence of congenital dermal melanocytosis (Figure 1) was 74.6%. It was also observed that the incidence of congenital dermal melanocytosis was more in neonates with maternal illness (88.07%) as compared to new-borns of healthy mothers (70.23%). Incidence was also more in new-borns weighing more than 2.5 kgs. Similar observation was also made by Kulkarni et al. also. However there was no difference in their incidence with respect to mode of delivery, maturity of the new born or with sex.

Figure 1: Multiple bluish grey macules over the back.

Microscopically, dermal melanocytes have been found in the foetus by the age of 3 months and macroscopically by the age of 7 months [10]. Melanocytes are derived from melanoblasts that arise from neural crest cells and migrate dorsolaterally between the mesodermal and the ectodermal layers to reach the basal layer of epidermis and hair follicle. Melanocytes are present in dermis of the embryos, at the beginning of 10th week of gestation, and after 20th week, no melanocytes are found in the dermis [11]. This is attributed both to the migration of melanocytes to epidermis and their clearance by macrophages [12]. Failure of these mechanisms results in MS. Maternal illness might have resulted in failure of these mechanisms with increased incidence in our study.

Lanugo is the downy hair on the body of a foetus or new born baby. Lanugo has a preponderance to occur in preterm babies. In the presence study there is statistically significant increase in the incidence lanugo in new born babies with maternal illness, premature babies and low birth weight babies similar to earlier studies [4,13].

Chulabhom et al. [14] observed 3.5% of new-borns had cutis marmorata in their study. Cutis marmorata was observed in 3.8% of the cases. Its incidence was 8.24% in newborn of mother having illness as compared to new-borns with healthy mothers (2.33%) which were statistically significant. Also the incidence was high in preterms (14.9%) as compared with term (2.4%) and Post term (0%) new-borns the reason being preterm are more prone for temperature variation due to prematurity. It is also more in newborn with birth weight < than 2.5 kgs (9.97) as compared with new-borns with birth weight > 2.5kgs (2.06%). Cutis marmorata is thought to be an exaggerated vasomotor response to hypothermia and immaturity of autonomic nervous system facilitates its occurrence [15].

It is a normal physiologic response to ambient temperature changes; accentuates with decreased temperature and improves with rewarming. It is postulated to be caused by increased sympathetic tone with delayed vasodilatation in response to a flux in temperature resulting in dilatation of capillaries and small venules [16]. In the presence study there is statistically significant increase in the incidence of cutis marmorata in new born babies with maternal illness, premature babies and low birth weight babies as the immaturity of autonomic nervous system facilitates its occurrence.

Desquamation of neonatal skin is the most common finding of neonatal period. Post maturity in the neonate leads to increased desquamation as in the present study. The pathophysiology is unknown. Scaling is most prominent on the hands, ankles and feed in term infants. In post-terms it may be more generalized and accompanied by other cutaneous sings of posterm including absence of vernix, long nails and hair and decreased subcutaneous fat [17]. Increased incidence of perianal dermatitis in low birth weight babies the present study may be attributed to impaired barrier function of the skin in neonates.

Though there was statistically significant increase in the incidence of melanocytic nevi was found in post term infants no reasons can be attributed for it. The reported incidence of Epstein pearl is varied in different studies from 43.8% by Nanda et al. to 90.5% by Mishra et al. In the present study it was observed in 21.6% of cases with slight increased incidence in new-borns born to mothers with illness during pregnancy. Milia are small white, benign, superficial keratinous cysts. The incidence of milia in our study was comparable to that observed by other Indian workers. A higher incidence was seen in term babies and in babies weighing more than 2.5 kg, delivered vaginally, which has also been noted by other workers. Kulkarni et al. have shown the incidence of milia to be 26.2% which is similar to our study i.e. 26.7%.

Incidence of milia (Figure 2) is increased in term babies (27.9%) as compared to preterm (21.6%) and post term (12.8%). Kulkarni et al. and Baruah also have observed maximum incidence of milia in term new-borns.

Figure 2: White discrete papules of milia.

Erythema toxicum neonatorum (ETN) (Figure 3) was present in 21.6% of new-borns which is comparable to Nanda et al. (20.6%) and Kulkarni et al. (25.2%). The present study showed low incidence (0.3%) of harlequin colour change (Figure 4). Miliaria (Figure 5) was seen in 1.8% of new-borns. Physiological skin peeling (Figure 6) was more frequently seen in post term new-borns (34%). Griffith has stated that peeling occurs with increasing gestational age [11]. It was also seen that physiological peeling (87.8%) was more in new-borns weighing more than 2.5 kgs.

Figure 3: Tiny pustules over erythematous base over the trunk Erythema toxicum neonatorum.

Figure 4: Erythema in the dependant position with line of demarcation from normal looking skin. Harlequin color change.

Figure 5: Discrete vesicles and pustules of Miliaria crystallina on face and Miliaria pustulosa with discrete pustules in the groin.

Figure 6: Physiological peeling of skin in extremities.

Perianal dermatitis was observed in 18 (1.3%) new-borns with higher incidence in preterm new-borns due to immaturity of the skin. Transient neonatal pustular melanosis was seen in 28 (1.95%) cases which is comparable to kulkarni et al. (2.6%). Congenital anomalies were seen in 1.4% cases which were of digital (4-0.3%), ear (11-0.8%) (Figure 7) genitourinary (2-0.14%) and neural tube defect (3-0.21%). Birth injuries (Figure 8) were seen in 2.2% cases more in instrumental assisted deliveries (18.98%). Lanugo hairs (Figure 9) were observed more frequently in preterm (65.8%) and new-borns born to mother with illness (20.17%). The other conditions observed in this study include birth mark (10.4%) (Figure 10), tuft of hair (0.4%), vascular nevi (1.6%) (Figure 11), cradle cap (1.1%), ichthyosis (1.4%) (Figure 12), bullous disorders (0.42%) (Figure 13), skin tag (0.7%), umbilical sepsis (Figure 14) (1.4%), localized hypetrichosis (0.6%), acne neonatorum (1.7%).

Figure 7: Pre auricular sinus in a newborn.

Figure 8: Hematoma with blistering in a baby with face presentation.

Figure 9: Fine lanugo hairs on face.

Figure 10: Nevus on the trunk.

Figure 11: Hemangioma on the face.

Figure 12: Harlequin Icthyosis.

Figure 13: Epidermolysis bullosa with raw erosions on bilateral foot.

Figure 14: Infected umbilical stump.

The transient lesions include congenital dermal melanocytosis, epstein pearls, milia, ETN, cutis marmorata, Harelequin colour change, miliaria, transient neonatal pustulosis, physiological skin peeling, acne neonatorum, lanugo. Mongolian spots are rarely seen after the age of 6 years. However persistence of Mongolian spots have been reported in association with Hurler's disease and followed by GM1 gangliosidosis [1]. Mucolipidosis, Niemann-Pick disease and mannosidosis [18]. However certain lesions in new-borns are of clinical significance which requires further evaluation and management. Bullous lesions in neonates needs to be differentiated from transient suction blisters and evaluated to rule out conditions like epidermolysis bullosa, bullous icthyosiform erythroderma, neonatal pemphigus.

Persistent cutis marmorata which does not improve with warming may be indicative of cutis marmorata telangiectasia congenita.

Physiologic desquamation should be differentiated from ichthyosis vulgaris and continual peeling skin syndrome. Persistence of scaling beyond the first few weeks, combined with family history, distribution and appearance of scale lead to the correct diagnosis. Sometimes biopsy is required [17].

Neonatal skin manifestations include wide range physiological and pathological conditions. Recognition and understanding of these conditions will help dermatologist to reduce parental concern and anxiety and to initiate further evaluation and treatment where ever it is necessary.