skin, hair, and nails adapted from mosby’s guide to physical examination, 6 th ed. ch. 8
TRANSCRIPT
Newborn
• Vernix caseosa– Mixture of sebum and cornified
epidermis covers the infant’s body at birth
– Whitish, moist, cheeselike substance– Protective
www.brooksidepress.org/Products/OBGYN_101/MyDocuments4/Text/Newborn/Vernix.jpg
Newborn
• Transient puffiness of the hands, feet, eyelids, legs, pubis or sacrum occurs in some newborns
• Not a concern if it disappears within 2-3 days
Newborn
• Lanugo– Fine, silky hair
covering the newborn • particularly shoulders
and back
– Shed within 10-14 days
Lanugo. This fine body hair resembling peach fuzz is present on infants of 24 to 32 weeks' gestation.
Newborn
• Some newborns are bald while others are born with an inordinate amount of head hair…– Shed within 2-3 months and replaced
by more permanent hair (new texture and color)
Newborn• Dark-skinned newborns do not
always manifest the intensity of melanosis that will be readily evident in 2-3 months– Exceptions: nail beds and skin of the
scrotum
Newborn
• Skin may look very red the first few days of life
– Skin color is partly determined by subcutaneous fat (the less fat, the redder and more transparent the skin)
Newborn
• Subcutaneous fat– Poorly developed in newborns– Predisposed to hypothermia
*Newborns lose heat 4x faster than an adult
Expected Color Changes - Newborn• Acrocyanosis
– Cyanosis of hands & feet
• Cutis marmorata– Transient mottling when
infant is exposed to decreased temperature
CLINICAL NOTE
An underlying cardiac defect should be suspected if acrocyanosis is:– persistent– more intense in the feet than hands
Expected Color Changes - Newborn• Harlequin color
change– Clearly outlined color
changes as infant lies on side
– Lower half of body becomes pink and upper half is pale
www.adhb.govt.nz/newborn/TeachingResources/Dermatology/HarlequinColour/Harlequin.jpg
Expected Color Changes - Newborn• Mongolian spots
– Irregular areas of deep blue pigmentation
– Usually in sacral and gluteal regions
*Seen predominantly in African, Native American, Asian or Latin descent
Expected Color Changes - Newborn• Telangiectatic nevi (“stork bites”)
– Flat, deep pink, localized areas usually seen in back of neck
Stork bite, or salmon patch. A typical light red splotchy area is seen at the nape of the neck.
Expected Color Changes - Newborn• Erythema toxicum
– Pink papular rash with vesicles superimposed
– Thorax, back, buttocks, and abdomen– May appear 24-48 hrs after birth and
resolves after several days
Examining the Newborn for Hyperbilirubinemia
• Look at the whole body– Starts on the face and descends
• Bilirubin level is not high if only the face • May be at a worrisome level if jaundice
descends below the nipples
• Examine the oral mucosa and sclera• Natural daylight is preferred
Physiologic Jaundice• Present in 50% of newborns
– Starts after the first day of life– Usually disappears in 8-10 days but
may persist for 3-4 weeks
Physiologic Jaundice
Hyperbilirubinemia in the Newborn
Risk Factors:– Breast feeding
• glucuronidase in breast milk
– Cephalhematoma• or other cutaneous or subsutaneous bleeds
– Hemolytic disease– Infection
Physiological Jaundice
• appears to be an inability of the liver to conjugate the bilirubin present in the blood
• 5mg/dl bilirubin is visible in the skin
• seldom rises above the 20mg/dl necessitating transfusion
Physiological Jaundice
Treatment
• “Bili lamp” & “Bili Blanket” (blue lights), or direct sunlight– helps to conjugate the bilirubin– allows it to clear faster
NOTE
Intense and persistent jaundice… should consider pathological jaundice
– liver disease OR– severe, overwhelming infection
Other Causes of Pathological Jaundice
• RBC abnormalities & sensitivity• Hemorrhage• Impaired hepatic function• Infections
– Toxoplasmosis– Rubella– Herpes– Syphilis
• Careful inspection of all skin– Develop a pattern; Don’t overlook
body parts
• Examine skin creases– Assymetrical creases on thighs
• Possible hip dysplasia
– Simian Line (hands & feet)• possible Down syndrome
Schamroth Technique
• Place nail surfaces of corresponding fingers together
A. Normal: diamond shaped window
B. Clubbed: angle between distal tips increases
Clubbing of the Nails
• Associated with:– Respiratory disease– Cardiovascular disease– Thyroid disease – Cirrhosis– Colitis
Assessing Skin Turgor
• Best evaluated by gently pinching a fold of the abdominal skin
• Indication of state of hydration and nutrition
• Skin that retains “tenting” after it’s pinched indicates:– Dehydration– Malnutrition
Normal range is broad. Consider other factors…
External Clues to Internal Problems
• Faun tail nevus
– Tuft of hair overlying the spinal column usually in the lumbosacral area
– Associated with spina bifida occulta
External Clues to Internal Problems
• Café au lait spots
– Evenly pigmented (>5 mm diameter)
– Light, dark brown, or black in dark skin
– Present at birth or shortly thereafter
Café au lait spots may be related to:– Neurofibromatosis– Pulmonary stenosis– Temporal lobe dysrhythmia– Tuberous sclerosis
Suspect neurofibromatosis if you note: >5 patches with diameters >1cm in a
child under 5
External Clues to Internal Problems
• Freckling in the axillary or inguinal area
– May occur in conjunctionwith café au lait spots
– Associated with neurofibromatosis
External Clues to Internal Problems
• Facial port-wine stainWhen it involves the opthalmic division of the trigeminal nerve it may be associated with:• Sturge-Weber syndrome
– seizures
• Occular defects
External Clues to Internal Problems
• Supernumerary nipples– Especially in the presence of other
minor abnormalities…•associated with renal
abnormalities
• Milia– Small white discrete papules on the
face (bridge of the nose)
– Plugged sebaceous glands
– Common during the first 2-3 months
• Miliaria aka “Prickly Heat”(crystaline)– Caused by occlusion of sweat
ducts during periods of heat and high humidity
Typical sites of eczema
Younger children• Face, elbow, knees
Older children & adults• Hands, neck, inner
elbows, back of knees, ankles
• Face (less often)
• Seborrheic Dermatitis– Chronic, recurrent erythematous
scaling eruption– Areas dense with sebaceous glands
• Scalp, back, intertriginous, & diaper areas
“Cradle Cap”– Scalp Lesions are scaling, adherent,
thick, yellow, and crusted– Can spread over the ear and down
the nape of the neck
• Impetigo– Highly contagious Staph.
or Strep. infection– Honey colored crusts
– Causes pruritis, burning, and regional lymphadenpathy
• Strawberry hemangioma
Birth: often not present or noticeable1-2 months: becomes noticeable1-6 months: grows most rapidly12-18 months: begins to shrink