Alongside the midwife's role in antenatal care and during birth, responsibilities extend to some care of the newborn in the first few weeks of life, during which time a variety of skin problems may present. At this stage of the neonatal period, the skin has not fully matured and may be particularly vulnerable. It is important to understand the structure of neonatal skin and how the risk of complications may be reduced, and to recognise changes that will resolve spontaneously or with simple intervention, as well as those problems that require specialist supervision and advice. This article considers some common skin conditions that may occur in the neonatal period.
Neonatal skin
The thickness of the stratum corneum, the outer layer of the skin, plays an important part in its barrier function, where it helps to regulate the body's fluid and electrolyte balance, maintain temperature and reduce absorption and resulting toxicity of topical medications or other substances applied to the skin. The stratum corneum varies in thickness depending on age; in a term infant it is 30% that of an adult, and even thinner in a preterm infant, causing the skin to be more permeable and at risk of dryness (Crozier and Macdonald, 2010). Another factor in vulnerability is related to colonisation of the skin that protects against harmful bacteria. Skin is alkaline at birth but, within about 4 days, it becomes acidic and more protective against bacteria; however, the acidity may be delayed in preterm infants and thus less protective against bacterial infection (Jackson, 2008). In the last trimester of pregnancy, fetal skin is protected by the amniotic fluid and vernix, which is made up of sloughed cells from the stratum corneum; it helps early acidification as well as acting as a natural cleanser, moisturiser, anti-infective and antioxidant, and aids wound healing (Jackson, 2008).
Guidelines for bathing
It is generally thought that bathing a preterm or sick baby may have adverse effects and should be avoided until the child is physiologically stable. For healthy term babies, plain water, maintained at 37°C and preferably at 4-day intervals is recommended, and bathing is best deferred until the 2nd or 3rd day; however, it may occur within 2–4 hours of birth without ill effect. Toiletries and cleansers should be avoided for at least the first month (National Institute for Health and Care Excellence, 2006; Jackson, 2008).
Common skin abnormalities in neonates
At the first check on a newborn and/or subsequent observation of the skin when the infant is being changed or bathed, the midwife is in an excellent position to notice any skin blemishes or rashes that may be present at birth or develop in subsequent days and weeks. It is important that the midwife is able to recognise when some simple reassurance or advice for parents is required, or whether there is a problem that may need referral to a GP or specialist.
Birthmarks
Naevi, or birthmarks, are common in the newborn and often raise anxieties for parents. Types of naevi include pigmented or vascular birthmarks.
Pigmented birthmarks
Congenital melanocytic naevi are present at birth in up to 2.1% of infants. They may be brown/black and are usually flat but sometimes hairy and/or raised. Assessment of size is important as the potential for later malignant change increases with the size of the lesion and the number of melanocytic naevi present. Referral for consideration of excision, if this is possible, is suggested if the lesion in infancy is greater than 7 cm; lesions that are 0.5–7 cm should be followed up by a dermatologist while those smaller than 0.5 cm can be observed in primary care. The risk of melanoma is small, with up to 0.7% occurring, mainly in large lesions (McLaughlin et al, 2008).
Other naevi that occasionally have potential for malignant change of basal cell carcinoma, squamous cell carcinoma or certain benign tumours are sebaceous naevus and epidermal naevus. Any changes in size, shape, thickness or colour should be referred for further assessment.
Sebaceous naevus is rare. It presents at birth as a smooth, orange/yellow hairless patch, usually on the scalp or, occasionally, on the face or neck. It will require further monitoring and referral to a dermatologist if changes occur; biopsy or excision may then be indicated (Oakley, 2014).
In the case of epidermal naevus, 50% are present at birth or develop in the first year of life due to a genetic abnormality. At birth they are linear, flat, tan/brown marks, usually on the trunk or limbs; as the child grows the mark becomes larger, thickened and warty. No effective treatment is available other than laser or surgical excision (Ngan, 2015).
Mongolian blue spots present at or soon after birth, with one or more symptomless bluish-grey or brown patches that occur most commonly on the buttocks or lower back. The discolouration is thought to be due to melanocytes trapped in the top layer of the skin. They occur most commonly in people of Black or Asian ethnicity and usually disappear without treatment within a few years (The Birthmark Unit, 2013). A clinical diagnosis can be made but problems may arise if the lesions are thought to be bruising, raising the possibility of abuse. The midwife should note the presence of Mongolian blue spots and alert the health visiting team, so that future identification of the condition as bruising may be avoided.
Vascular birthmarks
There are various capillary vascular malformations that may affect newborns. Salmon patch presents with small, poorly defined flat pink or red patches in about 40% of newborns. They usually occur at the nape of the neck (Figure 1), between the eyebrows or on the eyelids. No treatment is required and many will disappear in the first year; however, some may persist into adult life (Oakley, 2004).
Port wine naevus presents at birth as a flat red or purple patch. The cause for this capillary malformation is unknown, but it is more common in girls and occurs in about 0.3% of children (The Birthmark Unit, 2012). In time the lesion thickens, becomes darker and develops an irregular ‘cobblestone’ appearance. Early referral to a specialist is recommended so that decisions can be made regarding laser treatment or cosmetic camouflage. Laser treatment usually achieves good results and would be considered after the age of 6 months. Port wine naevus in certain areas may carry specific risks, for example: around the eye it increases the risk of glaucoma; around the forehead and scalp it may be associated with fits (Sturge-Weber Syndrome); and large lesions on the limbs may be associated with extra growth of the arm or leg (Klippel Trenaunay Syndrome) (The Birthmark Unit, 2012).
Strawberry naevus is a common capillary haemangioma occurring in 5% of the population. It usually becomes obvious after birth, presenting as a small red patch (Figure 2) that rapidly grows and reaches its final size in the next few months. Gradual regression should follow and, by the age of 10 years, 90% have cleared; however, they sometimes leave scars, telangiectasia or hypopigmentation. Treatment is usually unnecessary and patients are advised to await spontaneous resolution unless the lesion interferes with feeding, respiration, hearing or vision, or it ulcerates or bleeds excessively. These cases should be referred for consideration of oral propranolol, steroids or laser treatment (McLaughlin et al, 2008).
Rashes
Milia usually occur on the face or scalp and affect about half of newborn babes. They present as small, white pearly globules of 1–2 mm in size (Figure 3). They are keratin-filled epidermoid cysts which occasionally may be itchy but more often are symptomless. No treatment is required for these lesions, which tend to resolve spontaneously within a few weeks (Payne, 2015).
Sebaceous gland hyperplasia (Figure 4) is another common problem affecting about half of newborn infants. It presents with multiple white and yellow papules, most commonly on the cheeks, upper lips and forehead, where sebaceous gland cells are most numerous. It develops due to maternal hormonal influences on the pilosebaceous follicles. No treatment is necessary as the lesions should clear spontaneously within a few months (Watkins, 2011).
Obstruction of the sweat glands in the lower level of the skin may lead to the development of erythematous papules and fragile vesicles, particularly under clothing, known as miliaria rubra or heat rash. This is a benign condition which can be resolved by cooling the infant via removal of excess clothing, bathing in cool water or air conditioning (Levin, 2015).
Neonatal seborrhoeic dermatitis occurs in the form of cradle cap (Figure 5) in the newborn, and is thought to be due to overactive sebaceous glands stimulated by residual maternal hormones in the child. Inflammation and greasy scales usually form on the scalp, and a non-irritating rash may sometimes extend to the face, ears, neck, flexures and nappy area. Milder cases may resolve without treatment within a few weeks but if necessary, frequent shampoos and attempts to gently remove the softened scales may suffice, or the application of an emollient overnight before washing the scalp may be more effective. If this is insufficient, it may be necessary to refer the infant and they may then be recommended to use an antifungal shampoo and mild topical corticosteroid (Sasseville, 2015).
Atopic dermatitis is a common problem in infancy, but does not usually present until the age of 2–4 months. However, if infants at greater risk are recognised and possible triggers avoided, the severity of the condition may be reduced. Children with atopic dermatitis frequently have a family history of eczema, hay fever and/or asthma, so any preventive measure is particularly important where this is a factor. There is evidence that a daily application of an unperfumed moisturiser in the first 8 months of life reduces the risk of developing atopic dermatitis (Horimukai et al, 2014). This is especially important if the skin shows evidence of dryness, inflammation and irritation, often starting on the face, behind the ears or in the neck creases; scratching may introduce secondary infection. The infant should be dressed in cotton next to the skin, rather than wool or nylon. Should eczema develop, the use of a suitable topical corticosteroid alongside continuing use of emollients may be recommended (NHS Choices, 2015a).
One of the most common skin complaints in newborns is nappy rash. Few infants get by without a nappy rash at some point in the first 18 months of life, owing to prolonged exposure to stools and urine, rubbing of nappies, use of soaps or detergents, or in association with an illness or diarrhoea. The skin in the nappy area may become inflamed and/or develop spots, pustules or blisters. Spread to the flexure areas might suggest secondary infection with candida. Frequent nappy changes, cleaning from front to back with plain water or baby wipes, avoidance of trigger factors, and applying a barrier cream at each nappy change should help to reduce the incidence, especially if the infant is left uncovered for as long as seems sensible. Should candida be suspected, an additional antifungal cream may be recommended (NHS Choices, 2015b).
Infections
Owing to the different structure of the skin of the newborn—especially preterm infants—and with a diminished function of the immune system, the infant is more vulnerable to infection and has a lower ability to fight it. It is not uncommon for bacterial, viral or fungal infections to occur.
Bacterial infections
Bacterial infections are most commonly due to a Staphylococcus or Streptococcus, which may cause impetigo with erythema, eroded lesions and golden exudate and crusts. The usually preferred antibiotic is flucloxacillin. Bullous impetigo is an erythematous vesiculopustular rash that coalesces to form bullae, usually in the nappy area, which is due to Staphylococcus aureus. S. aureus is also the cause of scalded skin syndrome (Figure 6), in which desquamation follows bullae formation due to epidermolytic toxins. Care must be taken to avoid spreading the infection to others by ensuring the sores are not touched, hands are regularly washed, and towels and bedding are not shared.
Other infections include paronychia, where the nail fold or the umbilicus may become infected. This is often associated with sucking the fingers or traumatic cutting of nails.
Omphalitis is inflammation, oedema and exudation of the umbilical stump, which tends to occur at about 3 days. Staphylococcus is usually involved, but other bacteria are also common so a doctor will take a swab before starting an antibiotic, which can then be changed if indicated by the results. Swabs from the infected areas should confirm the bacteria and sensitivities to antibiotics. Because of the infant's vulnerability, antibiotics should be started as soon as the swabs have been taken. Localised impetigo may respond to topical mupirocin or fusidic acid but more widespread or non-responsive infections may require oral flucloxacillin; 48 hours after starting antibiotics, the infant is no longer contagious (Read, 2015).
Viral infection
Herpes simplex and varicella-zoster virus are rare, but may be acquired during birth if the mother has genital herpes simplex or has suffered with chickenpox in pregnancy. Skin vesicles and the mother's history may alert practitioners to the problem even though the child may be afebrile. Both infections may have serious complications and would require urgent specialist referral (Kimberlin, 2004).
Fungal infections
Candida albicans is a common commensal but, not infrequently, may cause problems. It presents with small, white adherent plaques on the tongue. Often it will be a secondary invader of other skin problems, such as nappy rash. Treatment with a topical antifungal such as nystatin suspension for the mouth and/or imidazole cream for skin problems is recommended (Tidy, 2013).
Conclusion
This article has discussed some of the more common skin conditions that may occur in the neonatal period, a time during which the midwife plays an important role and can give advice regarding the management of the infant and ways in which the parents can reduce the risk of problems such as eczema and nappy rash. It is important that the midwife can recognise both conditions where reassurance is sufficient and those that may require treatment or referral to general practice or a specialist.