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Common skin conditions in newborns

Key learning points:
 - Recognise the presenting symptoms of specific skin complaints in young babies

 - Treating and helping to prevent recurrence of these conditions

 - Advice and reassurance for parents and carers

Managing newborn skin problems can present specific challenges for both parents and healthcare professionals. The newborn dermis is less mature than that of adults or older children, with an immature vascular and nerve structure. There are fewer collagen and elastic fibres resulting in skin being more fragile with reduced barrier function. Newborns have a developing immune system and can develop non-specific rashes to many things. It is therefore crucial to identify associated symptoms and altered pathophysiology.1

Skin rashes are a source of anxiety for parents/carers and are one of the most common reasons for parents attending GP clinics in the primary care setting, paediatric accident and emergency departments and outpatient clinics.

The surface of the skin is colonised by numerous harmless micro-organisms, staphylococcus aureus and streptococcus which are not part of the normal skin flora; however they are frequently found on the skin surface and it is these organisms that are responsible for the majority of cutaneous skin infections which range from minor irritation skin eruptions to major skin involvement. Some of the most commonly seen complaints are described below.

Milia (milk spots)

Sebaceous glands active late in foetal life and higher levels of maternal androgens can often result in milia. They are commonly found on nose and cheeks. These are generally harmless and will spontaneously resolve. No treatment is indicated other than reassurance.

Milaria (heat rash)

Milaria, or heat rash, is secondary to thermal stress as immature eccrine glands mean infant has reduced ability to sweat. It is characterised by an erythematous papular rash mainly affecting face, scalp and trunk.1 Reassure parents that the rash will resolve with removal of (or from) the source of heat.

Toxic erythema

Erythema toxicorum neonatorum is a benign condition for which cause is usually unknown, and generally appears in the first few days of life. It is characterised by a combination of erythematous macules/papules and pustules. It generally affects the face but can spread to trunk and limbs. Although the infant generally appears well, it is important for a paediatric review as there are numerous differential diagnoses.

Infantile seborrhoeic dermatitis (ISD) and cradle cap

This is a common skin condition affecting newborns and infants, mainly affecting the scalp face and flexures. It presents as thick greasy scales on the scalp which may extend to eyebrows, and can extend to skin flexures and nappy area. The affected areas of body present as erythematous, mildly dry and with fine scaling.

The exact pathogenesis of ISD is unclear but there are links to an inflammatory reaction to yeast, especially pityrosporum ovale, and it is also thought that maternal androgens may play a part.2

As with all skin conditions in babies, parents will need reassurance and support. Generally only mild emollients are required, such as a daily emollient bath and twice daily application of emollient creams. Parents should be advised to discontinue use of soaps/scented products. Depending on severity and lack of response to initial treatment, a mild combination topical steroids /antifungal treatments may be indicated. This highlights need for frequent review and reassessment. 

Cradle cap varies in severity and can usually be treated with a mild, unscented baby shampoo. If crusting is present then a mineral oil can be massaged into the scalp and left for 30 minutes, or slightly longer depending on the severity, before washing out with a mild baby shampoo. Parents should avoid using nut oils such as arachis or almond due to sensitisation, and olive oil should not be left on the scalp for long periods as it proliferates the yeast. Whichever oil is used should be washed out between treatments.

Parents can use a soft baby brush to gently remove the loosened scales but should be discouraged from picking at the scales as it can cause irritation and damage to hair follicles. If the scalp has an offensive odour there may be a secondary infection that requires treatment with antifungal/antibacterial topical therapies.

Nappy rash

This is a common condition that will affect majority of children at some point in the early years. Affected children are often fretful, irritable and uncomfortable. In the majority of cases it will be short-lived and easy to clear.

The normal pH of skin is acidic, and the moistness (from occlusive nature of nappies) increases skin pH, with a subsequent increase in skin permeability. Nappy rash will occur when these characteristics are combined with processes such as friction from nappy, irritation from urine and faeces and fungal contamination.3

Nappy rash has a red moist appearance over the area covered by the nappy. There may be peripheral scaling and in severe cases ulceration and bleeding.

Candida will affect the flexures, has a red glazed appearance, and often there are visible peripheral pustules. 

Psoriasis in nappy area rare but the plaques will present as a bright red/weepy rash.

It is essential to note any lesions with an unusual appearance and rule out non-accidental injury. It is crucial that they are consistent with the history given. 

Uncomplicated nappy rash can be cleansed with non-soap/non-perfumed cleansers and a regular mild barrier cream applied. Frequent nappy changes and nappy-free time should be encouraged.

For nappy rash not responding to treatment, consider other aetiologies such as a nutritional deficiency or systemic illness.

Impetigo

This is a highly contagious bacterial infection caused by staphylococcus aureus and/or beta haemolytic streptococcus. The two categories referred to as non-bullous and bullous. Non-bullous impetigo is the most common form and is frequently seen in children over two years. 

Impetigo is characterised by small erythematous vesicles which rupture easily, and the exudate leaves a tell-tale honey coloured crust. Although any areas of the body can be affected it is most common on corners of mouth and the nostrils. It is generally self-limiting but widespread impetigo is commonly seen in infected eczema.

Bullous impetigo generally found those under two years old and is caused by staphylococcus aureus. They tend to be large bulla with an erythematous base and can resemble a small scald. Presentation similar to bullous, but nappy areas can be affected. The child may be systemically unwell.

Treatment of impetigo must be individually assessed and will depend on various factors including age of child, severity of the infection, the locality and extent of lesions. It may in mild cases be possible treat with topical antibiotics. There may be some mild discomfort to the child and an over the counter childhood analgesia may be required. 

Severe cases are usually indicative of beta haemolytic streptococcus and will require systemic antibiotics as some strains of streptococcus can cause post streptococcal glomerulonephritis.

Do not wait for skin swab results before initiating the appropriate treatment. The infection spreads easily through touching infected lesions and transferring to clothing and linen. As children tend to frequently touch their mouths, they rapidly cross-infect others.

As it is highly contagious the parents need to be informed of measures to take to prevent/minimise spread to others must be reiterated to all.

This includes:

 - Increased levels of hand-washing.

 - Using own flannel/towel.

 - Cleaning of all toys.

 - Affected children must be kept out of nursery until the infection has cleared.

Conclusion

It is useful to assess whether the presenting complaint is a manifestation of a serious or chronic illness and whether is it the mains symptom or a secondary symptom.

There are various bacterial, viral and fungal infections that can invade the skin, and the majority will be easy to treat. However any condition that does not respond to treatments, or where the child is systemically unwell, should be referred for a general paediatric review.

 

References 

1. Peters J, Turnbull R. My child has a rash IN Paediatrics a clinical guide for nurse practitioners, ED K Barnes chapter 9:1. Butterworth Heinemann; 2003.

2. Gill S. Infantile seborrhoeic dermatitis including Cradle cap IN Paediatrics a clinical guide for nurse practitioners, ED K Barnes chapter 9:10 p73. Butterworth Heinemann; 2003.

3. White R, Denyer J. Infant napkin dermatitis and differential diagnoses. IN Paediatric skin and wound care. Chapter 7. Trowbridge: Wounds UK & Cromwell Press; 2006.

 

Resources

Harper J. Handbook of Paediatric Dermatology 2nd Ed. London: 

Butterworth-Heinemann; 1990.