The skin in the neonatal period is fascinating. During this time, the outer protective layer of our bodies adapts rapidly from a sterile aqueous environment to a dry environment rich with many new exposures. The changes occur in a way that is not readily visible in other organs. With this comes many questions from parents, thus it is imperative for pediatricians to know when to confidently reassure parents, when treatments are necessary, and when a referral to dermatology is needed for a variety of birthmarks and rashes. Even more important is to recognize when a true emergency may be at hand.
The skin is unfortunately often overlooked in medical education and presents a challenge for many physicians. Although the topics reviewed in this issue on pediatric dermatology only touch the surface of complexity seen in newborn skin, they were chosen based on referrals made to pediatric dermatology and common questions the authors receive from pediatricians and parent friends. Clinically useful handout templates and tables will be provided where appropriate. We also invite you to review the Pediatric Annals issue on “Innovations in Pediatric Dermatology” from August 2016,1 which covered several topics pertaining to the neonate; we provide updates to those topics here, including hemangiomas and congenital melanocytic nevi.
The qualities and characteristics that make newborn skin unique are explained by Drs. Yasser Albahrani and Raegan Hunt in the article “Newborn Skin Care.” Evidence-based recommendations are provided to guide parents and pediatricians on how to best care for term and premature newborn skin with a focus on special circumstances including bathing, circumcision care, diaper care, and sun protection.
Many benign rashes appear in the neonatal period, which often mimic more worrisome rashes. Although the pediatrician easily identifies many of those discussed, for example, erythema toxicum neonatorum, it is the less straight-forward cases where physicians struggle. In the article, “Common Neonatal Rashes,” Drs. Angad Chadha and Marla Jahnke attempt to demystify these rashes by helping the reader expand his or her differential diagnosis accordingly and guide evaluation when a case is less than clear.
In the article, “Common Neonatal Skin Lesions: Melanocytic Nevi, Pigment Alterations, and Nonmelanocytic Nevi,” Drs. Kaiane A. Habeshian and A. Yasmine Kirkorian simplify common but poorly understood birthmarks. Unfortunately, patients with tuberous sclerosis complex and neurofibromatosis type 1, for example, often have delayed or extremely delayed diagnoses because the subtle signs of disease are not recognized early. The authors clarify which birthmarks may be a sign of a bigger systemic issue.
One of the main challenges in the skin is when to pursue additional testing. In the article, “Uncommon Neonatal Skin Lesions,” Drs. Jamie Rosen Manning and Diana H. Lee look at malignancy, immunodeficiency, signs of nutritional deficiency, and developmental anomalies to guide the pediatrician with evaluation and referral. Even though the topics discussed are not nearly exhaustive, they aim to help narrow down specific signs and symptoms that may help identify broader medical diseases.
Finally, in the article, “Neonatal Skin Emergencies,” Drs. Mark Siegel and Lara Wine Lee review many of the most urgent skin diseases. The poor biological reserve of neonates enables infections to spread quickly and the immature blood-brain barrier allows otherwise mild or minor infections to progress with grave consequences. In addition to infectious emergencies, this article discusses purpura fulminans, sclerema neonatorum, neonatal lupus, and the blueberry muffin rash, all of which have underlying systemic diseases requiring prompt recognition to prevent additional morbidity and mortality. Although some of the topics discussed are seen infrequently, they are critical to recognize urgently to expedite testing by the pediatrician and emergency department clinicians.
We hope this issue is useful to your clinical practice, no matter the setting. We aimed to simplify the approach to the neonate with a rash or unusual lesion and give the pediatrician confidence in doing a cutaneous examination and advising parents on best practices. The skin is a window into the body. A prepared and knowledgeable pediatrician knows when to provide benign reassurance and can minimize unnecessary testing that may come with morbidity and expense. He or she will help direct additional evaluation when a subtle skin sign is a clue to a more significant problem.
- Weinstein M, Kamat D. Innovations in pediatric dermatology. Pediatr Ann. 2016;45(8):e278–e279. doi:. doi:10.3928/19382359-20160720-04 [CrossRef]