Transcript Neonatal Dermatology

Neonatal Skin Care
Prepared by: LCDR Belinda Rand, RN, RNC
Objectives







Name three functions of the skin.
Describe two ways in which the skin of a newborn or preterm
infant differs from that of an adult.
Identify three factors that affect the appearance of the
neonate’s skin.
Identify two nursing interventions that provide protection for
the preterm infant’s skin.
Recognize three common skin lesions that are normal
variations in the newborn infant. Describe their appearance
and treatment, if any.
Describe three common vascular lesions in the neonate, their
appearance, and appropriate treatment.
Identify two syndromes associated with vascular lesions.
Clinical Significance

Careful assessment of the skin is an important element of the
neonatal physical examination. The appearance of the skin
gives the nurse important clues regarding the gestational age,
nutritional status, function of organs such as the heart and
liver, and the presence of cutaneous or systemic disease. It is
important for the RN to be familiar with normal variances in
the skin of the newborn infant, as well as those variances that
signify disease.

Proper care of the neonate’s skin can directly affect mortality
and morbidity, especially in the preterm infant. The skin is the
first line of defense against infection. Proper skin care can
protect the integrity of the skin and prevent breakdown.
Anatomy and Physiology of the skin

Three main layers

Epidermis: outermost layer, which functions as a barrier from
outside penetration.

Dermis: directly under the epidermis, 2 to 4 cm thick at birth.
Contains blood vessels and nerves that carry sensation; heat,
touch, pain, and pressure, sweat glands and hair shafts.
Collagen and elastic fibers that connect the epidermis and dermis,
and provide the skin with the ability to stretch and return to
normal shape.

Subcutaneous layer: fatty tissue functions as insulation,
protection of internal organs, and calorie storage.
Layers and Structures of Human Skin
 Insert Figure here
Functions of the Skin
 Physical Protection
 Mechanical
 provides a protective barrier against
transepidermal water loss and eternal
invasions.
 Process of sloughing prevents colonization
of the skin surface by bacteria and other
organisms.
Functions of the Skin
 Physical Protection
 Chemical/ bacterial
 Acidic surface (pH) defends against bacteria
and microorganisms
 Production of melanin protects against
damage from UV light radiation.
Functions of the Skin
 Heat Regulation



Production and evaporation of sweat.
Dilatation and constriction of blood vessels.
Insulation of body by subcutaneous fat.
 Sense Perception

Heat, touch, pain, and pressure.
Differences in Newborn & Preterm Skin
 Basic structure is same as that of the adult
 The less mature the infant, the less mature
is the functioning of the skin.
 The earlier the age, the more thin and
gelatinous is the skin. Gradual maturing;
however, at 4 wks of age a 25 wk infant has
twice the transepidermal water loss as a
term infant.
Differences in Newborn & Preterm Skin
 Subcutaneous fat is accumulated
predominantly during the third
trimester….
 Preterm babies have little fat resulting in
decreased ability to maintain body temp
and blood glucose levels.
 Brown fat (for temp regulation) begins to
differentiate in the 7th month of
gestation.
Differences in Newborn & Preterm Skin
 Newborn skin is thinner and more
permeable.
 Infants, esp. preterm, quickly absorbs
topically applied meds and chemicals.
 Allows for greater insensible water loss
in the preterm infant.
Differences in Newborn & Preterm Skin
 Fewer fibrils connect the dermis and
epidermis, & they are more fragile
than that of an adult.
 Risk of injury from tape, monitor, and
handling is increased.
 Ex. Removal of the outermost layer of
the dermis with removal of tape or
electrodes.
Differences in Newborn & Preterm Skin
 Sweat glands are present at birth, but
full functioning is not present until
2nd/3rd year of life.
 Newborn has limited ability to tolerate
excessive heat.
 Vasodilatation to increased heat loss can
result in hypotension and dehydration,
which is attributed to increased
insensible water loss.
Care of Newborn Skin
 Term Newborn
 Initial bath with water and a mild soap.
 Soaps containing hexachlorophene have
been shown to be absorbed through the
skin. Don’t use.
 Bacteriostatic soap safety has not been
established. Use with caution, rinse
completely.
 Parents may want to give the first bath.
Care of Newborn Skin
 Term Infant
 Need a stable body temp to bathe Infant
(>36.5 C) When stable it is advisable to
bathe infant to reduce caregiver’s
exposure to blood-borne pathogens.
 Vernix is good! The vernix caseosa
contains large amounts of fats, which
protect and insulates the skin, should not
be scrubbed off with bath.
Care of Newborn Skin
 Term Infant
 Routine use of emollients is not
recommended. Creams and lotions
contain perfumes and are drying and can
irritate the skin.
 Some products can change the pH of the
skin and decrease bacteriostatic
properties.
 Avoid puncturing skin when suspicious of
maternal infection.
Care of Preterm Skin
 Preterm infant
 Keep skin clean with water, mild non
alkaline soap may be used.
 Handle infant gently and minimally to
avoid trauma.
 Need infrequent bathing to avoid
 Excessive drying of the skin
 Avoid over stimulation,
 Stress and fatigue
Care of Preterm Skin
 Preterm Infants
 Minimize the use of tape, removing tape can
strip the epidermis.
 Transparent adhesive dressings can be used for
wounds, abrasions, to secure IV’s etc.
 Safety of adhesive solvents is uncertain, cotton
balls soaked with warm water can be used.
 Increased permeability of the skin allows for
absorption of some meds and products; alcohol
and betadine; can lead to chemical burns. Wash
off well with water.
Care of Preterm Skin
 Preterm Skin
 Emollient creams, free of preservatives
and perfumes may be of benefit by
decreasing transepidermal water loss
and skin breakdown when cracking,
excessive dryness, or fissures are
present.
 Tent with warm mist may protect the
skin and decrease insensible water loss
in the very low birth weight infant.
Assessment of Newborn Infant Skin
 Factors affecting the appearance of the skin








Gestational age
Postnatal age
Nutritional status and hydration
Racial origin
Type and amount of available light
Hemoglobin and bilirubin levels
Environmental temperatures
Oxygenation status
Assessment of Skin
 Definitions to describe skin lesions
 Macule; pigmented, flat spot that is
visible but not palpable.
 Papule; solid, elevated, palpable lesion,
with distinct borders > 1 cm in size
 Plaque; solid, elevated, palpable lesion,
with distinct borders > 2 cm in size
 Nodule; a solid lesion, elevated with
depth, up to 2 cm in size
Assessment of Skin
 Definitions
 Tumor; solid lesion, elevated with depth > 2 cm
is size.
 Vesicle; elevated lesion or blister filled with
serous fluid and < 1 cm in diameter.
 Bulla; fluid filled lesion larger that 1 cm.
 Pustule; a vesicle filled with cloudy or purulent
fluid.
 Petechiae; subepidermal hemorrhages, pinpoint
in size, that do not blanch.
Assessment of Skin
 Definitions
 Ecchymosis; a large area of
subepidermal hemorrhage.
 Wheal; area of edema in the upper
dermis, creating a palpable, slightly
raised lesion.
 Ulcer; erosion of skin with damage of the
epidermis into the dermis. Will leave a
scar after healing.
Common Skin Lesions
 Normal variations in newborn skin
 Cutis marmorata
 Bluish mottling or marbling effect of skin
 Physiologic response to chilling caused by
dilation of capillaries
 Disappears when infant is rewarmed
 May be sign of stress or overstimulation in
newborn.
Common Skin Lesions
 Normal Variations
 Erythema toxicum (Newborn Rash)
 Small white or yellow pustules surrounded
by an erythematous base (redness caused
by a histamine release)
 Differential Diagnosis; may resemble a
staphylococcal infection, (confirmed by a
smear of aspirated pustules showing
increased eosinophils).
Common Skin Lesions
 Normal Variations
 Milia
 Multiple yellow or pearly white papules
about 1mm in size; “inclusion cysts”,
usually on brow, cheeks, and nose.
 Observed in about 40% of newborn infants.
 No treatment needed, resolve
spontaneously during the first few weeks
after birth.
Common Skin Lesions
 Normal Variations
 Epstein pearls
 Oral counterpart of facial milia. Can be seen
on the midline of palate or on the alveolar
ridges.
 Occurs in approx 60% of neonates.
 No treatment needed.
Lesions from Trauma
 Forceps marks
 Red or bruised areas seen over the
cheek, scalp, for face of infant following
forceps delivery.
 On assessment look for underlying tissue
damage or other signs of birth trauma;
scalp abrasions, fractured clavicles, or
facial palsy.
Lesions from Trauma
 Scalp Lacerations
 May occur during delivery, with
placement of scalp electrodes, or fetal
blood pH sampling.
 Treatment consists of keeping the area
clean and dry, and assessing for
infection.
Lesions from Trauma
 Intravenous extravasations
 Vascular access sites in infants should be
assessed hourly, evaluate for patency
and extravasations. If apparent or if
patency is not certain remove IV
catheter immediately.
 If extravasation occurs, elevate
extremity. Avoid heat or moist dressings.
Topical antimicrobial ointments may aid.
Pigmented Skin Lesions
 Hyperpigmented macules (mongolian
spots)
 Large macules or patches, gray or bluegreen, seen most commonly over the
buttocks, flanks, or shoulders.
 Most common lesion seen at birth,
occurring in 90% of black, Asian, and
Hispanic babies, in 1-5% of white babies.
 Due to increased presence of
melanocytes dispersed in the dermis.
Pigmented Skin Lesion
 Cafe’-au-lait spots
 Tan or light brown patches with welldefined borders.
 Less that 3 cm in length and less that 6
in number, no pathological significance.
 6 or more spots may be an indication of
neurofibromatosis (Eichenfield & Gibbs,
2001). Tumors which form on cutaneous
nerves & along the thoracic, brachial,
and lumbar nerve trunks.
Vascular Lesions
 Nevus simplex
 “Stork bite” macular pink areas of
distended capillaries found on the nape
of the neck, upper eyelids, nose, or the
upper lip.
 They have diffuse borders, blanch with
pressure, and become pinker with
crying.
 Tend to fade, but may persist.
Vascular Lesions
 Port-wine stain
 Flat vascular nevus, present at birth. Usually
pink, may be purple or red. May be small or may
cover almost half the body. Flat, sharply
delineated, and blanches minimally. Facial
lesions are most common.
 Stains consist of mature capillaries that are
dilated and congested directly below the
epidermis. Cause not known.
 Nevus does not grow in area or size. I will not
resolve and should be considered permanent.
May become darker and thicker.
Vascular Lesions
 Strawberry Hemangioma
 Raised, lobulated, soft, bright red tumor
located on the head, neck, trunk, or
extremities. May occur in the throat, can
lead to airway obstruction.
 Caused by dilated capillaries occupying
the dermal and subdermal layers with
endothelial proliferation.
 20-30% are present at birth, and 90%
are evident by w month of age.
Strawberry Hemangioma
 Usually will increase in size in the first 6
months, then become stable in size before
gradual spontaneous regression, most
leave no trace. Will take several years.
 Often there is more than one lesion.
 Treatment is to allow spontaneous
regression. If lesion effects vision, is
bleeding, or ulcerating, impinging on other
vital functions further treatment should be
considered.
Infectious Lesions
 Thrush
 Fungal infection of the mouth or throat,
caused by Candida albicans, very
common in infants.
 Shows as patches of adherent white
material scattered over the tongue and
mucous membranes.
 Treated with oral antifungal preparations
such as nystatin (Mycostatin).
Infectious Lesions
 Candida diaper dermatitis
 Fungal infection of skin in the diaper
area, buttocks, groin, thighs, and
abdomen. (check for thrush as well)
 Caused by organism C. Albicans.
 Shows as moist, erythematous eruption,
often with white or yellow satellite
pustules.
 Treatment is antifungal cream or
ointment preparation, nystatin.
Infections Lesions
 Systemic Candida infection
 Very low birth weight infants are at risk
of having systemic, invasive fungal
infections with invasion of the fungus
beyond the stratum corneum.
 Tx: Improve barrier function of the skin
by minimizing trauma and maintaining a
sterile environment may help prevent
onset of illness.
Infections Lesions
 Herpes
 Neonatal herpes simplex infection is one
of the most serious viral infections in the
neonate.
 Rash appears as vesicular or pustular
rash.
 70% of infants with herpes will have
subsequent rash, but not always before
other signs and symptoms of illness
develop.
Herpes
 Absence of rash or vesicles does not
eliminate the possibility of disease.
 Tx: with antiviral agent such as
acyclovir should begin immediately.
The earlier treatment is begun, the
better the outcome (Weston et
al.,2002).
References
 Verklan, M. T., Walden, M., (Eds.). (2005). Neonatal
Dermatology. Core Curriculum for Neonatal Intensive
Care Nursing. (3rd Ed). Elsevier Saunders.
 Thureen, P.J., Decan, J., Hernandez, J.A., Hall, D.M.
(2005) Assessment and Care of the Well Newborn.
(2nd Ed). Elsevier Saunders.
 Eichenfield, L.F. and Gibbs, N.F.: Hyperpigmentation
Disorders. Textbook of neonatal dermatology.
Philadelphia, 2001, Saunders, pp. 370-394.
 Weston, W.L., Lane, A.T., and Morelli, J.T.: Color
textbook of pediatric dermatology (3rd ed.). St Louis,
2002, Mosby.