BIRTHMARKS (types) (MedRelatedCourse Essentials)

Several common types of birthmarks occur in newborns. Most will fade by school age, although an association between children with birthmarks and the development of childhood cancer exists (Johnson et al., 2007). It is important to be able to differentiate the various types of hemangiomas that occur, so that you neither give false reassurance to parents nor worry them unnecessarily about these lesions.

o   Hemangiomas. The hemangiomas are vascular tumors of the skin.

Three types occur. Nevus Flammeus. Nevus flammeus is a macular purple or dark-red lesion (sometimes called a portwine stain because of its deep color) that is present at birth. These lesions typically appear on the face, although they are often found on the thighs as well. Those above the bridge of the nose tend to fade; the others are less likely to fade. Because they are level with the skin surface (macular), they can be covered by a cosmetic preparation later in life or removed by laser therapy, although lesions may reappear after treatment (Berger, 2009). Nevus flammeus lesions also occur as lighter, pink patches at the nape of the neck, known as stork’s beak marks or telangiectasia (see Fig. 18.10B). These do not fade, but they are covered by the hairline and therefore are of no consequence. They occur more often in females than in males. Strawberry Hemangioma. Strawberry hemangioma refers to elevated areas formed by immature capillaries and endothelial cells (see Fig. 18.10C). Most are present at birth in the term neonate, although they may appear up to 2 weeks after birth. Typically, they are not present in the preterm infant because of the immaturity of the epidermis. Formation is associated with the high estrogen levels of pregnancy. They may continue to enlarge from their original size up to 1 year of age. After the first year, they tend to be absorbed and shrink in size. By the time the child is 7 years old, 50% to 75% of these lesions have disappeared. A child may be 10 years old before the absorption is complete. Application of hydrocortisone ointment may speed the disappearance of these lesions by interfering with the binding of estrogen to its receptor sites. Cavernous Hemangioma. Cavernous hemangiomas (see Fig. 18.10D) are dilated vascular spaces. They are usually raised and resemble a strawberry hemangioma in appearance. However, they do not disappear with time as do strawberry hemangiomas. Such lesions can be removed surgically. Steroids, interferon-alfa-2a, or vincristine can be used to reduce these lesions in size, although their use must be weighed in light of side effects (Edmonds, 2008). Children who have a skin lesion may have additional ones on internal organs. Blows to the abdomen, such as those from childhood games, can cause bleeding from an internal hemangioma. For this reason, children with cavernous hemangiomas usually have their hematocrit levels assessed at health maintenance visits, to evaluate for possible internal blood loss.

o   Mongolian Spots. Mongolian spots are collections of pigment cells (melanocytes) that appear as slate-gray patches across the sacrum or buttocks and possibly on the arms and legs. They tend to occur in children of Asian, southern European, or African ethnicity (Thilo & Rosenberg, 2008). They disappear by school age without treatment. Be sure to inform parents that these are not bruises; otherwise, they may worry their baby sustained a birth injury.

    Vernix Caseosa

Vernix caseosa is a white, cream cheese–like substance that serves as a skin lubricant in utero. Usually, it is noticeable on a term newborn’s skin, at least in the skin folds, at birth. Document the color of vernix, because it takes on the color of the amniotic fluid. For example, a yellow vernix implies that the amniotic fluid was yellow from bilirubin; green vernix indicates that meconium was present in the amniotic fluid. Until the first bath, when vernix is washed away, handle newborns with gloves to protect yourself from exposure to this body fluid. Never use harsh rubbing to wash away vernix. A newborn’s skin is tender, and breaks in the skin caused by too vigorous attempts at removal may open portals of entry for bacteria.

    Lanugo

Lanugo is the fine, downy hair that covers a newborn’s shoulders, back, and upper arms. It may be found also on the forehead and ears. A baby born between 37 to 39 weeks of gestation has more lanugo than a newborn of 40 weeks’ gestational age. Postmature infants (more than 42 weeks of gestation) rarely have lanugo. Lanugo is rubbed away by the friction of bedding and clothes against the newborn’s skin. By 2 weeks of age, it has disappeared.

    Desquamation

Within 24 hours after birth, the skin of most newborns has become extremely dry. The dryness is particularly evident on the palms of the hands and soles of the feet. This results in areas of peeling similar to those caused by sunburn. This is normal, however, and needs no treatment. Parents may apply hand lotion to prevent excessive dryness if they wish. Newborns who are postmature and have suffered intrauterine malnutrition may have extremely dry skin, with a leathery appearance and cracks in the skin folds. This should be differentiated from normal desquamation.

    Milia

All newborn sebaceous glands are immature. At least one pinpoint white papule (a plugged or unopened sebaceous gland) can be found on the cheek or across the bridge of the nose of almost every newborn. Such lesions, termed milia, disappear by 2 to 4 weeks of age, as the sebaceous glands mature and drain. Teach parents to avoid scratching or squeezing the papules, to prevent secondary infections.

    Erythema Toxicum

In most normal mature infants, a newborn rash called erythema toxicum can be observed.This usually appears in the first to fourth day of life but may appear up to 2 weeks of age. It begins with a papule, increases in severity to become erythema by the second day, and then disappears by the third day. It is sometimes called a flea-bite rash because the lesions are so minuscule. One of the chief characteristics of the rash is its lack of pattern. It occurs sporadically and unpredictably and may last hours rather than days. It is caused by a newborn’s eosinophils reacting to the environment as the immune system matures. It requires no treatment.

    Forceps Marks

Forceps are rarely used for birth today but if they are used, they may leave a circular or linear contusion matching the rim of the blade of the forceps on the infant’s cheek. This mark disappears in 1 to 2 days, along with the edema that accompanies it. The mark is the result of normal forceps use and does not denote unskilled or too vigorous application of forceps. Closely assess the facial nerve while a newborn is at rest and during crying episodes, to detect any potential facial nerve compression requiring further evaluation.