Here are a number of skin changes in the early months which can be considered ‘normal’ that do not usually require any intervention except reassurance. The terms may be a little strange but please bear with science, they have a very strange way of naming things.
These are tiny white spots which appear over the nose and face of babies; they are common. Their formation is probably related to the stimulus of the sebaceous glands which become temporarily blocked. There is no need to squeeze them as they will resolve of their own accord. The sebaceous glands become small and inactive soon after birth and as they do the milia resolve. The sebaceous glands remain inactive until puberty.
Mongolian blue spot
These are also relatively common in babies of Indo-Asian or Afro-Caribbean origin and occur in over 90% of children of Mongolian extraction. They consist of a blue grey patch on the skin which often occurs on the sacrum but can occur anywhere on the body. The skin surface is normal. The cause is thought to be elongated melanocyte precursor cells in the dermis. They can be mistaken as trauma from non-accidental injury, so should be documented in the notes. For most children these patches will fade as they get older, some however will persist into adulthood.
Benign acquired melanocytic lesions
Both freckles and lentigo can be described as benign acquired melanocytic lesions. Freckles are areas of skin where melanocytes are seen to be more active than in neighbouring areas. As a result, small (less than 5 mm in diameter), flat areas of pigmentation appear, generally scattered over the face, neck and arms, appearing in a variety of shades depending on the individual and the time of the year (darker in summer). Lentigo (plural being lentigenes) are also flat and a similar variety of sizes as the freckles, but they do not vary with sun exposure. Unlike freckles where there is no increase in the number of melanocytes, in lentigo there are.
Congenital melanocytic naevi
These lesions may be small or giant and occur in approximately 1% of births. The surface of the lesion may be smooth or rough and warty; there may be one or more hair follicles in the lesion. Giant congenital melanocytic naevi (those that cover a large area of the body and may be accompanied by thousands of smaller lesions) are associated with malignant melanomas and parents will need careful counselling about what action to take. Sometimes, the lesions are too large to consider surgical excision and grafting.
Vascular naevi are caused by dilated and tortuous, but otherwise normal blood vessels. Where capillary vessels are involved, a superficial or deep type may be described.
The superficial capillary naevi are caused by abnormal dilated vessels in the superficial dermis leading to salmon-coloured patches often on the face that will fade quite quickly. They are relatively common, occurring in approximately 50% of all neonates. The deeper capillary naevi are known as ‘port wine stains’, and because the vascular abnormality extends deeper into the dermis, these do not resolve and may even extend throughout life. The colour of the patches varies from pale pinkish red to dark purple; the colours will deepen with age. These changes can be associated with intracranial vascular changes and neurological pathology, so any child with a facial port wine stain should be investigated.
Otherwise known as superficial angiomatous naevi or strawberry birth marks, these occur in around 10% of children by the age of 1. Commonly, they start growing within a few days to a few weeks of birth and are usually relatively soft and irregular in outline. Sometimes there is a deeper component to these naevi where the subcutis is involved, in these instances the changes may lead to a distortion of normal anatomy. Growth of the lesion usually stops at around 6 months and resolution is usually spontaneous and complete, although if the lesion was particularly large, lose skin or atrophy may be left. The following rule of thumb is usually quite accurate:
Forty percent are gone by the age of 4 years; 50% by 5 years; 60% by 6 years; 70% by 7 years; 80% by 8 years and 90% by 9 years. (Graham-Brown and Bourke, 1998).
If the lesion interferes with feeding, breathing or sight, treatment may be recommended. For smaller areas, this is likely to be a steroid injection, but other options may be necessary including laser therapy. These types of naevi usually occur on the head, neck, buttocks or perineal areas. If they are associated with the lower back, sacrum or buttocks, a scan is usually recommended to exclude problems of tethering of the spinal cord.
Physiological jaundice (icterus neonatorum)
At about 2 days of age, parents may notice that their newborn is a yellowish colour. This is quite normal and results from the breakdown of the excess red blood cells that the child needed when they were in utero. As the child breaths following delivery, it no longer has any need of these red blood cells, so they break down leading to high serum bilirubin levels and the consequent yellow colour. This type of jaundice should not be confused with pathologic jaundice which occurs within 24 hours of birth and may be indicative of ABO or rhesus incompatibilities.