Skin, Hair, and Nails

Adapted from Mosby’s Guide to Physical Examination, 6th

Ed.Ch. 8

Newborn

• Vernix caseosa– Mixture of sebum and cornified

epidermis covers the infant’s body at birth

– Whitish, moist, cheeselike substance– Protective

www.brooksidepress.org/Products/OBGYN_101/MyDocuments4/Text/Newborn/Vernix.jpg

Newborn

• Transient puffiness of the hands, feet, eyelids, legs, pubis or sacrum occurs in some newborns

• Not a concern if it disappears within 2-3 days

Newborn

• Lanugo– Fine, silky hair

covering the newborn • particularly shoulders

and back

– Shed within 10-14 days

Lanugo. This fine body hair resembling peach fuzz is present on infants of 24 to 32 weeks' gestation.

Newborn

• Some newborns are bald while others are born with an inordinate amount of head hair…– Shed within 2-3 months and replaced

by more permanent hair (new texture and color)

Newborn• Dark-skinned newborns do not

always manifest the intensity of melanosis that will be readily evident in 2-3 months– Exceptions: nail beds and skin of the

scrotum

Newborn

• Skin may look very red the first few days of life

– Skin color is partly determined by subcutaneous fat (the less fat, the redder and more transparent the skin)

Newborn

• Subcutaneous fat– Poorly developed in newborns– Predisposed to hypothermia

*Newborns lose heat 4x faster than an adult

Expected Color Changes - Newborn• Acrocyanosis

– Cyanosis of hands & feet

• Cutis marmorata– Transient mottling when

infant is exposed to decreased temperature

CLINICAL NOTE

An underlying cardiac defect should be suspected if acrocyanosis is:– persistent– more intense in the feet than hands

Expected Color Changes - Newborn• Harlequin color

change– Clearly outlined color

changes as infant lies on side

– Lower half of body becomes pink and upper half is pale

www.adhb.govt.nz/newborn/TeachingResources/Dermatology/HarlequinColour/Harlequin.jpg

Expected Color Changes - Newborn• Mongolian spots

– Irregular areas of deep blue pigmentation

– Usually in sacral and gluteal regions

*Seen predominantly in African, Native American, Asian or Latin descent

Expected Color Changes - Newborn• Telangiectatic nevi (“stork bites”)

– Flat, deep pink, localized areas usually seen in back of neck

Stork bite, or salmon patch. A typical light red splotchy area is seen at the nape of the neck.

Expected Color Changes - Newborn• Erythema toxicum

– Pink papular rash with vesicles superimposed

– Thorax, back, buttocks, and abdomen– May appear 24-48 hrs after birth and

resolves after several days

Examining the Newborn for Hyperbilirubinemia

• Look at the whole body– Starts on the face and descends

• Bilirubin level is not high if only the face • May be at a worrisome level if jaundice

descends below the nipples

• Examine the oral mucosa and sclera• Natural daylight is preferred

Physiologic Jaundice• Present in 50% of newborns

– Starts after the first day of life– Usually disappears in 8-10 days but

may persist for 3-4 weeks

Physiologic Jaundice

Hyperbilirubinemia in the Newborn

Risk Factors:– Breast feeding

• glucuronidase in breast milk

– Cephalhematoma• or other cutaneous or subsutaneous bleeds

– Hemolytic disease– Infection

Physiological Jaundice

• appears to be an inability of the liver to conjugate the bilirubin present in the blood

• 5mg/dl bilirubin is visible in the skin

• seldom rises above the 20mg/dl necessitating transfusion

Physiological Jaundice

Treatment

• “Bili lamp” & “Bili Blanket” (blue lights), or direct sunlight– helps to conjugate the bilirubin– allows it to clear faster

NOTE

Intense and persistent jaundice… should consider pathological jaundice

– liver disease OR– severe, overwhelming infection

Other Causes of Pathological Jaundice

• RBC abnormalities & sensitivity• Hemorrhage• Impaired hepatic function• Infections

– Toxoplasmosis– Rubella– Herpes– Syphilis

Exam

• Careful inspection of all skin– Develop a pattern; Don’t overlook

body parts

• Examine skin creases– Assymetrical creases on thighs

• Possible hip dysplasia

– Simian Line (hands & feet)• possible Down syndrome

Schamroth Technique

• Place nail surfaces of corresponding fingers together

A. Normal: diamond shaped window

B. Clubbed: angle between distal tips increases

Clubbing of the Nails

• Associated with:– Respiratory disease– Cardiovascular disease– Thyroid disease – Cirrhosis– Colitis

Assessing Skin Turgor

• Best evaluated by gently pinching a fold of the abdominal skin

• Indication of state of hydration and nutrition

• Skin that retains “tenting” after it’s pinched indicates:– Dehydration– Malnutrition

Normal range is broad. Consider other factors…

External Clues to internal Problems

External Clues to Internal Problems

• Faun tail nevus

– Tuft of hair overlying the spinal column usually in the lumbosacral area

– Associated with spina bifida occulta

External Clues to Internal Problems

• Café au lait spots

– Evenly pigmented (>5 mm diameter)

– Light, dark brown, or black in dark skin

– Present at birth or shortly thereafter

Café au lait spots may be related to:– Neurofibromatosis– Pulmonary stenosis– Temporal lobe dysrhythmia– Tuberous sclerosis

Suspect neurofibromatosis if you note: >5 patches with diameters >1cm in a

child under 5

External Clues to Internal Problems

• Freckling in the axillary or inguinal area

– May occur in conjunctionwith café au lait spots

– Associated with neurofibromatosis

External Clues to Internal Problems

• Facial port-wine stainWhen it involves the opthalmic division of the trigeminal nerve it may be associated with:• Sturge-Weber syndrome

– seizures

• Occular defects

External Clues to Internal Problems

• Supernumerary nipples– Especially in the presence of other

minor abnormalities…•associated with renal

abnormalities

Common Conditions

• Milia– Small white discrete papules on the

face (bridge of the nose)

– Plugged sebaceous glands

– Common during the first 2-3 months

Heat rash (miliaria)Allergic reaction

• Miliaria aka “Prickly Heat”(crystaline)– Caused by occlusion of sweat

ducts during periods of heat and high humidity

• Diaper rash– Over the buttocks and anogenitals

• acid urine output• yeast

• Eczematous rash

Typical sites of eczema

Younger children• Face, elbow, knees

Older children & adults• Hands, neck, inner

elbows, back of knees, ankles

• Face (less often)

• Ring worm– Tinea corporis– Tinea capitis

Most common vector?

• Seborrheic Dermatitis– Chronic, recurrent erythematous

scaling eruption– Areas dense with sebaceous glands

• Scalp, back, intertriginous, & diaper areas

“Cradle Cap”– Scalp Lesions are scaling, adherent,

thick, yellow, and crusted– Can spread over the ear and down

the nape of the neck

• Impetigo– Highly contagious Staph.

or Strep. infection– Honey colored crusts

– Causes pruritis, burning, and regional lymphadenpathy

• Strawberry hemangioma

Birth: often not present or noticeable1-2 months: becomes noticeable1-6 months: grows most rapidly12-18 months: begins to shrink

• Trichotillomania– Excessive emotional stress– Obsessive Compulsive Disorder