Skin, Hair, and Nails Adapted from Mosby’s Guide to Physical Examination, 6 th Ed. Ch. 8

Newborn Vernix caseosa –Mixture of sebum and cornified epidermis covers the infant’s body at birth –Whitish, moist, cheeselike substance –Protective

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 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

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 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 conjunction with café au lait spots –Associated with neurofibromatosis

External Clues to Internal Problems Facial port-wine stain When 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 noticeable 1-2 months: becomes noticeable 1-6 months: grows most rapidly months: begins to shrink

Trichotillomania –Excessive emotional stress –Obsessive Compulsive Disorder