Dermatology Review
Clinical Decision Pearls:
Newborn skin findings can cause angst in parents. Learning normal vs not normal is important for reassurance or determining need for further workup. Management is driven by distribution, evolution, and infant appearance, not by the lesion name alone
Normal / Transient Findings
Reassure & Document:
Vernix Caseosa
White, greasy biofilm present at birth. Protective against infection and transepidermal water loss. No intervention required.
Lanugo
Fine hair on shoulders, back, or ears. Common in preterm and term infants. Resolves spontaneously.
Milia
Pinpoint white papules on nose or face caused by keratin retention. Benign and self-limited.
Erythema Toxicum
Erythematous macules and papules with central pustules, typically appearing DOL 1–3. Infant otherwise well. No treatment.
Transient Neonatal Pustular Melanosis
Pustules present at birth that rupture, leaving hyperpigmented macules with collarettes of scale. Pigmentation fades over weeks to months.
Congenital Sacral Dermatosis (Dermal Melanocytosis, formerly called Mongolian Spots)
Blue-gray pigmentation over sacrum/buttocks. Benign. Document size and location to avoid misinterpretation later.
Vascular Lesions
Nevus Flammeus (Salmon Patch)
Pink macular lesions on eyelids, glabella, or nape of neck. Usually fade over months to years. Reassurance only.
Infantile Hemangioma
Superficial (bright red) or deep (bluish) vascular tumors with postnatal growth phase. Escalate if:
- Facial or periorbital location
- Segmental distribution
- 5 cutaneous lesions (consider hepatic hemangiomas)
Port-Wine Stain
Flat, dark red to purple lesion that does not fade.
*Facial lesions in trigeminal distribution:
- Require ophthalmology evaluation and consideration of neurologic referral (Sturge-Weber risk).
Pigmented Lesions
Café-au-Lait Macules
- Light brown, well-circumscribed macules.
Clinical significance:
- ≤2 small lesions: common
- ≥6 lesions or large size: consider genetic evaluation (e.g., NF1)
Petechiae
Non-blanching pinpoint lesions
- Localized, pressure-related petechiae are often benign
- Diffuse, truncal, or progressive petechiae — especially in an ill infant — require evaluation (CBC ± infection workup)
Congenital Skin Defects
Aplasia Cutis Congenita
Focal absence of skin, most commonly on the scalp.
- Escalate if:
- Large lesion
- Midline location
- Visible depth or pulsatility
- → consider imaging for skull or vascular involvement
Umbilical Cord
Normal vs Abnormal Cord Findings
- Normal stump dries and separates spontaneously.
Concerning for omphalitis:
- Erythema extending onto surrounding skin
- Purulent drainage
- Foul odor or systemic symptoms
→ requires prompt evaluation and treatment