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Physical Assessment > Neonatal Skin > Flashcards

Neonatal Skin Flashcards

1
Q

What are the functions of the skin?

A
  • physiologic and immunologic protection
  • heat regulation
  • sense perception
  • self cleaning
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2
Q

What is the top layer of skin?

A

epidermis

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3
Q

Describe the epidermis.

A

comprised of 5 layers; stratum corneum is the top layer; made up of dead cells, constantly being replaced

lower layers are comprised of keratin- forming cells and melanocytes

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4
Q

Where is the dermis located and what elements does it contain?

A

directly under the epidermis; contains fibrous tissue, elastic tissue, sweat glands, sebacceous glands and hair shafts

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5
Q

What is the fx of subcutaneous fat?

A
  • insulation
  • protection for internal organs
  • calorie storage
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6
Q

How does neonatal skin differ from adult skin?

A
  • less mature = less mature function
  • immature infant = thinner, more permeable
  • fibrils more fragile
  • stratum corneum is thinner
  • sweat glands- adult fx by 2-3mo of life
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7
Q

Describe the sweating function in neonates.

A

limited < 36 week GA, ability increases with postnatal age; sweating on forehead- check for hyperthermia, CHD

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8
Q

What is vernix caseosa?

A

sebacceous gland secretions and exfoliated skin cells; coats skin until 37-38th wk

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9
Q

What is the differential dx of yellow vernix?

A
  • passage of mec
  • hgb break down r/t chronic abruption
  • hgb break down r/t hemolytic disease
  • chorio
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10
Q

When does lanugo appear and disappear?

A

starts @ 20 weeks- gone by 40

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11
Q

What might a sacral hair tuft indicate?

A

a tethered cord

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12
Q

What is a lesion?

A

area of altered tissue

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13
Q

What is a macule?

A

discolored, flat spot < 1cm in diameter that is not palpable

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14
Q

What is a patch?

A

a macule > 1cm in diameter

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15
Q

What is a papule?

A

an elevated, palpable lesion, solid and circumscribed,

< 1cm in diameter

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16
Q

What is a plaque?

A

an elevated, palpable lesion with circumscribed borders

> 1 cm or a fusion of several papules

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17
Q

What is a vesicle?

A

an elevation of the skin filled with serous fluid & < 1cm in diameter; ex: blister

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18
Q

What is a bulla?

A

vesicle > 1cm in diameter

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19
Q

What are petechiae?

A

small, purplish hemorrhagic, pin point size point

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20
Q

What are purpura?

A

small hemorrhagic spot larger than petechiae, 1-3cm in size

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21
Q

What is ecchymosis?

A

large area of subepidermal hemorrhage- does not blanch; a mogolian spot doesn’t blanch but is differentiated from a bruise because it does not change color over time

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22
Q

What is a pustule?

A

an elevation of the skin filled with cloudy or purulent fluid

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23
Q

What is a cyst?

A

raised palpable lesion with fluid or semi soft filled sac; can be drained

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24
Q

What is a nodule?

A

an elevated palpable lesion with indistinct borders- can palpate below the skin; can NOT be drained; mobile lesion

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25
Q

What is a crust?

A

a lesion of dried serous exudate, blood or pus

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26
Q

What is a wheal?

A

a collection of fluid in dermis that appears as a reddened, solid elevation; ex: allergic reaction

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27
Q

What can account for petichae on the neck?

A

nuchal cord

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28
Q

What factors can influence the findings of a thorough skin exam?

A
  • approach (organized and consistent)
  • history
  • L&D experience ( forceps, vacuum, nuchal cord, etc)
  • environment ( lighting, temp of room, heat source)
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29
Q

How should skin be examined?

A

1) undress the infant
2) use same pattern of examination
3) start at head and progress downward
4) turn infant to examine the back
5) inspect all skin folds, including axillae & groin
6) inspect color, moisture, thickness & opacity of skin
7) turgor- hydration and nutrition
8) note size, color and placement of any lesions
9) note hair distribution

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30
Q

How should skin be described?

A

elastic, fragile, good recoil, etcc

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31
Q

What can palpation of the skin reveal?

A
  • examine the underlying dermis
  • determine thickness of the skin
  • subcutaneous fat
  • presence of edema
  • irregularities in texture and consistency
  • helps to determine skize or configuration of lesions
  • blanching- take away coloring by hgb and can observe whats underneath (ex petichae or jaundice)
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32
Q

How should most neonatal lesions be interpreted?

A

most lesions are benign and transient

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33
Q

Why does harlequin color change appear?

A

due to immature autonomic nervous system

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34
Q

What is erythema neonatorum?

A
  • generalized hyperemia
  • occurs in the first few hours post birth
  • resolves in minutes up to one hour
  • indicates successful completion of fetal to neonatal circultion
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35
Q

What accounts for an infant with plethora coloring?

A
  • check hematocrit (>65% = polycythemia)

- monitor hypoglycemia and RDS

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36
Q

Why is plethora a risk factor for hypoglycemia?

A

only fuel for RBCs is glucose; polycythemia monopolizes glucose in the serum

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37
Q

What accounts for an infant with acrocyanotic coloring?

A

bluish discoloration of hands and feet, present at birth; persists up to 48h of life and is exacerbated by low environmental temp; mucous membranes are pink

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38
Q

What accounts for an infant with circumoral cyanosis coloring?

A

more pronounced in the first 12-24h after birth; also seen with feeding which resolves after feeding; can be a normal finding in fair infants and is simply the blue color of the veins below the skin in this area

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39
Q

At what level of hgb desaturation for cyanosis to be present?

A

3-5gm/dL (~ sats of 70%)

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40
Q

What is the correlation between hypoxia and cyanosis?

A

terms aren’t mutually exclusive; what is important is the concentration of oxygenated hemoglobin

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41
Q

What is jaundice?

A

yellow coloring of the skin & sclera; deposits of bile pigment in the skin r/t hyperbilirubinemia; pay attention to age of infant & degree of jaundice present
*Always pathologic if seen in 1st 24h

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42
Q

How does jaundice progress in the infant?

A

general rule: first appears on the face, then progresses to the toes as levels rise; cephalocaudal progression

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43
Q

What is the risk for sick babies and hyperbili?

A

sick babies permit bili to cross the blood brain barrier much more readily

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44
Q

What does yellow jaundice indicate?

A

jaundice due to indirect or unconjugated hyperbili

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45
Q

How does the amount of subQ fat influence the presentation of jaundice?

A

amount of subQ fat influences progression in color; chubby babies don’t appear as jaundiced

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46
Q

What does the appearance of jaundice in the sclera indicate?

A

deposition in sclera indicates a bili level >10mg/dL

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47
Q

What is the relative serum bili level when an infant’s face is jaundiced?

A

4.8-8 mg/dL

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48
Q

What is the relative serum bili level when an infant’s chest to the umbilicus are jaundiced?

A

5.5-12 mg/dL

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49
Q

What is the relative serum bili level when an infant’s groin and thighs are jaundiced?

A

8-16.5 mg/dL

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50
Q

What is the relative serum bili level when an infant’s legs are jaundiced?

A

11-18 mg/dL

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51
Q

What is the relative serum bili level when an infant’s palms and soles are jaundiced?

A

> 15 mg/dL

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52
Q

Why is skin color assessment s/p phototherapy an unreliable assessment?

A

after being on bili lights, it’s impossible to determine jaundice based on skin color & lights bleach the skin

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53
Q

How does jaundice d/y direct or conjugated hyperbilirubinemia present?

A

green/ brown; direct bili babies take much longer to correct

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54
Q

What is cutis marmorata?

A

bluish mottling or marbling of skin

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55
Q

When is cutis marmorata present?

A

seen in response to chilling, stress or overstimulation caused by dilation of capillaries & vessels; should disappear when infant is warmed; persistent in trisomy 21 & 18

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56
Q

What is the most common newborn benign rash?

A

erythema toxicum; 30-70% of term infants; rarely seen in preterms

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57
Q

What is the peak incidence of erythema toxicum?

A

24-48h but can occur up to 3 months of age; duration is typically a few hours to several days; resolves spontaneoulsy

58
Q

Where can erythema toxicum be found?

A

found on any part of the body; disappears and reappears moments or hours later on a different body area

59
Q

What causes erythema toxicum?

A

cause is unknown; possible immune reaction, possible inflammatory response

60
Q

How is erythema toxicum diagnosed?

A

visual recognition

61
Q

How does erythema toxicum present?

A

1) urticaria neonatorum “flea bit dermatitis”; small, white or yellow papules or vesicles with an erythematous base
2) vesicular lesions: look like pustules, no inflammation around them

62
Q

How is erythema toxicum differentiated from herpes?

A

herpes generally has a more clustered and vesicular appearance; scraping of a lesion can be done and fluid examined under microscope for definitive dx

63
Q

What will the examination of erythema toxicum scrapings reveal?

A

erythema toxicum lesions will show eosinophils on gram stain; eosinophils are present in allergic reactions

64
Q

What will the examination of herpes scrapings reveal?

A

positive direct fluorescent antibody test; positive Tzanck smear (giant multinucleated cells)

65
Q

How do herpetic lesions present in the newborn?

A
  • may appear at birth as lesions or eroded skin
  • may not appear until day 7-10
  • appears virulent; herpes can involve the skin, CNS or dissemenated (CNS & dissemenated may present w/o lesions)
66
Q

What are milia?

A

multiple yellow or pearly white papules about 1mm in size

67
Q

Where are milia usually located?

A

found on brow, cheeks, nose in up to 40% of newborns; if in mouth = epstein’s pearls or bohn’s nodules (rice like kernels on gums)

68
Q

What causes milia?

A

keratin- filled epithelial cysts; resolve spontaneously in first few weeks

69
Q

What is subaceous gland hyperplasia?

A

numerous tiny (< 0.5mm) white or yellow papules found on nose, cheeks and upper lip

70
Q

What causes the appearance of subaceous gland hyperplasia?

A

maternal androgenic stimulation (testosterone) androgen exposure in utero; spontaneously resolve after birth; no tx req’d

71
Q

How can milia and subaceous gland hyperplasia be differentiated?

A

SGH lesions are more yellow in contrast to milia

72
Q

What is the etiology of milliaria?

A

obstruction of sweat ducts due to excessively warm, humid environment; sweat ducts are immature and easily obstructed; classified as 1 of 4 types depending on severity

73
Q

Where do milliaria present?

A

seen over forehead, on scalp and in skin folds

74
Q

What is the appearance of Miliaria Crystallina- type I?

A

clear, thin vesicles, 1-2mm in diameter; no inflammation around them

75
Q

Where do Miliaria Crystallina develop?

A

in the epidermal portion of the sweat gland; typically present on the head and chest

76
Q

How do Milia differ from Miliaria Crystallina?

A

lesions lack opacity and they appear later

77
Q

What is the appearance of Miliaria Rubra- type II?

A

appears as small erythematous papules

78
Q

What is the etiology of Miliaria Rubra?

A

prolonged obstruction of the ducts of the sweat glands leading to: 1) release of sweat into adjacent tissue 2) accompanied by prickly sensation

79
Q

What is the etiology of Miliaria Pustulosa- type III?

A

progressive occlusion caused by:

1) leukocyte infiltration of papule
2) if not resolved, secondary infection can occur in deeper part of sweat gland
3) leads to Type IV- Miliaria Profunda

80
Q

How is Miliaria treated?

A

eliminate source, eliminate extreme heat/ humidity… keep

81
Q

What are some of the most common pigmented lesions?

A

1) hyperpigmented macule “mongolian spot”
2) transient neonatal pustular melanosis
3) pigmented nevus
4) cafe au lait patches

82
Q

In what populations are hyperpigmented macule mongolian spots observed?

A

90% of AA, Asian & Hispanic infants

10% caucasian

83
Q

Describe mongolian spots.

A

grey or blue-green in color; commonly present on buttocks, flanks or shoulders; Document size and location to avoid later suspicion of NAT

84
Q

What is the etiology of mongolian spots?

A

melanocytes that infiltrate the dermis; fade over the first 3 years as skin darkens- may persist into adulthood.

85
Q

What is transient neonatal pustular melanosis?

A

superficial, vesiculopustular lesions; vesicles rupture in 12-48 hours leaving small pigmented macules; macules are surrounded by very fine white scales; look like pustules, but when lanced are dry inside

86
Q

When is transient neonatal pustular melanosis alarming?

A

when present at birth

87
Q

Where do transient neonatal pustular melanosis typically present?

A

seen most often in clusters under chin, neck, lower back and extremities; most common in AA babies

88
Q

What is the long term prognosis for transient neonatal pustular melanosis?

A

usually regree in 1-2 months; may remain for up to 3 months; hyperpigmented area blends as the surrounding tissue darkens

89
Q

How do transient neonatal pustular melanosis present on gram stain?

A

numerous neutrophils

90
Q

What is the etiology and treatment available for transient neonatal pustular melanosis?

A

etiology unknown, benign- no treatment is necessary

91
Q

Describe the pigmented nevus.

A

dark brown or black macule; commonly present on lower back or buttocks (can occur anywhere)

92
Q

Why are hairy pigmented nevi concerning?

A

10% hairy pigmented nevi become malignant melanomas; can become basal cell carcinomas or melanomas

93
Q

How should pigmented nevus be treated?

A

generally benign- malignant changes can occur in up to 10% of infants; observe closely for changes in size and shape

94
Q

What is the potential progression of a hairy pigmented nevus?

A

pigmentation increases in 1st year> plastic surgery by 5 years of age > risk of cancer as an adult

95
Q

What percentage of multiple pigmented nevi are malignant?

A

10-15%

96
Q

What is concerning about the neurocutaneous melanosis sequence?

A

can be a/w sz and mental deterioration

97
Q

What is the typical presentation of junctional nevus?

A

flat, superficial; excessive melanocytes at dermal- epidermal junction; usually benign if present at birth

98
Q

What changes occur with a sebaceous nevus during puberty?

A

become larger d/t sensitivity to andrgoens and become more wart like; carry an increased risk of becoming malignant

99
Q

What is an epidermal nevus?

A

proliferations of the epidermis and papillary dermis; usually unilateral following Blaschko lines in linear configurations on limbs

100
Q

What are Blaschko lines?

A

skin lines are invisible under normal condition; believed to trace embryonic skin cell migration

101
Q

What other anomalies are epidermal nevus associated with?

A

CNS, bone and eye anomalies, more likely in those with extensive lesions

102
Q

Describe cafe as lait patches.

A

tan or light brown macules or patches with well defined borders; 19% of normal children have one; it is common to have 1-3

103
Q

What are the implications of cafe au lait patches?

A

when < 3 cm in length & < 6 in number, no pathologic significance; larger spots & > 6in # may indicate neurofibromatosis (90% of patient, can be a spontaneous mutation)

104
Q

What are skin lesions a/w trauma?

A
  • scratches
  • forceps marks
  • subQ fat necrosis
  • bruising
  • petechiae
  • sucking blisters
  • scalp lesions
105
Q

How do forcep marks present?

A

seen on cheeks, scalp and face; red or bruised area where forceps were applied

106
Q

What should be assessed for when forceps were used to facilitate a delivery?

A

assess for other complications such as facial palsy, fractured clavicles or skull fractures

107
Q

How do subQ fat necrosis spots present?

A

subcutaneous nodule- hard, non pitting and sharply circumscribed; appears during 1st week of life, grows larger over several days then resolves over several weeks

108
Q

What causes subQ fat necrosis?

A

trauma, cold or asphyxia

109
Q

Why might hypercalcemia occur with subQ fat necrosis?

A

more likely if more than one lesion; releases calcium from damaged cells

110
Q

What calcium level is preferred to be checked?

A

iCa: biological, active conjugated calcium- what is available for use; total Ca- total #, no helpful dx

111
Q

Describe sucking blisters.

A

vesicles or bullae; appear on lips, fingers or hands; may be intact or ruptured; no tx req’d

112
Q

What is the cause of a sucking blister?

A

vigorous sucking; can occur in utero

113
Q

What can cause a scalp lesion?

A

trauma during delivery, insertion of scalp electrodes or scalp pH sampling

114
Q

How does a scalp lesion present and how should it be treated?

A

presents as an abrasion or laceration; keep area clear & dry & observe for secondary infx

115
Q

What are the 4 types of vascular skin lesions?

A

1) nevus simplex
2) nevus flammeus (port wine stain)
3) strawberry hemangioma
4) cavernous hemangioma

116
Q

How is a nevus simplex described?

A

“stork bite” or “salmon patch”- most common birthmark; seen in up to 50% of all newborns; irregular bordered pink macule composed of dilated, distended capillaries- BLANCH with pressure, more prominent with crying

117
Q

Where can nevus simplex be observed?

A

found at nape of neck, forehead, eyelids, bridge of nose or upper lip; fade by 2 years of life, if on nape of neck, may persist

118
Q

Describe a nevus flammeus (port wine stain).

A
  • flat pink or reddish purple lesion consisting of dilated, congested capillaries directly below the epidermis
  • has sharply delineated edges and DOES NOT BLANCH with pressure
  • does not grow in size or spontaneously resolve
119
Q

Where can nevus flammeus be observed?

A
  • may be small or cover up to 1/2 of the body
  • usually unilateral but may cross midline
  • most often on face, but can be anywhere
120
Q

How are nevus flammeus lesions treated?

A

laser therapy is needed to eliminate or reduce

121
Q

How does a nevus flammeus lesion present in Sturge-Weber syndrome?

A

port wine stain presents in the trigeminal region, may have sensory defects as well

122
Q

Describe a strawberry hemangioma lesion.

A
  • bright red, raised, lobulated tumor
  • soft & compressible with sharply demarcated margins
  • occur in up to 10% of newborns
  • can have more than one (can be internal)
  • gradually increase in size for 6 months, then regress (will turn grey and then involute)
  • surrounding skin will blanch
123
Q

Where can strawberry hemangioma lesions be observed?

A
  • occur on the head, trunk or extremities

- 20-30% present at birth, remainder present by 6 months

124
Q

What causes a strawberry hemangioma lesion?

A

dilated capillaries with endothelial proliferation in the dermal and dub dermal layers, may ulcerate

125
Q

What are common complications of strawberry hemangiomas?

A

bleeding, ulceration, infection and compression of underlying organs

126
Q

How can strawberry hemangiomas be treated?

A
  • propanolol

- can be lasered off in beginning stages (flat and macular) and stop the evolution not the hemangioma

127
Q

Describe the cavernous hemangioma.

A
  • similar to the strawberry hemangioma
  • larger, more mature vascular elements lined with endothelial cells and involves the dermis and subQ tissue
  • skin is bush red in color
  • soft, compressible with poorly defined borders
128
Q

How should cavernous hemangiomas be treated?

A

increase in size during first 6-12 months, disappear spontaneously

  • no tx unless interfering with vital functions
  • tx with systemic corticosteroids
129
Q

The presence of cavernous hemangiomas are a/w which 2 syndromes?

A

1) Kasabach- Merritt

2) Klippel- Trenaunay- Weber

130
Q

What should be closely monitored in an infant with Kasabch- Merritt syndrome with a cavernous hemangioma?

A
  • thrombocytopenia r/t plt sequestration

- consumption of fibrinogen and coagulation factors

131
Q

What are the defining characteristics of Kippel- Trenaunay- Weber syndrome?

A
  • increased blood flow and malformed vessels in extremities = hypertrophy of limb (bone and soft tissue)
  • rare
  • incidence is higher in Males
132
Q

Describe neurocutaneous lesions.

A

tuberous sclerosis- “white leaf” macules

133
Q

What is the etiology of blueberry muffin lesions?

A
  • secondary to maternal CMV, Rubella

- extramedullary hematopoiesis (blood formed outside the medulla of the bone)

134
Q

Of what concern is a neonatal lupus and thrombocytopenia rash?

A

benign rash, goes away in 6 months

135
Q

What are the 4 stages of incontinentia pigmenti skin lesions?

A

1) vesicular
2) verrucous
3) hyperpigmented
4) atrophic/ hypopigmented

136
Q

Describe incontinentia pigmenti skin lesions.

A

lesions follow Blaschko lines; F>M; males usually don’t survive

137
Q

What is neurofibromatosis?

A
  • autosomal dominant disorder
  • tumors of various sizes form on peripheral nerves
  • cranial nerves may also be affected
  • 90% of neurofibromatosis patients will have cafe au lair spots
  • neurofibromas (small skin - colored nodules) may be present at birth or may not appear until adolescence
138
Q

What is Tuberous Sclerosis?

A
  • hereditary disorder
  • characterized by cutaneous and central nervous system tumors
  • p/w sz, developmental delays and behavioral problems
  • “ash leaf”- if more than 3 are present, further eval is req’d
  • most often present on trunk and buttocks
139
Q

What is Sturge- Weber syndrome?

A
  • disorder causes a proliferation of endothelial cells, particularly in the small blood vessels
  • intracerebral calcifications and atrophic changes may be present
  • p/w sz, MR, hemiparesis and glaucoma
140
Q

What syndromes should be suspected with the absence or atrophy of the nails?

A
  • trisomy 13
  • trisomy 18
  • Turner syndrome

Physical Assessment (11 decks)

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