Newborn Skin Part II
Newborn Skin Part II
Newborn Skin Part II
Birthmarks
Katherine A. M. Snyder, MD, Mosaic Community Health–Madras Health Center, Madras, Oregon
Adam D. Voelckers, MD, University of Pittsburgh Medical Center, Lititz Family Medicine Residency Program, Lititz, Pennsylvania
Birthmarks in newborns can be classified as vascular, melanocytic or pigmented, or markers of underlying developmental
abnormalities of the nervous system. A nevus simplex is a benign capillary malformation. Newborns with a nevus flammeus
can be safely treated before one year of age with a pulsed dye laser to reduce the visibility of lesions. Infantile hemangiomas
should be treated with systemic beta blockers if there is a risk of life-threatening complications, functional impairment,
ulceration, underlying abnormalities, permanent scarring, or alteration of anatomic landmarks. Dermal melanocytosis is a
benign finding that is easily recognized and does not warrant further evaluation. A solitary congenital melanocytic nevus
that is less than 20 cm in diameter may be observed in primary care;children with larger or multiple nevi should be referred
to pediatric dermatology due to the risk of melanoma. Newborns with skin markers of occult spinal dysraphism (other than a
simple, solitary dimple) should have lumbar spine imaging using ultrasonography or magnetic resonance imaging. (Am Fam
Physician. 2024;109(3):217-221. Copyright © 2024 American Academy of Family Physicians.)
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NEWBORN SKIN: BIRTHMARKS
SORT:KEY RECOMMENDATIONS FOR PRACTICE
Evidence
Clinical recommendation rating Comments
Newborns with a nevus flammeus that involves the forehead should be C Expert consensus statement
referred for ophthalmologic and neurologic evaluations.4
For infantile hemangiomas that have high-risk features, propranolol at a A Cochrane review
dosage of 2 to 3 mg per kg per day is the most effective treatment.10,15
Patients with a solitary congenital melanocytic nevus with a projected size C Expert opinion
of greater than 20 cm in any dimension or multiple congenital melanocytic
nevi of any size should be referred to dermatology.18
Newborns with lumbosacral findings such as hypertrichosis, hemangiomas, B Prospective and retrospec-
or a subcutaneous mass (e.g., lipoma) or caudal appendage, and those with tive clinical case reviews and a
multiple lumbosacral skin abnormalities should be evaluated for occult spi- cost-effectiveness analysis model
nal dysraphism with ultrasonography or magnetic resonance imaging. 21,23-25
Newborns with a solitary, atypical lumbosacral dimple should be evaluated B Prospective and retrospec-
for occult spinal dysraphism using ultrasonography. 21,23-25 tive clinical case reviews and a
cost-effectiveness analysis model
FIGURE 1 FIGURE 2
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NEWBORN SKIN: BIRTHMARKS
starts by 12 months of age and lesions disappear by four gestational age or in older infants with poor social support
years of age in 80% of children.10 or cardiovascular or respiratory comorbidities.10 Adverse
Most hemangiomas are benign and do not require treat- effects of propranolol include changes in sleep, acrocyanosis,
ment. High-risk features are those that increase potential bronchial irritation, gastrointestinal symptoms, hypoten-
for life-threatening complications, functional impairment, sion, bradycardia, or hypoglycemia.9,10 Propranolol adminis-
ulceration, underlying abnormalities, permanent scarring, tration with or after feeding and withholding the medication
or alteration of anatomic landmarks. Hemangiomas on during times of reduced intake or vomiting can lower the
the face or anterior neck can be associated with functional risk of treatment-associated hypoglycemia. Systemic or
impairment of feeding or vision or, if they are associated intralesional corticosteroids and topical timolol are alterna-
with airway hemangiomas, life-threatening complications. tives to propranolol.10
The presence of five or more hemangiomas increases the
likelihood of hepatic hemangioma, which rarely can lead to Melanocytic Lesions
high-output heart failure. Hemangiomas in the perineum, Melanocytic or pigmented lesions are caused by displaced
gluteal cleft, or lumbosacral area can be associated with melanocytes, such as those in dermal melanocytosis, or
occult spinal dysraphism or LUMBAR (lower body heman- atypical growth of melanocytes, such as those in congenital
gioma, urogenital abnormalities/ulceration, myelopathy, melanocytic nevi.
bony deformities, anorectal malformations/arterial anom-
alies, and rectal anomalies) syndrome. Hemangiomas with
a diameter greater than 5 cm that involve the face or scalp
can be an indicator of PHACE (posterior fossa anomalies, FIGURE 3
hemangioma, arterial anomalies, cardiac anomalies, and eye
anomalies) syndrome. Hemangiomas located over the axilla,
much of the face, or diaper area have the potential for per-
manent scarring or alteration of key anatomic landmarks.
Urgent referral to a hemangioma specialist is recommended
if any high-risk features are present.10 The Infantile Heman-
gioma Referral Score screening tool (https://w ww.ihscoring.
com) reliably identifies infantile hemangiomas that require
referral, can be used quickly by primary care physicians, and
has good interrater reliability between expert and nonex-
pert users.12,13
Imaging should be performed if there is concern for
associated anatomic abnormalities. Abdominal Doppler
ultrasonography is indicated in children with five or more
cutaneous hemangiomas or if there is concern for LUMBAR
syndrome. Infants should be evaluated for occult spinal
dysraphism if hemangiomas are present in the perineum,
gluteal cleft, or lumbosacral area. Magnetic resonance angi-
ography of the head and neck should be performed if there is
concern for PHACE syndrome.10
Success rates are significantly higher if treatment is started
before 10 weeks of age, and current guidelines recommend
starting by one month of age.10,14 Systemic beta blockers
are the treatment of choice, specifically propranolol, 2 to
3 mg per kg per day.10 This is supported by moderate-qual-
ity evidence, with a number needed to treat of 2 vs. placebo
for clearance of hemangiomas.15 Propranolol is superior to
systemic atenolol in the rate of complete response;how- Dermal melanocytosis is characterized by benign,
ever, propranolol is associated with significantly more hyperpigmented macules primarily found in the lum-
adverse effects.16 Treatment should be initiated in the inpa- bosacral and gluteal regions.
tient setting for infants younger than five weeks’ corrected
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FIGURE 4 TABLE 1
Hemangioma
Hypertrichosis
Subcutaneous mass
(e.g., lipoma)
Congenital melanocytic nevus on the lower Any two skin findings Ultrasonography or mag-
extremity. netic resonance imaging
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NEWBORN SKIN: BIRTHMARKS
skin findings, suggest an increased risk of occult spinal 4. Sabeti S, Ball KL, Burkhart C, et al. Consensus statement for the man-
agement and treatment of port-wine birthmarks in Sturge-Weber syn-
dysraphisms.20,22,23 drome. JAMA Dermatol. 2021;157(1):98-104.
Ultrasonography and magnetic resonance imaging (MRI) 5. Tran JM, Kelly KM, Drolet BA, et al. Light-based treatment of pediatric
can be used to evaluate newborns with markers of occult spi- port-wine birthmarks. Pediatr Dermatol. 2021;38(2):351-358.
nal dysraphisms (Table 1).20,21,23-25 Although ultrasonography is 6. Chapas AM, Eickhorst K, Geronemus RG. Efficacy of early treatment of
facial port wine stains in newborns:a review of 49 cases. Lasers Surg
more difficult to obtain in newborns after three months of age Med. 2007;39(7):563-568.
due to ossification of the vertebral bodies, MRI requires the 7. Jeon H, Bernstein LJ, Belkin DA, et al. Pulsed dye laser treatment of
use of sedation.21,22 Ultrasonography is cost-effective for initial port-wine stains in infancy without the need for general anesthesia
[published correction appears in JAMA Dermatol. 2019;155(4):504].
evaluation in patients with a solitary atypical dimple, has good JAMA Dermatol. 2019;155(4):435-441.
diagnostic agreement with MRI, and appropriately identifies 8. Shi MD, Yang K, Li SB, et al. Complication rates and safety of pulsed dye
patients with spinal lesions that may require intervention.23-25 laser treatment for port-wine stain:a systematic review and meta-anal-
ysis. Lasers Med Sci. 2023;39(1):16.
In patients with multiple dimples or cutaneous findings other
9. Püttgen KB. Diagnosis and management of infantile hemangiomas.
than dimples that infer a higher risk of a surgical lesion, evalu- Pediatr Clin North Am. 2014;61(2):383-402.
ation with MRI may be a more time efficient and cost-effective 10. Krowchuk DP, Frieden IJ, Mancini AJ, et al.;Subcommittee on the
approach;however, in resource-limited settings, ultrasonog- Management of Infantile Hemangiomas. Clinical practice guideline
for the management of infantile hemangiomas. Pediatrics. 2019;143(1):
raphy is appropriate as initial imaging.21,23,25 Newborns should e20183475.
be referred to neurosurgery for any abnormal imaging find- 11. Fimiani M, Bilenchi R, Mandato F, et al. Neonatal skin disorders. In:
ings or before imaging if there is discharge from any dimple.21 Buonocore G, Bracci R, Weindling M, eds. Neonatology. A Practical
Approach to Neonatal Diseases. 2nd ed. Springer International;2018:
This article updates a previous article on this topic by McLaugh- 2391-2425.
lin, et al. 20 12. Léauté-Labrèze C, Baselga Torres E, Weibel L, et al. The Infantile
Hemangioma Referral Score:a validated tool for physicians. Pediatrics.
Data Sources:A PubMed search was completed using the terms 2020;145(4):e20191628.
nevus simplex, nevus flammeus, infantile hemangiomas, dermal
13. Qiu T, Yang K, Dai S, et al. Analysis of therapeutic decisions for infan-
melanocytosis, congenital melanocytic nevi, markers of spi- tile hemangiomas:a prospective study comparing the Hemangioma
nal dysraphism, and key terms for diagnosis and management. Severity Scale with the Infantile Hemangioma Referral Score. Children
The search included meta-analyses, randomized controlled (Basel). 2022;9(12):1851.
trials, clinical trials, and reviews. The Cochrane database, UpTo- 14. Léauté-Labrèze C, Frieden I, Delarue A. Early initiation of treatment with
Date, Essential Evidence Plus, and the TRIP database were also oral propranolol for infantile hemangioma improves success rate. Pedi-
searched. Search dates:November 2022 to February 2023, May atr Dermatol. 2023;40(2):261-264.
to June 2023, and January 2024. 15. Novoa M, Baselga E, Beltran S, et al. Interventions for infantile haeman-
giomas of the skin. Cochrane Database Syst Rev. 2018;(4):CD006545.
The authors thank the patients’ families who allowed their new- 16. Chen T, Gudipudi R, Nguyen SA, et al. Should propranolol remain the
borns to be photographed for this article. gold standard for treatment of infantile hemangioma? A systematic
review and meta-analysis of propranolol versus atenolol. Ann Otol Rhi-
nol Laryngol. 2023;1 32(3):332-340.
The Authors 17. Dinulos JG, Graham EA. Influence of culture and pigment on skin con-
KATHERINE A. M. SNYDER, MD, is a staff physician and the ditions in children. Pediatr Rev. 1998;19(8):268-275.
clinical medical director at Mosaic Community Health– 18. Jahnke MN, O’Haver J, Gupta D, et al. Care of congenital melanocytic
nevi in newborns and infants:review and management recommenda-
Madras (Ore.) Health Center.
tions. Pediatrics. 2021;148(6):e2021051536.
19. Dinulos JGH. Habif’s Clinical Dermatology:A Color Guide to Diagnosis
ADAM D. VOELCKERS, MD, is a faculty physician at the Uni-
and Therapy. 7th ed. Elsevier;2021.
versity of Pittsburgh Medical Center, Lititz (Pa.) Family Medi-
20. McLaughlin MR, O’Connor NR, Ham P. Newborn skin:part II. Birth-
cine Residency Program.
marks. Am Fam Physician. 2008;7 7(1):56-60.
21. Zywicke HA, Rozzelle CJ. Sacral dimples [published corrections appear
Address correspondence to Katherine A. M. Snyder, MD,
in Pediatr Rev. 2011;32(4):151 and Pediatr Rev. 2011;32(5):207]. Pediatr
Mosaic Community Health, 500 NE A St. Ste. 100, Madras, Rev. 2011;32(3):109-113.
OR 97741 (katie.snyder@mosaicmedical.org). Reprints are not
22. Choi SJ, Yoon HM, Hwang JS, et al. Incidence of occult spinal dysra-
available from the authors. phism among infants with cutaneous stigmata and proportion man-
aged with neurosurgery:a systematic review and meta-analysis. JAMA
Netw Open. 2020;3(7):e207221.
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