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
• b-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
Allergic reaction
Heat rash (miliaria)
• 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
12-18 months: begins to shrink
• Trichotillomania
– Excessive emotional stress
– Obsessive Compulsive Disorder