|Year : 2015 | Volume
| Issue : 1 | Page : 8-12
The incidence of birthmarks in neonates born in Zanjan, Iran
P Khoshnevisasl1, M Sadeghzadeh2, S Mazloomzadeh3, A Azizi Zanjani4
1 Department of Pediatrics, Ayatollah Moussavi Hospital, School of Medicine, Zanjan University of Medical Sciences, Social Determinants of Health Research Center, Zanjan, Iran
2 Department of Pediatrics, Ayatollah Moussavi Hospital, School of Medicine, Zanjan University of Medical Sciences, Zanjan Metabolic Disease Research Center, Zanjan, Iran
3 Department of epidemiology School of Medicine, Zanjan University of Medical Sciences, Social Determinants of Health Research Center, Zanjan, Iran
4 Department of Pediatrics, Ayatollah Moussavi Hospital, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
|Date of Web Publication||10-Feb-2015|
No 773, Apt. #5 Third Floor, Faz-e-Yek Shahrak Karmandan, 4513985455 Zanjan
Source of Support: This project was financially supported by the
Research vice councilor of Zanjan University of Medical Sciences, Conflict of Interest: None
Introduction: Skin manifestations are common in neonates. Most of them are considered transient. It is important to differentiate these lesions from pathologic ones to avoid unnecessary diagnostic or therapeutic procedures. The present study was designed to evaluate the frequency of skin manifestations and its related factors in neonates born in Zanjan, Iran. Materials and Methods: All neonates born in the teaching Moussavi hospital in Zanjan, Iran from December 2010 to July 2011were examined for skin manifestations. The influences of variables such as gestational age, gender, route of delivery, skin and hair color, placental status, history of drugs used by mother and neonatal age by hours were evaluated. Data were collected by using SPSS software 16 and Statistical analysis was performed by Chi-squared test. Results: Five hundred neonates were examined. In 95.6% at least one lesion was found. The most common skin lesions were epstein pearl (60.4%) and Mongolian spot (56%) respectively. Mongolian spot was related significantly to gestational age and black hair color (P = 0.03). Epstein Pearl was significantly related to normal delivery (P = 0.02). There were a significant relationship between sebaceous hyperplasia and increasing gestational age (P = 0.004), and erythema toxicum was significantly related to cesarean section (P = 0.02). Conclusion: In this study the incidence of skin manifestations and epstein pearl were similar to other studies. We found significant relationship between epstein pearl and erythema toxicum with type of delivery. Sebaceous hyperplasia and Mongolian spot were related to gestational age.
Keywords: Birthmark, cutaneous lesions, dermatosis, neonate, skin manifestations
|How to cite this article:|
Khoshnevisasl P, Sadeghzadeh M, Mazloomzadeh S, Zanjani A A. The incidence of birthmarks in neonates born in Zanjan, Iran. J Clin Neonatol 2015;4:8-12
|How to cite this URL:|
Khoshnevisasl P, Sadeghzadeh M, Mazloomzadeh S, Zanjani A A. The incidence of birthmarks in neonates born in Zanjan, Iran. J Clin Neonatol [serial online] 2015 [cited 2020 May 26];4:8-12. Available from: http://www.jcnonweb.com/text.asp?2015/4/1/8/151158
| Introductio|| |
The neonatal period is the first 4 weeks of life.  In this period the newborns are at a high risk of infection which is partly due to the skin characteristics  the development of skin, the largest organ of the body, begins in the first gestational week and continues until 8-10 weeks after birth.  Neonatal skin is different from adult skin;  since it is 40-60% thinner with lesser amount of sweat glands and weaker intercellular attachments , the stratum corneum of the skin which is a protective barrier with 10-20 cellular layers in adults, is thinner in preterm neonates with only 2-3 layers and 0.9 mm thickness. Furthermore neonatal skin is alkaline at birth and develops to acidic pH in 4 days that is important for normal stratum corneum formation. The acidic pH of the skin will form later in preterm newborns.  The important roles of skin consist of mechanical protection, thermoregulation, fluid balance and immunosurveillance. , These functions are partly due to the intact mature stratum corneum. The compromised development of stratum corneum is responsible for skin manifestations.  Most of the cutaneous lesions which are common in neonates ,, are considered physiologic and transient,  but there are also grossly pathologic lesions that are of a great concern. It is important to differentiate these lesions from physiologic ones to provide appropriate counseling to parents  and avoid unnecessary diagnostic or therapeutic procedures.  It should be considered that some lesions such as epidermolysis bullosa need genetic counseling and family planning. , On the other hand, the influence of race has been also studied and its role in the prevalence of birthmarks is well documented. , Furthermore geographic region and maternal factors influence the prevalence of a large amount of skin manifestations. ,,
Considering that neonatal skin lesions have not been studied in Zanjan, in northwest Iran, the present study was designed to evaluate the frequency of skin manifestations and its related factors in neonates born in this region. Skin manifestations in newborns consist of physiological conditions, transient eruptions, cutaneous infections, birthmarks and inherited disorders.  Since in many studies, ,,,,,,, birthmarks and skin lesions are studied with transient mucosal lesions such as epstein pearl, we decided to check all these skin manifestations in our neonates and mention all the lesions diagnosed.
| Materials and methods|| |
This cross sectional study was carried out in the Department of Pediatrics of Zanjan Ayatollah Moussavi Hospital. This hospital is the sole referral and teaching pediatrics Hospital of Zanjan University of Medical Sciences in Zanjan province in Iran. The sample size calculated by the formula based on P = 0.5, a = 0.05 and d = 0.05. A total of 500 newborns, born in obstetrics ward, from December 2010 to July 2011, were randomly enrolled in this study and examined for skin manifestations. The inclusion criteria consisted of healthy full term neonates born in Ayatollah Moussavi hospital, newborns with <3 days of life, and willing to participate in the study. The exclusion criteria consisted of neonates with gross congenital malformations and those admitted in sick neonatal ward or Neonatal Intensive Care Unit.
Each case was fully undressed and the entire skin surface, including palms, soles, nails, genitalia, scalp, and the oral cavity was examined by a pediatrician. Suspicious lesions were consulted by a dermatologist. All diagnoses were made on clinical impression and skin biopsies were not required based on the discretion of the dermatologist. The data were collected and documented. Variables such as gestational age, gender, route of delivery, skin and hair color, placental status, history of drugs used by mother and neonatal age by hours were recorded for each baby. The local Ethical Committee approved the study, and parental consent was taken prior to enrollment into the study.
Values were expressed as numbers and percentages. Comparisons for categorical variables were performed by Chi-square test. Logistic regression models were used to estimate the Odds Ratios (ORs) for the association between neonatal skin lesions and other variables. A P < 0.05 was considered as statistically significant. Analysis of the data was carried out using SPSS 16.0 (SPSS Inc., Chicago, IL, USA).
| Results|| |
Among 500 examined healthy newborns, there were 265 (53%) boys and 237 (47%) girls. The range of birth weight was between 1760 and 4450 g with the mean of 3109.63. Two hundred and thirty-nine (47.8%) were born by cesarean section and 261 (52.2%) were vaginally delivered. Twenty one (4.2%) mothers had a history of drug usage during pregnancy including levothyroxine, salbutamol, seretide, ranitidine, carbamazepine, insulin, fluticasone, methyl dopa and morphine. Only one baby had placenta previa and the rest of newborns had normal placentas. Twenty-one neonates (4.2%) had blond hair. Nine babies required dermatologist consultation.
Of 500 examined neonates, 95.6% had at least one lesion. The most common skin lesions were epstein pearl (60.4%) and mongolian spot (56%) respectively. The frequency of birthmarks is shown in [Table 1].
|Table 1: The frequency and percentage of skin manifestations in zanjanian neonates |
Click here to view
One hundred fifty seven (65.7%) cases who were vaginally delivered had epstein pearl whereas this lesion was seen in 55.6% of cesarean section deliveries (P = 0.02). Mongolian spot was more frequent in neonates with black hair color (P = 0.03). It was also seen in 135 (56.5%) neonates with more than 40 weeks of gestational age and this relationship was statistically significant (P = 0.03). Sebaceous hyperplasia was significantly related to maturity (P = 0.004). Although milia was seen in 41.9% of boys and 43.4%of girls, and salmon patch in 23.4% of boys and 26% of girls, we did not find a statistically significant relationship between milia, salmon patch, hair tufts and our variables. Thirty-seven (15.5%) vaginally delivered babies and 61 (23.4%) babies born by cesarean section had erythema toxicom, this relationship was statistically significant (P = 0.02).
All newborns in our study had similar race therefore there was not any difference in this aspect. The frequency of different neonatal skin lesions based on variables have been shown in [Table 2].
| Discussion|| |
Of 500 examined neonates, 95.6% had at least one lesion. The most common skin lesions were epstein pearl (60.4%) and Mongolian spot (56%) respectively. the frequency of skin manifestations in our study is similar to other studies. ,,,, In the study of El-Moneim et al. it was surprisingly lower (40%) with Mongolian spot being the most common birthmark  also the study of Ekiz et al. stated that the prevalence of skin lesions was lower in Turkish newborns (67.3%) and this was explained by racial and geographic diversity.  Howbeit study design, the inclusion criteria and the time of examination can explain the diversity of different studies.
Epstein pearl was the most common skin lesion (60.4%) in our study as it was in some other studies ,,, but some authors didn't mention it, this may be due to the fact that they didn't examined the oral mucosa. We found a significant relationship between epstein pearl and vaginal delivery. There were a significant relationship between epstein pearl and gestational age in the study of Gokdemir et al. and Moussavi et al. , Our study was carried out in obstetrical ward and postterm and preterm neonates might have been admitted in neonatal ward. This fact could explain the difference in the results of our study.
The second common finding in the present study was Mongolian spot (56%) which was similar to some studies. ,,,, In some studies it was the most frequent lesion ,,, but in the studies in Turkey and Egypt ,, it was much less frequent. This finding confirms the fact that Mongolian spot is more frequent in non-European races. ,,
In our study, Mongolian spot had a significant relationship with gestational age and hair color but not with sex, placental abnormality, drug usage and type of delivery. Our results were similar to the study of Ferahbas et al.  who found that Mongolian spot was related with gestational age and had not a relationship with sex and type of delivery. Egemen et al. in his study in turkey revealed the same results regarding hair color and sex  and Gokdemir et al. showed that it was not significantly related with gender and mode of delivery.  The relation between Mongolian spot and hair color may be due to its relation with race which is mentioned in many studies. This issue is more emphasized in the study of Sachdeva et al. and Chatproedprai and Wananukul who stated Mongolian spot has higher incidence in African ancestry and Asiatic babies. ,
Sebaceous hyperplasia was the third frequent skin lesion found in our neonates. Similar frequencies was stated in other investigations. ,, although it was the most frequent lesion in some studies , comparing to preadolescent children, sebum secretion rates are high in neonates which reflects the stimulation of this gland by placentally transferred maternal androgen, particularly by dehydroepiandrosterone.  In the present study sebaceous hyperplasia was significantly related to gestational age (P = 0.004) which is similar to the study of Ferahbas et al. and Moosavi et al. , We didn't found its relation with sex as was mentioned in the study of Gokdemir et al., Al-Dahiyat et al. and Ahsan et al. ,, In the study of Sachdeva et al. Sebaceous hyperplasia was more common in vaginal delivery and babies with weight more than 2500 g. 
Milia was the fourth most frequent finding in our study as well as the others. , In the two other studies in Iran , it was the seventh and sixth frequent lesion respectively. In the study of Ferahbas et al. and Kanada et al. , it was in only 1.4% and 8% of neonates respectively. In our study milia was not related to any of the variables although in Gokdemir's et al. study  it was significantly seen in females.
Salmon patch was seen in 24.6% of our newborns, which was like some other studies ,, and was less frequent in two studies in Turkey. , These results may suggest its relation with race or geographic area. In our study although salmon patch was more frequent in higher gestational age infants, it wasn't significantly related to any of our variables. In other studies it was related to female sex ,, and term neonates ,, and maternal age. 
Erythema toxicum, was the 6 th frequent skin lesion but it's frequency was different in many studies ,,,,, that may be due to its transient Character and difference in the visit time and its frequency in Caucasian race. In literatures we found many relations with this lesion like gestational age, , race ,, cesarean section  but in our study it was only related to cesarean section. These data are similar to the study of Ekiz et al.  that may be due to an increased rate of cesarean section in both countries.
| Conclusion|| |
In this study, the most common skin lesion were epstein pearl (60.4%) and Mongolian spot (56%) respectively. We found a significant relationship between epstein pearl and vaginal delivery and meanwhile Mongolian spot was significantly related with gestational age and hair color. In the present study sebaceous hyperplasia, the third common lesion was significantly related to gestational age, salmon patch was more frequent in higher gestational age and Erythema toxicum was only related to cesarean section.
| Acknowledgments|| |
This project was a thesis for a medical degree and was founded by the Research Department of Zanjan University of Medical Sciences and the Ethical Committee of Zanjan University of Medical Sciences has approved this study. We greatly appreciate all participants in this study .
| References|| |
Ekiz O, Gül U, Mollamahmutoglu L, Gönül M. Skin findings in newborns and their relationship with maternal factors: Observational research. Ann Dermatol 2013;25:1-4.
Cuenca AG, Wynn JL, Moldawer LL, Levy O. Role of innate immunity in neonatal infection. Am J Perinatol 2013;30:105-12.
Jackson A. Time to review newborn skincare. Infant 2008;4:168-71.
Brzezinski P. Dermatology of neonatal period - Skin diseases undemanding of treatment. Przegl Lek 2009;66:535-7.
Haveri FT, Inamadar AC. A cross-sectional prospective study of cutaneous lesions in newborn. ISRN Dermatol 2014;2014:360590.
Mogre DA. Generalised staphylococcal pustulosis in a neonate: A case report. Australas Med J 2013;6:532-5.
Ferahbas A, Utas S, Akcakus M, Gunes T, Mistik S. Prevalence of cutaneous findings in hospitalized neonates: A prospective observational study. Pediatr Dermatol 2009;26:139-42.
Conlon JD, Drolet BA. Skin lesions in the neonate. Pediatr Clin North Am 2004;51:863-88, vii.
Gokdemir G, Erdogan HK, Köslü A, Baksu B. Cutaneous lesions in Turkish neonates born in a teaching hospital. Indian J Dermatol Venereol Leprol 2009;75:638.
Moosavi Z, Hosseini T. One-year survey of cutaneous lesions in 1000 consecutive Iranian newborns. Pediatr Dermatol 2006;23:61-3.
Shajari H, Shajari A, Sajadian N, Habiby M. The incidence of birthmarks in Iranian neonates. Acta Med Iran 2007;45:424-6.
Al-Dahiyat KA. Neonatal skin lesion in Jordan, study of consecutive 500 neonates at king Hussein medical center. Calicut Med J 2006;4:e1-3.
Shih IH, Lin JY, Chen CH, Hong HS. A birthmark survey in 500 newborns: Clinical observation in two northern Taiwan medical center nurseries. Chang Gung Med J 2007;30:220-5.
Ahsan U, Zaman T, Rashid T, Jahangir M. Cutaneous manifestations in 1000 Pakistani newborns. J Pak Assoc Dermatol 2010;20:199-205.
Monteagudo B, Labandeira J, León-Muiños E, Carballeira I, Corrales A, Cabanillas M, et al.
Prevalence of birthmarks and transient skin lesions in 1,000 Spanish newborns. Actas Dermosifiliogr 2011;102:264-9.
Agarwal G, Kumar V, Ahmad S, Goel K, Goel P, Prakash A, et al
. A study on neonatal dermatosis in a tertiary care hospital of Western Uttar Pradesh India. J Community Med Health Educ 2012;2:169. http://dx.doi.org/10.4172/2161-0711.1000169.
Magana M, Velerio J, Mateo A, Magana LM. Skin lesion in two cohorts of newborns in Mexico city. Bol Med Hosp Infant Mex 2005; 62(2);62:122-3.
El-Moneim AA, El-Dawela RE. Survey of skin disorders in newborns: Clinical observation in an Egyptian medical centre nursery. East Mediterr Health J 2012;18:49-55.
Onayemi O, Adejuyigbe EA, Torimiro SE, Oyelami O, Jegede OA. Prevalence of Mongolian spots in Nigerian children in Ile-Ife, Nigeria. Niger J Med 2001;10:121-3.
Sachdeva M, Kaur S, Nagpal M, Dewan SP. Cutaneous lesions in new born. Indian J Dermatol Venereol Leprol 2002;68:334-7.
Chaithirayanon S, Chunharas A. A survey of birthmarks and cutaneous skin lesions in newborns. J Med Assoc Thai 2013;96 Suppl 1:S49-53.
Boccardi D, Menni S, Ferraroni M, Stival G, Bernardo L, La Vecchia C, et al.
Birthmarks and transient skin lesions in newborns and their relationship to maternal factors: A preliminary report from northern Italy. Dermatology 2007;215:53-8.
Zagne V, Fernandes NC. Dermatoses in the first 72 h of life: A clinical and statistical survey. Indian J Dermatol Venereol Leprol 2011;77:470-6.
Egemen A, Ikizoglu T, Ergör S, Mete Asar G, Yilmaz O. Frequency and characteristics of mongolian spots among Turkish children in Aegean region. Turk J Pediatr 2006;48:232-6.
Chatproedprai S, Wananukul S. Survey of common cutaneous lesions in healthy infants at the well baby clinic. J Med Assoc Thai 2008;91:1356-9.
Kanada KN, Merin MR, Munden A, Friedlander SF. A prospective study of cutaneous findings in newborns in the United States: Correlation with race, ethnicity, and gestational status using updated classification and nomenclature. J Pediatr 2012;161:240-5.
Lorenz S, Maier C, Segerer H, Landthaler M, Hohenleutner U. Skin changes in newborn infants in the first 5 days of life. Hautarzt 2000;51:396-400.
[Table 1], [Table 2]