So your precious new bundle of joy suddenly has red bumps on her face, thick greasy scale clumped throughout her hair, and a few spots that look like grandpa's skin, too. Baby's delicate skin is prone to a wide array of conditions, just like adults. With infants, however, not only is some of this due to heredity, such as birth marks, but some rashes ike cradle cap are due to continued maternal hormones circulating throughout the baby's blood stream. Those early sleepless nights are difficult enough without wondering what is happening to your child's skin, so acquaint yourself with the most common skin concerns of infancy.

BABY ACNE (ACNE NEONATORUM)

Baby acne is just that, acne lesions that form on the baby's face sometime in the second or third month of life and lasts usually 4-6 weeks or so. Acne neonatorum is a result of the maternal hormones that continue to circulate in the baby's bloodstream after birth, stimulating the sebaceous glands. There are some studies that suggest that infants who experience really severe infantile acne may have more problems with acne in their teenage years.

Baby acne may include red bumps, pustules or even blackheads. I have a good friend that mistook the normal baby acne of her first-born which looked like red bumps on the face as a drug allergy to an antibiotic given for an ear infection. Not familiar with baby acne and living away from family, she rushed the baby off to the ER. Of course we laugh about it now, but she was very frightened at the time.

Another friend had given birth to her first child during the winter time and had her wrapped under several layers of clothing and had the bassinette near the fire place. Sure enough, the baby developed a full blown case of acne within a few days. Over heating is a flare factor with respect to baby acne. While it is certainly important to keep your newborn warm and out of drafts, don't go overboard indoors with heavy clothing and blankets.

My typical approach is to simply clean the skin with a very mild cleanser and allow Mother Nature to resolve the situation. Rarely, I have to resort to using OTC products such as low potency benzyl peroxide or prescription acne products, such as in the case of a 3 month old infant I once saw as a patient who had a severe case of blackheads.

CRADLE CAP (SEBORRHEA)

Thick, greasy scale on the baby's scalp is another condition that is the result of the maternal hormones still circulating in the baby's system. Seborrheic dermatitis of infancy often presents itself at the third month of life and may last a few weeks. Some infants have minor scale that easily rinses out with No Tears baby shampoo, while others require more aggressive treatment to eradicate this greasy mess.

My newborn had such thick scale that would rub off onto clothing or furniture, that I finally took matters into my own hands. I wasn't about to deal with that for weeks on end, nor was I going to continue to listen to concerned family about why the dermatologist's child had such a bad skin condition. Remember, typically it is the parents who are bothered by most transient baby skin conditions, not the baby. I have found that gently rubbing Robathol Bath Oil onto the scalp, followed by gentle combing of the scale will help remove the scale before shampooing.

In rare instances, I have used some OTC zinc or salicylic acid based dandruff shampoos for newborns, or some very mild % - 1% hydrocortisone cream to the area to help improve the situation quickly. You must make absolutely certain that these products do not get into the baby's eyes!

Seborrhea may also affect the face, primarily the eyebrows and around the nose. I often use Cetaphil Gentle Skin Cleanser and Cetaphil Moisturizing Cream or Cetaphil Moisturizing Lotion for routine skin care, and rarely have to use some % -1% hydrocortisone cream (Cortaid Advanced Maximum Strength Cream) on these areas. I don't recommend using the cortisone or zinc/salicylic acid based shampoos without first asking your doctor about these options.

STORK BITES

Stork bites are the result of dilated small blood vessels knowon as capillaries that are located within the dermis. This is considered a remnant of fetal circulation. Stork bites are the most common vascular formation seen in newborns, affecting anywhere from 30-40% of babies. Most often thought of at the base of the scalp and nape of the neck, but they can also arise on the eyelids, globella (area between the eyebrows), as well as on the nose, on the philtrum (the depressed area between the nose and the upper lip), and the chin.

Speaking from personal experience, these can be quite shocking at birth. My daughter's were so widespread and swollen I thought initially they might actually be hemangiomas, a more permanent vascular lesion. However, the good news is that facial stork bites do fade away over the course of the first year of life. Those on the back of the scalp and neck don't always fade, but eventually they become hidden by hair. True to statistics, this is how my daughter's stork bites have resolved.

No treatment is required for stork bites, just understanding and patience.

CAF AU LAIT SPOTS

These innocuous, light brown stains are actually hereditary pigmented lesions. They aren't technically moles or freckles. Cafe au lait spots often have an irregular border. Interestingly enough, they are not usually present at birth but present within the first few months to a year of life. While it's not unusual to have a caf au lait spot (they can be seen in up to 20% of people) these can be an indication of internal disease when they are numerous or large. Diseases, such as neurofibromatosis or tuberous sclerosis, may be accompanied by 6 or more caf au lait spots and the lesions are often larger than centimeter in diameter in children. For adults, 1.5 centimeters in diameter for multiple cafe au lait spots is a warning sign.

Cafe au lait spots may respond to bleaching agents, although often the pigment is located within the dermis (as opposed to more superficial pigment within the epidermis as seen with freckles). When this is true, many times bleaches or microdermabrasion will not resolve them. I would not recommend the use of bleaching agents in early childhood. However, if you do want to keep the spots less noticeable, I would encourage sun protection. Just like melasma, moles or freckles, the more sun exposure a cafe au lait spot receives, the darker the lesion may become.

Caf au lait spots are a funny thing. My son looke just like my baby pictures when he was an infant. But he happened to have a caf au lait spot in the exact location and the same unusual shape as one my husband has. This is obviously a hereditary trait and certainly one that made my husband quite happy in those early years when my son looked like my carbon copy!

BIRTH MARKS (GIANT CONGENITAL NEVI)

Nothing is as concerning or controversial as the giant congenital nevus (GCN). These nevi may be present at birth or develop shortly in the first year of life. GCN are a subset of moles that are more prone to developing malignant melanoma.

The rule of thumb is that they are greater in 1.5 centimeters. The closer to the midline, such as the spinal area and/or the more irregularly bordered or colored, the more concerning the lesion. Not all of these moles turn into melanoma. The lifetime rate of developing into a melanoma is approximately 5%.

Removal of the lesion is often advocated especially if it's not going to be a cosmetically devastating defect, or if it's in a relatively easy area to remove. The more lax the skin of the area, the easier the removal. Generally, if the lesion isn't immediately medically suspicious, I try to wait until the child is older before removing the mole. When children reach puberty, the risk of melanoma increases, primarily due to the change of hormones.

"Bathing trunk" nevi are extremely large GCN overlying the lower back or sacral area that are more concerning. Not only do these have an increased risk of developing melanoma, they may be associated with central nervous system abnormalities. This is called neurocutaneous melanosis and is often seen in the first 2 years of life. Many of these lesions are so large or in areas requiring flaps/grafts/ or tissue expansion, so I often work with a pediatric plastic surgeon in treating these children.

As with all moles and the risk of skin cancer, it is vitally important to protect your children from the effects of sun damage. After the age of 6 months, the use of sunscreen with an SPF of 15+ that protects against both UVA and UVB wavelengths of light on a DAILY basis is important. So is the use of sun protective clothing, Sun Guard Laundry Treatment UV Protectant, hats and sunglasses.

APLASIA CUTIS CONGENITA

This unusual condition in which the skin fails to grow together during pregnancy is seen in a significant minority of newborns. Most commonly found on the scalp, it represents a failure of the skin to close during embryonic development. At birth, a superficial midline wound or even a healed scar may be seen. As the area is void of normal skin tissue, no appendages such as hair will grow in this area. There may be a single or multiple areas affected, however, the vast majority are single defects.

Aplasia Cutis Congenita is not a hereditary condition. Medical evaluation normally tries to differentiate it from birthing complications such as the use of forceps or scalp electrodes.

Treatment is aimed at keeping any open areas clean and free of infection. I have seen these areas take anywhere from a few weeks to a few months to fully heal, depending upon the extent of the area affected.

When the areas are healed, the scar is often innocuous and the areas on the scalp are typically hidden by the growth of hair surrounding the area.

There are many other skin conditions related to newborns and infancy, some common, some rare. I have found that there are many pediatricians who are up on their dermatology. But if you find your doctor is unfamiliar with a certain skin lesion or your baby's rash is not responding as expected, ask to be referred to a dermatologist.

Thank you for taking the time to read my article. I hope you have found it informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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