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ORIGINAL ARTICLE
Year : 2022 | Volume
: 42
| Issue : 2 | Page : 115-126
An observational study of infant dermatoses at a tertiary care health center in Delhi region
Amen Dhillon DNB Dermatology; , Ajay Chopra
Department of Dermatology, Base Hospital, Delhi Cantt, Delhi, India
Correspondence Address:
Amen Dhillon
86/21, Kirby Place, Delhi Cantt, Delhi 110010
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ejdv.ejdv_21_21
Objectives To know the prevalence and clinical patterns of infant dermatosis at a tertiary care referral institute.
Patients and methods The present observational cross-sectional study was carried out on 508 neonates and infants with physiological and pathological skin conditions from August 1, 2018 to February 1, 2020. A standard study proforma was used to obtain detailed systemic and dermatological findings. Data entry was done in MS Excel, and data analysis was carried out using Statistical Package for Social Sciences, version 22.0.
Results The common dermatoses were bacterial infection [folliculitis (29.03%) and staphylococcal scalded skin syndrome (19.35%)], fungal infections [candidal intertrigo (41.67%) and pityriasis versicolor (37.50%)], developmental abnormalities [accessory tragi (21.43%), anencephaly (14.29%), and cleft lip (14.29%)], diaper area eruptions [diaper dermatitis (81.82%), atopic dermatitis (45.92%), hemangiomas: infantile congenital hemangioma (60.87%) and nevus simplex/stork bite (21.74%)], hyperpigmentation disorders [Café-au-lait (44.44%) and congenital melanocytic nevi (22.22%)], hypopigmentation disorder [pityriasis alba (42.31%)], iatrogenic/traumatic disorders [Stevens-Johnson syndrome (40%)], immunologic disorders [insect bite hypersensitivity (41.18%) and acute urticaria (29.41%)], and transient benign disorders [Mongolian spots (23.28%) and Lanugo (14.29%)].
Conclusion Physiological dermatoses are transient and self-resolving and need to be differentiated from the pathological ones for management and parents’ reassurance. The pathological dermatoses are caused most commonly by infections and infestation, which warrants a clean and hygienic living. Owing to wide variety, burden, and public health problem of cutaneous dermatoses in infants, the current data can be useful in creating awareness among the dermatologists, pediatricians, and the health care system.
Keywords: dermatoses, infant, pathological, physiological
Infancy lasts from birth up to 1 year of age, which includes neonatal period of first 28 days [1],[2]. There is an abrupt transition from the intrauterine life to the external environment during this time period [3]. Neonatal skin plays a vital role in the transition of newborn from an aqueous to an air-dominant environment. It gives physical protection and also aides in fluid balance, thermoregulation, and immunosurveillance [3].
An infant skin differs from that of the adult as it is thinner, has less hair, has weaker intercellular attachments, and even produces lesser sweat and sebaceous gland secretions [4].
Most skin disorders occur in the infancy, some of which may be transient and self-resolving whereas others may require treatment [3].
Skin diseases have a reported incidence varying between 9 and 37% and hence they are common in the pediatric population across the world. However, there are insufficient data regarding pediatric health-seeking behavior in India. The incidence of several dermatologic conditions in infants varies according to race, geographic locations, age, climate, hygiene, nutrition, socioeconomic conditions, and heredity [2].
The dermatosis incidence in neonates is frequent and varies from 96 to 99.3% of all newborn babies, and this may vary from benign diseases to life-threatening ones [3]. The pediatric age group forms a sizeable percentage of patients at the dermatology OPD [5], and this demands a review of the infant dermatoses separately [2].
Erythema toxicum neonatorum (ETN), miliaria, and physiological desquamation are a few of the commonly encountered benign and transient lesions during the neonatal period and last for first few days of life, and some others such as Mongolian spots and hemangiomas might remain for many months. These conditions may cause anxiety and concern among the parents to seek medical advice, though they are harmless. A few other conditions could be congenital anomalies, pigmentary birthmarks, cutaneous signs of internal disease, or a pathological condition like epidermolysis bullosa [6].
The number of pediatric patients with skin diseases has been increasing recently. A large proportion of patients present in an advanced course of the disease owing to lack of education, lack of proper sanitation, social backwardness, lack of rural health care facilities, and overcrowded hospitals. In spite of this, parents are getting increasingly aware about pediatric dermatoses [2].
Although very little is known about variations and activity of the skin in neonates, a lot has yet to be reported regarding many disorders that are peculiar to the skin of infants. Therefore, this study was conducted to analyze the clinical spectrum of infant dermatoses.
Various studies have been conducted to understand dermatosis patterns among older and school-going children from varied parts of India, but not much data are available on infant dermatosis from India. To counsel the parents for prevention and also to make available the optimal therapy to the patients, it is a must to know the prevalence, clinical patterns, and factors responsible for dermatosis in infants.
Patients and methodsThe present observational cross-sectional study was carried out on 508 neonates and infants who attended the OPD of Department of Dermatology and Venereology and Department of Pediatrics of a tertiary care hospital, New Delhi, from August 1, 2018 to February 1, 2020. Institute ethical committee clearance was obtained before the study was begun. An informed written consent was obtained from either of the parent/guardian of the study infants, before including them in the study.
The sample size estimation was based on previous research studies [7] assessing the prevalence and pattern of various physiological and pathological dermatoses occurring in neonates and infants attending OPD. The prevalence found in these articles ranges from 10 to 60%. Therefore, assuming P=20% as the prevalence of various physiological and pathological dermatoses with 5% margin of error, the minimum required sample size at 5% level of significance was calculated to be 245 patients. However, to make the study more significant, a sample size of 500 was taken. Convenient nonprobability sampling technique was applied to select patients for the study for all those who are eligible to participate.
The study included all children below the age of 1 year with physiological and pathological skin conditions. All critically ill patients were excluded from the study.
A standard study proforma was used to obtain a comprehensive demographic and clinical history about the mother and the child, comprising of age, sex, parity, gestational age of the mother, duration of illness, and type and extent of skin lesions. The relevant family history and ante-partum history of the mother were obtained. A detailed systemic and dermatological examination was carried out and recorded in a standard proforma.
Special investigations were carried out wherever necessary, which included skin biopsy for specific lesions, skin scrapings and KOH mount for fungus, special stains for histopathology, and dermoscopy.
Statistical analysis
Means and proportions were calculated for continuous and categorical variables, respectively. Data entry was carried out in MS Excel 2013, and data analysis was carried out in SPSS (Statistical Package for Social Sciences (SPSS); IBM, Chicago, USA), version 22.0.
ResultsOf 508 children enrolled in the study, 352 (69.30%) were infants and 156 (30.70%) were neonates. Total boys were 298 (58.70%) and girls were 210 (41.30%). Overall, 93.90% were term babies, 5.30% were preterm, and four (0.80%) were postterm babies. Most mothers (59.40%) were in the age group of 21–25 years, followed by 21.10% in 26–30-year age group. Overall, 59.60% of the mothers were primipara and 40.40% were multipara. Moreover, 82.10% of the babies were delivered through vaginal delivery and 17.90% by lower segment Cesarian section (LSCS). Consanguinity of parents’ marriage was present in 13.20% of the babies ([Table 1]).
The most common types of bacterial infection were folliculitis (29.03%) and staphylococcal scalded skin syndrome (19.35%). Other bacterial infections were bullous impetigo, impetigo, periporitis, necrotizing fasciitis, carbuncle, and miscellaneous infections. The most common type of fungal infections included candidal intertrigo (41.67%) and pityriasis versicolor (37.50%). Other viral infections were tinea capitis, oral candidiasis, and tinea corporis.
Type of viral infections present in most of the babies were Hand, Foot, and Mouth Disease (HFMD) (45.83%) and Gianotti Crosti syndrome (16.67%); other infections were chicken pox (12.50%), molluscum contagiosum (12.50%), herpes zoster (8.33%), and herpetic gingivostomatitis (4.17%). Blistering diseases present in babies included epidermolysis bullosa (60.00%), chronic bullous disorder of childhood (30.00%), and paederus dermatitis (10.00%).
The most common types of developmental abnormalities present in babies were accessory tragi (21.43%), anencephaly (14.29%), and cleft lip (14.29%). Other developmental abnormalities were vulvomegaly, ectodermal dysplasia, ectopia vesicae, hydrocephalus, pseudotail, supernumerary digits, and umbilical granuloma.
Among diaper area eruptions, diaper dermatitis was present in 81.82% babies, and infantile gluteal granuloma and lichen sclerosus in 9.09% of the babies each. Atopic dermatitis was the most common eczematous disorder present in 45.92% of the babies, followed by seborrheic dermatitis (41.84%) and atopic dermatitis with postinflammatory hypopigmentation (8.16%). Other eczematous disorders were irritant contact dermatitis and perianal dermatitis.
Alopecia areata and brittle nails were present in 66.67 and 33.33% of the babies, respectively. Among hemangiomas and other vascular disorders, most common included infantile congenital hemangioma (60.87%) and nevus simplex/stork bite (21.74%). Others included port wine stain, angioma serpiginosum, and lymphangioma circumscriptum.
The most common hyperpigmentation disorders were Café-au-lait (44.44%) and congenital melanocytic nevi (22.22%); others were linear and whorled nevoid hypermelanosis, verrucous epidermal nevi, and incontinentia pigmenti. Pityriasis alba was the most common hypopigmentation disorder (42.31%) followed by nevus depigmentosus (23.08%). Others were vitiligo, hypomelanosis of Ito, chemical leukoderma to kajal, and albinism.
Most common iatrogenic and traumatic disorders were Stevens-Johnson syndrome present in 40.00% babies and BCG adenitis, necrotizing fasciitis after IV calcium, and postburn scar in 20.00% of the babies each. Acrodermatitis enteropathica and Flaky paint dermatoses were present in 75.00 and 25.00% of the babies, respectively.
Among immunologic, reactive, and purpuric disorders, most common were insect bite hypersensitivity (41.18%) and acute urticaria (29.41%). Others were papular urticaria, angioedema, bullous insect bite reaction, hemorrhagic edema of infancy, and urticarial vasculitis.
Lichen striatus and lichen planus were present in 85.71 and 14.29% of the babies, respectively. Among transient benign disorders, the most common were Mongolian spots (23.28%) and lanugo (14.29%); others included ETN, sebaceous hyperplasia, xerosis, neonatal milia, neonatal acne, miliaria rubra, vernix, miliaria crystalline, lingua villosa nigra, horizontal linear hyperpigmentation, and neonatal pustular dermatoses.
Other disorders included phakomatosis pigmentovascularis in two (22.22%) babies, and collodion baby/lamellar ichthyosis, congenital ichthyosiform erythroderma, ichthyosis, xeroderma pigmentosum, ectodermal dysplasia, nevus sebaceous syndrome, and Bart syndrome in one (11.11%) baby each ([Table 2]).
Some representative cases of infant dermatoses have been shown in [Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6],[Figure 7],[Figure 8],[Figure 9],[Figure 10],[Figure 11],[Figure 12],[Figure 13],[Figure 14],[Figure 15],[Figure 16],[Figure 17].
Figure 1 Bacterial infections: a case of SSSS. SSSS, staphylococcal scalded skin syndrome.
Figure 9 Disorders of keratinization: congenital ichthyosiform erythroderma. Discussion Dermatoses are a major health problem in the infancy and associated with significant morbidity [8],[9],[10],[11],[12]. The physiological and transitory nature of some of the skin diseases in the infancy age group must be identified and differentiated from the pathological lesions. It must be explained to the parents that such lesions resolve without treatment, and one needs not to worry about them.
In our study, transient (physiological) dermatoses comprised 33.07% and pathological dermatoses comprised 66.93% of the cases. The incidence of physiological dermatoses was comparable to other Indian studies by Jawade et al. [12] (39.69%), but significantly less than the Indian studies by Baruah et al. [13] (93%), Nobbay and Chakrabarty [14], (69%), Kulkarni and Singh [15], (72%), and Patel et al. [16] (78%). This was because Jawade et al. [12] included children from neonatal age to 14 years of age, and other studies included only neonatal population. Second, owing to wide variations in the ecology of the Delhi region and other areas, the incidence of such dermatoses may widely differ among studies. Other factors may include genetic background, socioeconomic status, living conditions, and medical resources [5].
Compared with the Indian prevalence, international literature shows wide variations. A study from Hungary [11] reports 52.2% prevalence of physiological dermatoses, whereas a study from Mexico reports a prevalence rate of 43.48% for physiological dermatoses among infants [17].
As transient (physiological) dermatoses majorly arise in the neonatal age group [8],[9],[10],[11] and except for Mongolian spots, which may persist for 9 months, others usually subside without treatment in the first month of life. Owing to this, in our study, Mongolian spots was the commonest infant dermatoses (23.28%), as we included neonates and infants (up to age of 1 year). Our findings were in line with the Indian studies by Pandit and Udaya [10] (n=150) and Shivakumar et al. [8] (n=104), where Mongolian spots was the most common dermatosis, as seen in 27.3 and 33% of the neonates. The incidence of Mongolian spots has shown variation in India from 9.16% [12] up to 42.5% [9]. In contrast, the infants of Mexico showed miliaria to be the commonest (132 infants, 37.67%) [17]. This shows that there may be a slight shift in the dermatoses from eastern to western society.
The second common transient dermatosis was lanugo (14.29%). In Shivakumar et al. [8], lanugo was observed in five (4.8%) of 104 neonates, and the incidence of lanugo hair ranged from 7 to 14.6% [4],[14],[18].
ETN was seen in 11.11% of the infants in our study, which was slightly less than that reported by Jawade et al. (India) [12] (12.97%) and Ábrahám et al. [11] (Hungary) (22.76%). ETN is one of the common transient disorders in newborn presenting as an erythematous macule, papule, or pustule, requiring no intervention. Its incidence varies from 1.3 to 40.8% as seen among Indian and Australian studies [11],[12],[19],[20],[21], which may be varied owing to different modes of delivery whether vaginal or cesarean [22], parity status of the mother [23],[24], sex of the baby [23], and gestational age and weight of the baby [11]. This suggests that ETN can be a result of the immunological response of the skin to microbiological colonization [11].
Among other physiological dermatoses, gland disorders comprising of xerosis (11.64%) and sebaceous hyperplasia (11.11%) were the common dermatoses, followed by milia (6.88%), neonatal acne (6.35%), and miliaria (1.59%). Jawade et al. [12], noted milia in 9.92% of the cases and Ábrahám et al. [11] in 2.71% of the cases. In Jawade et al. [12], miliaria was the second most common condition noted (11.45%), whose incidence may vary from 2.6 to 9.6% as seen in Australian and American studies [21],[25],[26]. One of the Mexican studies showed miliaria to be in high prevalence among the infants (132 infants, 37.67%) [17].
The infectious causes of dermatosis comprised of a major proportion among the pathological dermatoses. It included bacterial (6.1%), fungal (4.72%), viral (4.72%), and parasitic infestations, including scabies (2.9%). This was common in a Mexican study which reported scabies as the commonest infestation (16.1%) [17].
Among other Indian studies, infections and infestation etiology was seen in 35.6–85.2% of childhood dermatosis [27],[28]. Behera et al. [9] reported an incidence of 3.5% bacterial, 2% fungal, and 0.8% viral among the neonates. In the study by Dogra and Kumar [29], 11.4% of the disorders were of infectious etiology.
Similar to our study, bacterial infections have been common as seen in the studies by Patel et al. [16] (24.9%), Thappa [30] (25.64%), and Behera et al. [9] (3.5%). Though not seen in many studies [8],[9],[10], we found more serious infectious dermatoses, such as staphylococcal scalded skin syndrome, which require in-patient immediate management.
Fungal infections on the contrary are mainly in older age group children as was seen in 8.65% of the cases in the study by Jawade et al. [12]. It is also linked with the humid environment and the living conditions of the family. Candida infection was the commonest in our study. Among other studies, fungal infection was found in 7.81% of the cases in Patel et al. [16] and Thappa [30] (8.49%). In two of the international studies (Thailand and others) [31],[32], tinea capitis was the most common fungal infection. Recently, the fungal infections have been on an increase owing to the use of over-the-counter steroids and antifungals, which are responsible for the increasing antifungal resistance. In addition, fungal culture takes around 28 days of reporting, which becomes troublesome for the parents to wait for their children.
Among the viral causes, hand-foot-and-mouth disease (45.83%) was the commonest, which is typically a benign and common self-limiting childhood disease, caused by enterovirus and characterized by rapidly ulcerating vesicles in the mouth and lesions, usually vesicular, on the hands and feet. It is reported among all age groups of children. In one of the studies in Singapore, its incidence was 9–10% among infants (<1 year) [33]. Few Indian studies found molluscum contagiosum as the most common of all viral infections [12],[34], whereas some reported warts as the commonest among, including a study conducted in Switzerland [16],[35]; both of these were less commonly seen in our study.
Among the infections, scabies was the least common in our study. In Jawade et al. [12] and a few other studies [36],[37],[38], scabies was the commonest infection (9.92%), the reason being the studies were done on the family of neonates who belonged to a poor socio−economic status, whereas the present study was conducted in a tertiary care hospital of Delhi, where infants of all strata attended the hospital, accounting for a lower incidence of scabies.
Seborrheic dermatitis was found in 7.63% of neonates, as finding comparable with that in the studies by Patel et al. [16] and Dash et al. [4].
Among the eczematous disorders, atopic dermatitis and seborrheic dermatitis was seen in 8.8 and 8% of the neonates, respectively. In Jawade et al. [12], seborrheic dermatitis was found in 3.60% of the study population, mainly in more than 1-month to 1-year age group and atopic dermatitis in 4.27% neonates. Atopy is rather more common in developed countries, where the incidence ranges from 3 to 28% [39],[40],[41],[42]. We found a higher incidence of atopic dermatitis, as our tertiary center (a referral center) catered to wide regions showing different climate, dietary habits, genetics, or other unknown factors.
Among the pigmentation disorders, pityriasis alba was common, as seen in 11 (2.1%) neonates. In Jawade et al. [12], pityriasis alba was found in 4.16% of the cases. Pityriasis alba is usually seen in the older age group owing to irregular and inadequate food habits and worm infestation, and thus, their study reported a slightly higher incidence.
Hemangiomas and other vascular disorders were seen in 23 neonates. In the study by Behera et al. [9], hemangiomas were seen in five neonates.
We also found a single case each of ichthyosis, collodion baby, and xeroderma pigmentosum. Genodermatoses as seen in our study were also reported by Pandit and Udaya [10]. Keratinization disorders such as ichthyosis (1.45%) and palmoplantar keratoderma (1.12%) were also reported by Jawade et al. [12].
ConclusionThe study represents the physiological and pathological dermatoses among neonates and infants. Physiological dermatoses are transient and self-resolving and need to be differentiated from the pathological ones for management and parents’ reassurance. The pathological dermatoses are caused most commonly by infections and infestation, which warrants a clean and hygienic living. Owing to wide variety, burden, and public health problem of cutaneous dermatoses in infants, the current data can be useful in creating awareness among the dermatologists, pediatricians, and the health care system.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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