Paeds · fetal-neonatal-and-perinatal
Neonatal skin disorders and birthmarks
Also known as Neonatal skin lesions · Vascular birthmarks · Infantile haemangioma · Port-wine stain · Congenital melanocytic naevus · Neonatal pustular dermatoses
Fellowship guide to neonatal skin disorders and birthmarks: triaging benign and transient rashes from the syndromic and serious, the Mulliken–Glowacki biological split of vascular birthmarks, the natural history and propranolol management of infantile haemangioma, the Sturge–Weber and PHACE syndromes, giant congenital melanocytic naevi, midline lumbosacral lesions, and the counselling that reassures most families and escalates the few who need it.
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Red flags
- Facial or segmental haemangioma greater than 5 cm on the face — PHACE syndrome work-up and airway risk
- Port-wine stain of the forehead or upper eyelid (V1) — Sturge–Weber syndrome risk; needs MRI brain and ophthalmology
- Stridor in an infant with a cutaneous haemangioma, especially a beard-distribution lesion — subglottic or airway haemangioma
- Periocular haemangioma — urgent ophthalmology for amblyopia and astigmatism
- Giant congenital melanocytic naevus (projected adult size over 20 cm) — neurocutaneous melanocytosis and melanoma risk
- Midline lumbosacral lesion (dimple, lipoma, hair tuft, deviated gluteal cleft) — occult spinal dysraphism
- Five or more cutaneous haemangiomas — hepatic haemangioma, consumptive hypothyroidism and high-output cardiac failure
- Neonatal blistering or widespread erosion — staphylococcal scalded skin syndrome, herpes simplex, epidermolysis bullosa or incontinentia pigmenti
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Board mappings
- Neonatal and Perinatal Medicine
- General and Community Paediatrics
- Current 2026 PREP curriculum — Learning Objective 1.1.2: Assess and manage the newborn infant with perinatal risk factors
- Current 2026 PREP curriculum — Learning Objective 3.3.1: Recognise and manage common neonatal skin lesions and birthmarks
- Renewed curriculum for first-year trainees from 2027 — Learning goal 5: Clinical assessment – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Clinical management – essential general paediatrics
- Dermatology
- Short Cases
- Communication Stations
- 1. Neonatal medicine: neonatal skin disorders and birthmarks
- 4. Professional skills and knowledge: Patient management
- 5. Early detection and management of acutely ill children
- 7. Patient safety, including safe referral and counselling
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- General Pediatrics Content Outline — Domain 5: Understanding the Neonate
- General Pediatrics Content Outline — Domain 13: Dermatology
- General Pediatrics Content Outline — Universal Task 1: Physiology and Pathophysiology
- General Pediatrics Content Outline — Universal Task 4: Management and Treatment
- Patient Care 4: Patient Management
- Medical Knowledge 1: Core signs and symptoms of disease
- Medical Knowledge 2: Dermatologic and vascular birthmark conditions of the newborn
- Systems-Based Practice: neonatal referral and multidisciplinary care
- Medical Expert
- Neonatal-Perinatal Medicine
- Pediatrics: Foundations EPA #4 — Providing care to a healthy newborn
- Pediatrics: Foundations EPA #5 — Performing a complete newborn physical examination
Two questions that sort almost every neonatal skin lesion
Reassure (the majority)
Refer (the minority)
Overview & Definition
A newborn's skin is doing two jobs at once: adapting to dry air after months in amniotic fluid, and carrying the marks of how it formed. Both jobs produce lesions. Most are harmless and fleeting; a small number mark a disorder that will shape the child's whole childhood. The clinician's task at the cot side is to tell those two groups apart without sending every worried parent to a specialist. [11]
Neonatal skin disorders and birthmarks span three practical groups. Benign and transient lesions — erythema toxicum neonatorum, transient neonatal pustular melanosis, milia, sebaceous hyperplasia, miliaria, dermal melanocytosis (the Mongolian spot) and harlequin colour change — are common, self-limiting, and need only explanation and reassurance. [11] [12] Birthmarks divide into vascular and pigmented. Vascular birthmarks use the biological classification of Mulliken and Glowacki, which separates proliferating vascular tumours (chiefly infantile haemangioma) from vascular malformations present at birth (port-wine stain, venous, lymphatic and arteriovenous malformations). [1] Pigmented birthmarks include the congenital melanocytic naevus and dermal melanocytosis. [13]
The single idea that organises everything is this: a lesion's distribution and natural history are more informative than its colour. A red stain on a forearm is usually nothing; the same red stain on the forehead, or a rapidly growing red plaque beside an eye, demands a work-up. A blue patch over the sacrum fades and is forgotten; a brown patch over the lower spine may tether the cord. Keep that lens and the rest follows. [4]
References13ShowHide
- [1]Mulliken JB, Glowacki J Hemangiomas and vascular malformations in infants and children: a classification based on endothelial characteristics. Plastic and Reconstructive Surgery, 1982.PMID 7063565
- [2]Léauté-Labrèze C, Dumas de la Roque E, Hubiche T, Boralevi F, Thambo JB, Taïeb A Propranolol for severe hemangiomas of infancy. New England Journal of Medicine, 2008.PMID 18550886
- [3]Haggstrom AN, Drolet BA, Baselga E, et al. Prospective study of infantile haemangiomas: demographic, prenatal, and perinatal characteristics. Journal of Pediatrics, 2007.PMID 17307549
- [4]Darrow DH, Greene AK, Mancini AJ, Nopper AJ (American Academy of Pediatrics) Diagnosis and management of infantile hemangioma. Pediatrics, 2015.PMID 26416931
- [5]Drolet BA, Frommelt PC, Chamlin SL, et al Initiation and use of propranolol for infantile hemangioma: report of a consensus conference. Pediatrics, 2013.PMID 23266923
- [6]Pope E, Lara-Corrales I, Sibbald C, et al. Noninferiority and safety of nadolol vs propranolol in infants with infantile hemangioma: a randomized controlled trial. JAMA Pediatrics, 2022.PMID 34747977
- [7]Baselga E, Dembowska-Baginska B, Przewratil P, et al. Efficacy of propranolol between 6 and 12 months of age in high-risk infantile hemangioma. Pediatrics, 2018.PMID 30082451
- [8]Metry DW, Haggstrom AN, Drolet BA, et al Consensus statement on diagnostic criteria for PHACE syndrome. Pediatrics, 2009.PMID 19858157
- [9]Shirley MD, Tang H, Gallione CJ, et al Sturge-Weber syndrome and port-wine stains caused by somatic mutation in GNAQ. New England Journal of Medicine, 2013.PMID 23656586
- [10]Leung AK, Kao CP, Leung AA Persistent Mongolian spots in Chinese adults. International Journal of Dermatology, 2005.PMID 15663659
- [11]Patrizi A, Neri I, Ricci G, et al. Advances in pharmacotherapeutic management of common skin diseases in neonates and infants. Expert Opinion on Pharmacotherapy, 2017.PMID 28429969
- [12]Chadha A, Jahnke M Common neonatal rashes. Pediatric Annals, 2019.PMID 30653638
- [13]Krengel S, Scope A, Dusza SW, Vonthein R, Marghoob AA New recommendations for the categorization of cutaneous features of congenital melanocytic nevi. Journal of the American Academy of Dermatology, 2013.PMID 22982004