Dr. B.J.C.Perera MBBS(Ceylon), DCH(Ceylon), DCH(England), MD(Paediatrics), FRCP(Edinburgh), FRCP(London), FRCPCH(United Kingdom), FSLCPaed, FCCP, FCGP(Sri Lanka) Consultant Paediatrician
Birthmarks are marks that are present on the skin of a lot of newborn babies and they get the distinctive name of birth mark for one simple reason. A baby can develop birthmarks either before being born or soon after birth. Newborn babies often have temporary pimples or blotches that soon disappear as they adapt to life outside the womb. It is also quite common to see birthmarks on their skin at birth or shortly after. Birthmarks range from hardly noticeable ones to disfiguring entities and no matter how large or small they are, they can be quite upsetting to everybody around the baby.KEY POINTS
* Birth marks are abnormalities on the surface of the sking that is present from or around the time of birth.
* There are different types of birth marks.
* Most are harmless and do not indicate an underlying disease.
* The psychological impact of birth masrks can be quite considerable.
* Many birth marks can be treated with modern therapeutic measures.
Birthmarks can be flat or raised, have regular or irregular borders, and have different shades of colouring from brown, tan, black, or pale blue to pink, red, or purple. The two main types of birthmarks are differentiated by their causes. The first, pigmented birthmarks are caused by an overgrowth of the cells that create pigment or the dark colour in the skin while the second, vascular or blood vessel birthmarks, are due to collections of tiny blood vessels of the skin which do not form properly. In the latter case, either there are too many of these blood vessels they are wider than usual.
Birthmarks cannot be prevented and they are not caused by anything done or not done during pregnancy. There is no truth to old wives’ tales about "stains" being caused by something the mother did or ate. The cause of most birthmarks is unknown. They can be inherited, but usually are not, and typically are unrelated to trauma to the skin during childbirth.
The most common pigmented birthmarks are café-au-lait spots, Mongolian spots and moles. Café-au-lait spots are very common spots that are the colour of coffee with milk and hence their name. They can be anywhere on the body and sometimes increase in number as a child gets older. One alone is not a problem, but it is wise to have the child evaluated if there are several larger than the size of a new one rupee coin, which can be a sign of neurofibromatosis which is a genetic disorder that causes abnormal cell growth of nerve tissue.
Mongolian spots are flat, bluish-gray patches that are often found on the lower back or buttocks. They are most common on darker skin, such as on children of Asian, American Indian, African, Hispanic, and Southern European descent. They usually fade, often completely, by school age without treatment. They are quite harmless and do not indicate any underlying disease.
Moles, also known as congenital nevi and hairy nevi, are tan, brown or black patches on the skin. Most people get moles at some point in life. One present at birth is called a congenital nevus and will last a lifetime. Large or giant congenital nevi are sometimes more likely to develop into skin cancer known as melanomas later in life. Smaller moles may have a slight increase in risk. Moles can be flat or raised and may have hair growing out of them.
The most common vascular birthmarks are macular stains, haemangiomas and port-wine stains. Macular stains, also called salmon patches, angel kisses or stork bites, are faint red marks which are the most common type of vascular birthmarks. They are often found on the forehead or eyelids, the back of the neck or on the nose, upper lip or on the back of the head. They may be more noticeable when the baby cries. Most often they fade on their own by the time a child is 1 to 2 years old, although some last into adulthood.
Haemangiomas are classified as superficial when they appear on the surface of the skin ("strawberry marks") and deep when found deeper below the skin’s surface. They can be slightly raised and bright red and sometimes are not visible until a few days or weeks after a baby is born. Deep haemangiomas may be bluish because they involve blood vessels in deeper layers of the skin. Haemangiomas grow rapidly during the first 6 months or so of life, but usually shrink back and disappear by the time a child is 5 to 9 years old. Some, particularly larger ones, may leave a scar as they regress. These can be corrected by minor plastic surgery. Most are on the head or neck, although they can be anywhere on the body, and can cause complications if their location interferes with sight, feeding, breathing or other bodily functions.
One kind of haemangioma is called a strawberry haemangioma. If one thinks that the condition gets the name from the fruit, one is quite right. A strawberry haemangioma is bright red and sticks out of the skin, so it does look a little bit like a strawberry. Some strawberry haemangiomas go away on their own by the time a child is about 5 years old. Almost all strawberry haemangiomas go away by themselves by the time the child is about 9 to 10 years old.
Another type of haemangioma is beneath the outer layer of skin. It is called a cavernous hemangioma. Cavernous means "like a cave," which is deep in the earth, like this type of birthmark which is situated deep beneath the outer layer of the skin. This kind of birthmark is puffier than a strawberry haemangioma. It is also different in colour and not red like a strawberry but more bluish-red.
Another kind of birthmark is a port-wine stain. This is generally not puffy or raised like a strawberry or cavernous haemangioma. It is often level with the outer layer of skin. A port-wine stain is an area of skin that is either maroon or purplish-red in colour or dark red. It gets its name from port wine, a type of wine that is dark maroon. Those babies who have port-wine stains usually have them on the face and neck.
About 3 out of every 1,000 children are born with a port-wine stain. Though they often start out looking pink at birth, port-wine stains tend to become darker, usually reddish-purple or dark red, as children grow. Port-wine stains can be anywhere on the body but most commonly are found on the face, neck, scalp, arms, or legs. They can be any size, and usually grow in proportion with a child. They often change in texture over time, too. Early on, they are smooth and flat but they may thicken and feel like pebbles under the skin during adulthood. But port-wine stains often get darker and can sometimes become disfiguring and embarrassing for children. Port-wine stains, especially when they are on the face, can make children feel self-conscious, particularly during the already challenging preteen and teen years when they are often more interested in blending in than standing out.
Port-wine stains are usually nothing more than a harmless birthmark that doesn’t cause any problems or pain. However, they are sometimes, though quite rarely, a sign of other medical conditions. For example, port-wine stains on or near the eye or on the forehead need to be monitored. That is because they may be associated with a sort of "stain on the brain", a very uncommon neurological disorder called Sturge-Weber Syndrome that causes problems like seizures, developmental delays and learning disabilities. Stains on the eyelids may also, rarely, lead to glaucoma which is a condition that increases the pressure inside the eye, affect vision and lead to blindness if left untreated.
Although some port-wine stains are small and hard to see, some can be really upsetting for children, especially if they are large, dark or on the face. In fact, any birthmark can take a toll on a child’s self-confidence, no matter how large or small the mark might be. The good news is that lasers (highly concentrated light energy) can make many port-wine stains much lighter, especially when the birthmark is on the head or neck. Dermatologist or plastic surgeons usually give several treatments with the laser of choice for port-wine stains called a "pulsed-dye" laser. This treatment is often started in infancy when the stain and
the blood vessels are smaller and the birthmark is much easier to treat. But that does not mean laser treatments cannot help older children and teenagers. It is just that the longer someone has had the stain, the harder it might be to successfully treat it.
Laser therapy does not hurt a lot but can be uncomfortable. During the treatment, smaller children can usually be given a short acting anaesthetic, as a shot, spray or ointment to numb the area to so that the discomfort is lessened. Young ones may also be given general anaesthesia to help them sleep or relax during the procedure. After treatment, the area might be swollen and bruised at first, but it will be back to normal in 7 to 10 days. For port-wine stains that have become bumpy, thick, or raised, doctors sometimes need to use another type of laser or surgery. Port-wine stains can also develop grape-like growths of small blood vessels called vascular blebs. These are not usually a cause for concern but they often bleed and may need to be removed.
In the past some people have opted for other treatments, too such as freezing, tattooing and even radiation. However, these are not as effective or as safe as laser therapy. Laser surgery is the only treatment that works on port-wine stains with the least risk of damaging or scarring the skin. Sometimes, though, laser treatments may make the area look lighter or darker than normal, although this usually is just temporary.
It must be emphasised that laser treatments may not get rid of the birthmark entirely. Over time the birthmark may come back and need to be retreated. For a small number of children, laser treatment might not work at all. Every child’s port-wine stain is different, so whether or not the treatment works well will be different for each child, too.
As for treatment of other birthmarks, pigmented birthmarks are usually left alone, with the exception of moles and, occasionally, café-au-lait spots. Moles, particularly large or giant congenital nevi, sometimes are surgically removed, although larger ones may be more difficult to remove. Café-au-lait spots can be removed with lasers but they often return.
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