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Case reports

  1. Top of page
  2. Case reports
  3. Discussion
  4. Acknowledgments
  5. References

A four-day-old, full-term male neonate presented with a swelling over the scalp (Fig. 1A). The mother, a 21-year-old primigravida, had undergone an unsupervised home delivery. Immediately after birth the parents had noticed a large diffuse swelling over the scalp that turned black on the third day. The baby weighed 2.8 kg and was sick and febrile. On the fifth day the gangrenous scalp started separating and a well-defined line of demarcation between the normal and the involved scalp formed (Fig. 1B). Pus was discharged from under the involved scalp on the same day. Pus culture revealed the growth of Klebsiella. Blood and CSF culture were sterile. Skull X-ray did not show any fracture of cranial bones. Debridement of the gangrenous tissue under general anaesthesia was performed (Fig. 1C). The gangrene involved full thickness of the scalp tissue and the underlying cranial bones were exposed after debridement. However, the periosteum over the skull bones was intact. There was a small island [I] of 3 cm normal scalp tissue lying over the posterior fontanelle (Fig. 1B). The raw area was managed by daily dressings with topical antibacterial and parenteral antibiotics were given. The wound healed over seven weeks without skin grafting (Fig. 1D and 1F).

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Figure 1. (A) Gangrenous but intact caput on the fourth day. (B) The gangrenous caput has started separating and a well-defined line of separation can be seen. ‘I’ is the island of normal intact scalp over the posterior fontanel. (C) Scalp after debridement showing exposed underlying cranial bones. (D) Scalp wound after two weeks showing healthy granulations tissue. (E) Scalp wound after five weeks showing that about 70% of the raw area has been epithelised. (F) Scalp wound at seven weeks where the remaining 30% area has been covered by scar tissue. Note the island of normal intact scalp (I) has considerably increased in size and well-developed hairs can be seen over it.

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The second case was a 10-day-old full-term male who presented with a raw wound over the occipital region. The defect measured 11 × 7 cm and the underlying skull bones were exposed. The 18-year-old mother had undergone a prolonged unsupervised home labour at home. The parents stated that at birth the scalp was intact but swollen, and it had turned black on the fourth day. The unhealthy margins were excised, daily dressings with topical antibacterials started and systemic antibiotics given. The wound showed good healing but the baby was lost to follow up after four weeks.

Discussion

  1. Top of page
  2. Case reports
  3. Discussion
  4. Acknowledgments
  5. References

Uterine pressure can reach up to 80–100 mmHg during the second stage of labour.1 The scalp has a rich blood supply from four principal arteries on either side that come from all directions and form an abundant communication such that the entire scalp can survive over one vessel if avulsed.2 The spectrum of scalp injuries that can follow obstructed labour range from caput formation, which is so common that it can be regarded as a normal physiological change in the scalp. Temporary alopecia3 due to a milder form of ischaemia may affect the hair follicles only. Permanent alopecia4 may result due to a more extensive ischaemia that was not severe enough to cause gangrene of scalp but sufficient enough to cause necrosis of hair follicles. Complete ischaemia results in a full thickness loss of scalp within the compression ring. Morykwas et al.5 and Matthews1 have also reported two similar cases of full thickness scalp necrosis. One of these suffered from birth asphyxia and required ventilation. Surprisingly in both of our cases there were no immediate evidences of birth asphyxia.

These cases of ischaemic gangrene of caput need to be differentiated from aplasia cutis congenital. This is a congenital scalp and skull defect that affects first-born female babies and the scalp defect, which is usually less than 2 cm, is present over the posterior fontanel. In most cases, only scalp is involved but rarely underlying bone or even the dura may be involved.6 In our case the well-developed hair over the involved scalp differentiated it from aplasia cutis congenita. Secondly, aplasia cutis congenital is obvious at birth. Scalp cellulites due to some virulent organism or infection in the cephalhematoma can also cause extensive sloughing of the scalp. Kalra and Palaksha7 reported a case of a large scalp defect secondary to scalp cellulitis and osteomyelitis of scull bones that occurred at the end of second week.

The management depends on the size of the defect. Important facts that have to be considered while treating a scalp defect in neonates are, firstly, the surface area of head in neonate in relation to body is 2.7 times greater that those of adult8 and limited donor area is available for the grafting. Secondly, neonates have a poor tolerance to major surgery thus limiting the role of major flap coverage. Small or medium size defects can be closed by local flaps9,10; however, a large defect cannot be covered by a local rotation flap. Surgical treatment of these large defects remains difficult. Options that are available for large defects are (1) split skin grafting as advised by Matthews1; (2) use of cultured autologous keratinocytes as reported by Morykwas.5 This require a very small donor area and provides a good option in centres where facilities for harvesting autologous keratinocytes are available. (3) Use of helium–neon laser as an adjunct to split skin grafting as reported by Kalra7 in a case of a large scalp defect secondary to scalp cellulitis; and (4) conservative management to allow spontaneous healing. Considering the limited donor area in the neonates and encouraging results of previous reports,11,12 we opted for a conservative treatment. Although this achieved scalp coverage, the problems of residual alopecia and itching due to dryness in the healed area especially that healed by scarring remains.

Acknowledgments

  1. Top of page
  2. Case reports
  3. Discussion
  4. Acknowledgments
  5. References

The authors would like to thank the members of the ‘Society Against Birth Defects in Children’ who provided financial assistance for the management of these cases.

References

  1. Top of page
  2. Case reports
  3. Discussion
  4. Acknowledgments
  5. References
  • 1
    Matthews MS. Prenatal pressure necrosis of the scalp. Ann Plast Surg 1999;43: 7476 (July).
  • 2
    Freund RM. Scalp, calvarium and forehead reconstruction. In: AstonSJ, BeasleyRW, ThorneCHM, editors. Grabb and Smith's Plastic Surgery, 5th edition. Philadelphia, Pennsylvania: Lippincott-Raven, 1997: 473482.
  • 3
    Neal PR, Merk PF, Norins AL. Halo scalp ring: a form of localized scalp injury associated with caput succedaneum. Pediatr Dermatol 1984;2: 5254 (July).
  • 4
    Das S. Permanent baldness following caput succedaneum. J R Coll Gen Pract 1980;30: 428.
  • 5
    Morykwas MJ, Beason ES, Argenta LC. Scalp necrosis in a neonate treated with cultured autologous keratinocytes. Plast Reconstr Surg 1991;87: 549552 (March).
  • 6
    Marchac D. Deformities of the forehead, scalp and cranial vault. In: McCarthyJG, editor. Plastic Surgery. Philadelphia: W.B. Saunders, 1990: 15381573.
  • 7
    Kalra V, Palaksha HK. Helium–neon laser as an adjunctive modality for wound healing. Indian Pediatr 1997;34(5):437441.
  • 8
    Herndon DN, Pierre EJ. Treatment of burns. In: O'NeilJA, RoweMI, GrosfeldJL, FonkalsrudEW, CoranAG, editors. Pediatric Surgery, 5th edition. Missouri: Mosby-Yearbook Inc, 1998: 345.
  • 9
    Irons GB, Olson RM. Aplasia cutis congenital. Plast Reconstr Surg 1980;66: 199.
  • 10
    Schneider BM, Berg RA, Kaplan RA. Aplasia cutis congenita complicated by sagittal sinus hemorrhage. Pediatrics 1980;66: 948.
  • 11
    Muakkassa KF, King RB, Stark DB. Nonsurgical approach to congenital scalp and scull defects. J Neurosurg 1982;56: 711.
  • 12
    Handa J, Nakasu Y, Matsuda M. Conservative management of congenital defect of scull and scalp. Surg Neurol 1982;17: 152.

Accepted 28 November 2004