TREATMENT AND PROGNOSIS SCFN is usually treated symptomatically. Painful lesions can bemanagedwith acetaminophen or opiate analgesia such as morphine; refractory cases can add short-term predniso- lone that has a synergistic effect with morphine. 10,13 Tran et al. (2003) showed that aspiration of skin lesions may be used to relieve pain and skin breakdown. Hypercalcemia can be managed by conservative and symptomatic treatment such as low calcium and vitamin D formula, intravenous hydration, and loop diuretics. Severe cases can be treated with corti- costeroids, bisphosphonate, and calcitonin. Serum calcium levels should be monitored weekly or biweekly for up to six months or until the resolution of fat necrosis. Filippi et al. (2012) proposed that using a cooling blanket in an automatic “gradient variable mode,” where the circulating water was maintained at minimal change in temperature along with a special nursing protocol to change position of neonates every three hours by alternating pronation/supination during cool- ing, may reduce the risk of developing SCFN. 16 Therefore, it is prudent to change the skin contact site of cooling device more frequently and avoid direct pressure of cooling device against skin to minimize subcutaneous stress. SCFN is generally self-limiting with an excellent prog- nosis. Skin lesions usually resolve spontaneously in weeks to months without long-term sequelae, and most cases require only conservative and symptomatic treatment. Previous case series demonstrated good prognosis even when associated with hypercalcemia; 1,2,8 however, SCFN complicated by hy- percalcemia can be fatal if left untreated. 12 CONCLUSIONS SCFN is a rare, benign and self-limiting panniculitis of neonates. It can present as fluctuant lesions or with concur- rent infection, which may result in delayed diagnosis. The differential diagnosis of SCFN can be broad, and clinicopatho- logic correlation is essential to make the correct and timely diagnosis. With the increasing use of therapeutic whole-body hypothermia, SCFNmay become more prevalent. Physicians should be aware of this uncommon disease because of its potential serious complication. The patient should be moni- tored closely for skin involvement because skin lesions can appear several days after the completion of cooling therapy. The patient should be followedweekly or biweekly for serum calcium levels until skin lesions resolve, because hypercal- cemia may occur weeks to six months after the onset of skin lesions. The parents should be educated with the signs and symptoms of SFCN and hypercalcemia. REFERENCES 1. Mahe E, Girszyn N, Hadj-Rabia S, Bodemer C, Hamel-Teillac D, De Prost Y. Subcutaneous fat necrosis of the newborn: a systematic evaluation of risk factors, clinical manifestations, complications and outcome of 16 children. The British journal of dermatology . Apr 2007;156(4):709-715.
2. BurdenAD, Krafchik BR. Subcutaneous fat necrosis of the newborn: a review of 11 cases. Pediatric dermatology . Sep-Oct 1999;16(5):384- 387. 3. Akcay A, Akar M, Oncel MY, et al. Hypercalcemia due to subcutaneous fat necrosis in a newborn after total body cooling. Pediatric dermatology . Jan-Feb 2013;30(1):120-123. 4. HogelingM, Meddles K, Berk DR, et al. Extensive subcutaneous fat necrosis of the newborn associated with therapeutic hypothermia. Pediatric dermatology . Jan-Feb 2012;29(1):59-63. 5. Jacobs SE, Berg M, Hunt R, Tarnow-Mordi WO, Inder TE, Davis PG. Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database Syst Rev . 2013;1:CD003311. 6. Oza V, Treat J, Cook N, Tetzlaff MT, Yan A. Subcutaneous fat necrosis as a complication of whole-body cooling for birth asphyxia. Archives of dermatology . Aug 2010;146(8):882-885. 7. Sivanandan S, Rabi Y, Kamaluddeen M, Akierman A, Lodha A. Subcutaneous fat necrosis as a complication of therapeutic hypothermia in a term neonate. Indian journal of pediatrics . May 2012;79(5):664-666. 8. Strohm B, Hobson A, Brocklehurst P, Edwards AD, Azzopardi D. Subcutaneous fat necrosis after moderate therapeutic hypothermia in neonates. Pediatrics . Aug 2011;128(2):e450-452. 9. Shankaran S, Laptook AR, Ehrenkranz RA, et al. Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy. The New England journal of medicine . Oct 13 2005;353(15):1574-1584. 10. Woods AG, CederholmCK. Subcutaneous fat necrosis and whole- body cooling therapy for neonatal encephalopathy. Advances in neonatal care : official journal of the National Association of Neonatal Nurses . Dec 2012;12(6):345-348. 11. Zifman E, Mouler M, Eliakim A, Nemet D, Pomeranz A. Subcutaneous fat necrosis and hypercalcemia following therapeutic hypothermia--a patient report and review of the literature. Journal of pediatric endocrinology &metabolism : JPEM . Nov 2010;23(11):1185- 1188. 12. Norwood-Galloway A, Lebwohl M, Phelps RG, Raucher H. Subcutaneous fat necrosis of the newborn with hypercalcemia. Journal of the American Academy of Dermatology . Feb 1987;16(2 Pt 2):435-439. 13. Wiadrowski TP, Marshman G. Subcutaneous fat necrosis of the newborn following hypothermia and complicated by pain and hypercalcaemia. The Australasian journal of dermatology . Aug 2001;42(3):207-210. 14. Requena L, Sanchez Yus E. Panniculitis. Part II. Mostly lobular panniculitis. Journal of the American Academy of Dermatology . Sep 2001;45(3):325-361; quiz 362-324. 15. Schubert PT, Razack R, Vermaak A, Jordaan HF. Fine-needle aspiration cytology of subcutaneous fat necrosis of the newborn: the cytology spectrum with review of the literature. Diagnostic cytopathology . Mar 2012;40(3):245-247. 16. Filippi L, Catarzi S, Padrini L, et al. Strategies for reducing the incidence of skin complications in newborns treated with whole- body hypothermia. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstet . Oct 2012;25(10):2115-2121.
Dr. Feng is with the Department of Pathology and Laboratory Medicine, Tulane University School of Medicine, New Orleans. Dr. Guo is with the Department of Emergency Medicine, China-Japan Union Hospital of Jilin University, Changchun, China. Dr. Zhang is with the Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan.
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