Firm Erythematous Nodules in a Term Newborn

Correct Answer: Subcutaneous fat necrosis of the newborn (SCFN)

Subcutaneous fat necrosis of the newborn is distinguished by its onset within the first weeks of life, featuring firm red to violaceous nodules or plaques typically on the back, buttocks, cheeks, and proximal extremities in an otherwise well-appearing infant.^1,2 The condition is self-limited but associated with complications including thrombocytopenia, hypoglycemia, and most notably hypercalcemia, which can lead to systemic manifestations including vomiting, failure to thrive, dehydration, and arrhythmias.³

Sclerema neonatorum occurs in critically ill or premature infants, with diffuse woody induration of skin, whereas SCFN affects term/post-term infants and is often localized. Hemangiomas are soft, vascular, and often blanch with pressure, unlike the firm consistency of SCFN. Langerhans cell histiocytosis may present with skin nodules but usually accompanies systemic findings such as lytic bone lesions or other involvement. Cellulitis and abscess present with systemic signs (fever, irritability), progressive erythema, and often fluctuance with cultures growing bacteria. In the absence of systemic illness, fluctuance or vascular features, and in the setting of a healthy neonate, the correct diagnosis is SCFN.

Treatment and management. The infant remained asymptomatic and laboratory findings were within normal limits. Therefore, no pharmacologic therapy was required. The patient was managed with close outpatient monitoring of clinical symptoms and serial monitoring of serum calcium, glucose, and platelet counts.

Given the self-limited nature of SCFN, most infants require only observation.2 However, early recognition and proactive monitoring are essential to prevent morbidity from complications (Table 2).

Table 2. Complications with management

Outcome and follow-up. During hospitalization, the infant was closely monitored for signs of hypoglycemia, hypercalcemia, sepsis, and pain. No abnormalities were detected and the patient remained clinically stable without the need for pharmacologic intervention. The patient was discharged on day 3 of life with resolution of acute concerns. The infant’s parents were counseled extensively regarding the benign but potentially complicated course of SCFN and instructed to look for signs of possible complications such as poor feeding, lethargy, vomiting, or irritability. The parents were also advised to follow up in 3 days for outpatient evaluation of the shoulder nodules, serial monitoring of serum calcium, glucose, and platelet counts. At follow-up, the patient remained asymptomatic with stable laboratory values, and the nodules showed gradual improvement. No adverse effects or unanticipated events were noted.

Discussion. Subcutaneous fat necrosis of the newborn is a rare, self-limiting panniculitis that occurs within the first few weeks of life. Although uncommon, it has been seen in full-term and post-term infants with a history of perinatal stress. Reported risk factors include maternal gestational diabetes, pre-eclampsia, meconium aspiration, and obstetric trauma, conditions that result in perinatal stress and hypoxia. Additionally, therapeutic hypothermia for treatment of hypoxic-ischemic encephalopathy appears to contribute to the development of SCFN.⁶ Complications such as thrombocytopenia, hypoglycemia, hypertriglyceridemia, and most importantly, hypercalcemia may occur. Although the pathogenesis is not fully understood, hypercalcemia is thought to result from increased extrarenal activation of vitamin D by granulomatous inflammation, underscoring the importance of accurate diagnosis and close monitoring.⁴

Clinically, SCFN manifests as tender, firm, erythematous to violaceous subcutaneous nodules or plaques most frequently located on the back, buttocks, and arms. While lesions typically appear within the first few weeks of life², in our case, skin findings appeared as early as 33 hours of life, highlighting the need to include SCFN in the differential even in the immediate neonatal period. Other differentials to consider include sclerema neonatorum, cold panniculitis, and Scleredema of Buschke, which present similarly with SCFN-like lesions in newborns. However, sclerema neonatorum presents with diffuse, indurated skin lesions while SCFN presents with circumscribed lesions. Furthermore, sclerema neonatorum is associated with poor prognosis and comorbidities like congenital malformations, respiratory and gastrointestinal illnesses and sepsis, whereas SCFN has generally good prognosis.⁵ Cold panniculitis (“popsicle panniculitis”) presents with well demarcated, erythematous plaques commonly seen in infants and young children with cold exposure. However, cold panniculitis appears within 48-72 hours of cold exposure and resolves spontaneously without sequelae.⁷ Scleredema develops in infants exposed to cold injuries or acute infections and presents with thickened skin and pitting edema that most commonly affects the lower extremities.⁶

Although cutaneous manifestations are generally self-limiting, SCFN can be complicated by systemic disturbances. Hypercalcemia is the most clinically significant complication, occurring days to weeks after lesion onset and may involve symptoms of irritability, vomiting, poor feeding, and seizures. Other reported complications include thrombocytopenia, hypoglycemia and elevated triglycerides.³ In our case, the patient’s initial evaluation was normal; however, given the delayed nature of these complications, serial calcium monitoring and outpatient follow-up were emphasized.

Management of SCFN consists of supportive care and vigilant follow up. If hypercalcemia was present, IV fluids, loop diuretics, corticosteroids or bisphosphonates are to be administered. In our case, no treatment was required and the infant remained stable at discharge. This case emphasizes an unusually early presentation of SCFN within the first 48 hours of life, highlighting the importance of including SCFN in the differential diagnosis of neonatal skin lesions from birth onward. Early recognition of SCFN, perinatal risk factor identification and careful follow-up are essential to prevent morbidity from delayed systemic complications.

AUTHORS:
Margaret Taing, BS¹ • Andy Xiao, BS¹ • Thiagarajan Nandhagopal, MD²

AFFILIATIONS:
¹Western University of Health Sciences, College of Osteopathic Medicine Pomona, CA
²Department of Pediatrics, Kern Medical Center, Bakersfield, CA

CITATION:
Taing M, Xiao A, Nandhagopal T. Firm erythematous nodules in a term newborn. Consultant. Published online March 18, 2026. doi:10.25270/con.2026.03.000004
Received Sep. 5, 2025. Accepted Dec. 16, 2025.

DISCLOSURES:
The authors report no relevant financial relationships.

ACKNOWLEDGEMENTS:
None.

CORRESPONDENCE:
Thiagarajan Nandhagopal, MD, Chief of Pediatrics, Kern Medical Center, 1700 Mount Vernon Ave, Bakersfield, CA 93306. (email: Thiagarajan.Nandhagopal@kernmedical.com)  

References:

1. Stefanko NS, Drolet BA. Subcutaneous fat necrosis of the newborn and associated hypercalcemia: A systematic review of the literature. Pediatr Dermatol. 2019;36(1):24-30. doi:10.1111/pde.13640
2. DermNet. Subcutaneous fat necrosis of the newborn. DermNet®. https://dermnetnz.org/topics/subcutaneous-fat-necrosis-of-the-newborn. Published July 10, 2023. Accessed March 23, 2026.
3. Frank, L., Brandt, S. & Wabitsch, M. Subcutaneous fat necrosis in newborns: a systematic literature review of case reports and model of pathophysiology. Mol Cell Pediatr 9, 18 (2022). doi:10.1186/s40348-022-00151-1
4. Dudink J, Walther FJ, Beekman RP. Subcutaneous fat necrosis of the newborn: hypercalcaemia with hepatic and atrial myocardial calcification. Arch Dis Child Fetal Neonatal Ed. 2003;88(4):F343-F345. doi:10.1136/fn.88.4.f343
5. Del Pozzo-Magaña BR, Ho N. Subcutaneous fat necrosis of the newborn: A 20-year retrospective study. Pediatr Dermatol. 2016;33(6):e353-e355. doi:10.1111/pde.12973
6. Diamantis, S., Bastek, T., Groben, P. et al. Subcutaneous fat necrosis in a newborn following icebag application for treatment of supraventricular tachycardia. J Perinatol 26, 518–520 (2006). https://doi.org/10.1038/sj.jp.7211549
7. Zeb A, Darmstadt GL. Sclerema neonatorum: a review of nomenclature, clinical presentation, histological features, differential diagnoses and management. J Perinatol. 2008;28(7):453-460. doi:10.1038/jp.2008.33

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