"Sclerema neonatorum"

Sclerema is one of those conditions that leaves even seasoned neonatologists with a quiet heaviness. You see a baby whose skin — instead of the usual softness and warmth of early life — becomes pale, waxy, and almost marble-like. It is not inflammation; it is a chilling stillness of the subcutaneous fat.

What it is

A diffuse hardening of the skin and subcutaneous tissue in critically ill, often premature neonates. Unlike subcutaneous fat necrosis, sclerema has no nodules, no erythema, and no tenderness. The skin simply becomes rigid, board-like.

Why it happens

It reflects systemic collapse, not a primary dermatologic disorder. Several factors intersect:

• Severe sepsis

• Hypothermia

• Shock or poor perfusion

• Acidosis

• Very low birth weight

• Malnutrition or dehydration

The subcutaneous fat in preterm infants has a high saturated-fat content; under hypothermic and hypoperfused conditions, it solidifies — a literal freezing of metabolic life.

Clinical picture

• Diffuse hardening, starting from the thighs and buttocks, spreading truncally

• Skin appears cold, pale, non-pinchable

• Baby is lethargic, hypotonic

• Often accompanied by poor perfusion and multiorgan compromise

The moment you palpate that wooden texture, you know you’re dealing with a neonate in deep physiological trouble.

Investigations

No single test confirms it; labs reflect the underlying severity:

• Metabolic acidosis

• Hyperglycemia or hypoglycemia

• Elevated lactate

• Often deranged sepsis markers

• Ultrasound may show increased echogenicity of subcutaneous fat, but diagnosis is clinical.

  
  

Management

Treatment is aggressive supportive care, because the skin finding is a marker — not the disease itself.

1. Rapid correction of hypothermia: warmers, incubators, maintain stable thermal environment.

2. Treat sepsis aggressively: early broad-spectrum antibiotics, fluid resuscitation, inotropes as needed.

3. Correct metabolic derangements: acidosis, hypoglycemia, electrolyte imbalance.

4. Nutrition: parenteral support if necessary.

5. Exchange transfusion: Historically used; may offer benefit in severe cases by improving perfusion and oxygen-carrying capacity, though evidence remains mixed.

   
   

Prognosis

This is the hardest part: mortality remains high, often >50–75%, because sclerema doesn’t occur in isolation. It’s a sign that the neonate is losing their battle with sepsis or shock. Early recognition and decisive intervention are critical.