Birthmarks in newborns: What parents should know and when to seek help

From harmless to needing care, newborn birthmarks can raise questions for new parents. When Denise noticed a red mark on her baby’s cheek, she began learning what birthmarks mean and when a doctor should check them.

A few hours after bringing her newborn home, Denise, a first-time mother, noticed a deep red patch spreading across her baby’s cheek. What began as excitement quickly turned into anxiety. Was it a bruise? An allergy? Would it go away? “I thought I’d caused those marks on my baby by drinking coffee when I was pregnant,” she recalls. “Thankfully my doctor told me not to worry.”

Dr Sheree Koonin, a plastic and reconstructive surgeon at Mediclinic Sandton, explains that birthmarks are extremely common in newborns. “The vast majority are harmless and many resolve spontaneously with time. They’re not caused by anything the mother did or didn’t do during pregnancy.”

A birthmark is an area of skin that differs in colour or texture from the surrounding skin. Some birthmarks are visible at birth, while others appear days or weeks later.

Dr Koonin explains: “Birthmarks occur due to either an excess of pigment-producing cells called melanocytes, which give the skin its colour, or as a result of irregular vessels in the skin.”

The two main categories of birthmarks

1. Pigmented birthmarks

Caused by an excess or uneven distribution of pigment in the skin. Common types include:

• Café-au-lait spots: Light brown, flat spots that look like coffee with milk. Usually harmless, but multiple spots may occasionally indicate a genetic condition.
• Mongolian spots (congenital dermal melanocytosis): Blue-grey patches often found on the lower back or buttocks, more common in babies with darker skin. They usually fade by early childhood.
• Congenital moles: Darker, well-defined spots present at birth. Most are benign, but some may need monitoring over time.

2. Vascular birthmarks

Involve clusters of tiny blood vessels in the skin, creating red or pink marks.

Types include:

• Haemangiomas (“strawberry marks”): Raised, bright red marks that can grow rapidly in the first months of life due to rapid blood vessel proliferation. They usually shrink and fade over time.
• Port-wine stains: Flat, pink to purple marks caused by enlarged blood vessels. These tend to persist and may require laser treatment for cosmetic or functional reasons.
• Salmon patches (“angel kisses” or “stork bites”): Flat, pale pink marks commonly seen on the forehead, eyelids, or back of the neck. They usually fade by age one to two years.

“Pigmented birthmarks involve pigment cells, while vascular birthmarks involve clusters of blood vessels. Understanding this difference helps guide monitoring and treatment,” says Dr Koonin.

“For example, we expect that certain birthmarks like haemangiomas will grow rapidly during the first few months of life. But most haemangiomas eventually shrink on their own, often disappearing or fading significantly by early childhood.”

Other birthmarks, such as port-wine stains, usually persist and may require cosmetic treatment.

While most birthmarks are harmless, some need professional assessment, especially if they are:

• Growing rapidly
• Bleeding, ulcerated, or showing signs of infection
• Located near the eye, nose, or airway, where they may affect vision, breathing, or feeding
• Positioned along the spine, which could indicate underlying spinal issues
• Causing swelling, pain, or interference with normal function.

“Location often matters more than size. A small birthmark near the eye or airway can be more significant than a larger one on the arm or leg,” Dr Koonin explains.

Most birthmarks are purely cosmetic and do not affect a child’s growth or development.

“Parents often worry about cancer risk in pigmented lesions. It’s extremely rare for childhood birthmarks to become cancerous. In vascular lesions, the main concern is when a birthmark affects normal function, particularly near the eyes, nose, or airway.”

Treatment options

Many birthmarks require no treatment and careful observation is often sufficient.

When intervention is required, treatment options may include:

• Medication: Beta-blocker therapy, most commonly oral or topical propranolol, to help shrink problematic haemangiomas
• Laser treatment: Used to lighten persistent vascular birthmarks such as port-wine stains
• Surgery: Considered in selected cases, particularly when a birthmark affects function or long-term appearance.

Children are referred to a paediatric plastic surgeon if a birthmark might affect their growth, how their body works, or their appearance, Dr Koonin explains. “Early treatment can prevent complications and improve long-term appearance, but this very much depends on the type of birthmark.”

Reassurance for parents

Many parents, like Denise, feel anxious when they notice a birthmark, particularly on their child’s face. “Parents often arrive very worried, but after proper assessment and monitoring, most families feel relieved,” Dr Koonin assures.

“Birthmarks are not caused by maternal diet, stress, medication, or actions during pregnancy. There’s nothing a parent did to cause it.”

“My advice is not to panic, but not to ignore it either. If you’re worried, have it assessed early. In most cases, we can provide reassurance, and when treatment is needed, it is effective.”