Neonatal Dermatologic Findings

Common and Usually Benign Dermatologic Findings

24 hour old female with this rash, what is it?

Erythema Toxicum NeonatorumCentral papule or pustule surrounded by

area of erythemaBenign, self-limiting, asymptomatic

disorder of unknown etiologyOccurs in up to 50% of infantsPresents at 24-48 hours of life, fades within

5-7 days, but recurrences may occur for several weeks

Smear of pustule reveals eosinophils

What is this rash noted on this baby immediately after

birth?

Transient Neonatal Pustular Melanosis

Self-limiting dermatosis of unknown etiologyOccurs more frequently in black malesUsually presents at birthPustule on non-erythematous base, crusts

over several days, which desquamates and leaves a hyperpigmented macule with collarette of fine scale

Hyperpigmentation fades in 3 weeks to 3 months

Smear of pustule reveals neutrophils

Is this bruising from birth trauma or something else?

Mongolian SpotFlat, slate-gray to bluish-black, poorly

circumscribed macules/patchesMost commonly located over the

lumbosacral area and buttocksCommon in black, asian, and hispanic

infantsUsually fade by 7 years of age

Does this mottling mean this newborn is ill?

Cutis Marmorata

Transient, netlike, reddish-blue mottlingCaused by variable vascular constriction

and dilationResponse to chilling, resolves with warmingBenign in neonates and usually abates by 6

months, but may persist longer in very fair skinned individuals

If persists past 6 months, may be a marker for hypothyroidism

Is this lesion benign?

Congenital Nevomelanocytic Nevi

Pigmented macules or plaques with dense hair growth

Giant CNN are associated with a 2-10% lifetime risk of melanoma

Highest risk of malignant change occurs in first 3-15 years of life

Early treatment with full-thickness excision followed by grafting if possible, otherwise close observation

Small to medium sized CNNs are also associated with a higher risk of malignant change than acquired moles, but incidence is unknown

What’s wrong with this newborn’s hands and feet?

Acrocyanosis

Hands and feet become variably and symmetrically blue

Resolves with warming of the skinRecurrence unusual after 1 month of age

What is this and is this benign?

HemangiomasCongenital vascular malformationOccur in 10% of all newbornsPresents in first few months of lifeMarked vascular overgrowth resulting in

bright red discoloration and definite elevationRapid growth for the first 6-12 months, then a

plateau period, then slow involution50% involute by age 5, 90% by age 9Refer to dermatology if lesion involves a vital

structure or if there are multiple lesions

Can you guess the name for this rash?

Salmon Patch (Stork bite)

Vascular malformationSeen in 60% of infantsFades in first year of lifeUsually located nape of neck, forehead and

upper eyelids

What syndrome can be related to this vascular

malformation?

Port Wine Stain

Purplish-red vascular malformation present at birth

Lesions do not enlarge but remain flat and persist

When port wine stain involves ophthalmic branch of the fifth cranial (trigeminal) nerve, it can be associated be a constellation termed Sturge-Weber syndrome

Sturge-Weber syndrome involves seizures, mental retardation, hemiplegia, and glaucoma

Can babies get pimples?

Neonatal Acne

Develops in up to 20% of newbornsMaternal and endogenous androgens play a

role in the pathogenesisLesions involute within 1-3 months,

treatment usually unnecessary

What’s on this baby’s nose?

Sebaceous Gland Hyperplasia

Yellow papules over the nose and cheeks Result from maternal or endogenous

androgenic stimulation of sebaceous gland growth

Resolves within 4-6 months

Is this the same as the previous rash?

MiliaPearly yellow papules usually on the faceOccur in 50% of newbornsUsually resolve during the 1st month of life

Are these rashes the same?

MiliariaResults from obstruction to the flow of

sweat and rupture of the eccrine sweat gland

Miliaria crystallina - superficial 1-2mm vesicles on non-inflamed skin

Miliaria rubra (prickly heat) - small red papules and pustules

Occur in response to thermal stressUsually erupt in crops in the intertriginous

areas, scalp, face, and trunk

Is this polydactyly?

Supernumerary Digits

Most commonly occur as rudimentary structures at the base of the ulnar side of the 5th finger

Usually familialAsymptomaticCan usually be tied off as long as no bone

is palpated

Rare and Abnormal Dermatologic Findings

Collodian BabyBorn encased in thick cellophane-like

membraneMost go on to develop ichthyosis (a group of

scaling disorders)Barrier function is compromised by cracking

and fissuring -> increased insensible water loss, heat loss, and risk of infection

Complications are minimized by placing baby in high humidity, neutrally thermal environment

Desquamation usually complete by 2-3 weeks of life

Epidermolysis Bullosa

Group of inherited mechanobullous disordersBlisters form after mild friction or traumaThree types: epidermolytic EB, junctional EB,

dermolytic EBSkin biopsy distinguishes types and

determines prognosisPrenatal diagnosis is now possible for a

number of variants for which gene markers are available

Treatment is symptomatic and supportive

Incontinentia PigmentiNeurocutaneous syndromeX-linked dominant, lethal in malesStarts out with patches of erythema and

blisters that follow the lines of Blaschko (embryonic cleavage planes) -> warty plaques by several weeks to months -> increasing pigmentation at 2-6 months that look like marble cake swirls -> fade to hypopigmented patches in late childhood

Associated defects in the CNS, eye, dentition, heart, skeletal system

Congenital SyphilisMucocutaneous lesions usually appear

between 2-6 weeks of ageMost common finding = papulosquamous

eruption beginning in the palms and soles and spreading over extremities, face and trunk

Diagnosis confirmed with serological studies of the serum and CSF

Early diagnosis and treatment with high dose PCN prevents late complications

Newborns with disease can also be born premature, have poor growth, and develop hepatosplenomegaly and snuffles

Congenital RubellaBlueberry muffin lesionsSeen in severe disseminated disease with

jaundice, pneumonitis, meningitis, bony abnormalities, thrombocytopenia

Congenital rubella associated with cataracts, microphthalmia, glaucoma, congenital heart disease

Blueberry muffin lesions can also be seen in congenital CMV and toxoplasmosis

Can confirm diagnosis with serologic testingTreatment: isolation and supportive care

Herpes Simplex Infection

Of infected babies, 70% develop the skin rash and 90% of these children go on to develop systematic disease

Clustered red papules and vesicles, then become pustular, denuded, crusted, and hemorrhagic over the following 2-3 days

Diagnose by DFA or PCR of the lesionTreat with acyclovir as soon as infection is

suspected to prevent disseminated disease and morbidity/mortality

Neonatal VaricellaEarly exposure in utero during 1st trimester can

rarely lead to neonatal varicella syndrome: linear scars, limb anomalies, ocular defects, and CNS involvement

Late exposure in 3rd trimester increases the risk of baby acquiring the disease during the neonatal period (the closer to delivery, the higher the risk)

Vesicles usually develop over 1st 3-10 days of lifeDissemination can lead to pneumonitis, encephalitis,

purpura with hemorrhage, hypotension, and deathIf newborn at risk, should consider Varicella-zoster

immune globulin or IVIGStart acyclovir early if lesions are suspicious for

varicellaConfirm diagnosis with DFA or PCR of lesion

Aplasia Cutis CongenitaOften inherited as AD traitAbsence/failure of formation of a localized

area of scalp or skin, usually single lesion located over vertex of the scalp

Treatment is supportive until lesion is healed

Leaves an atrophic, hairless scar that can be excised later in life

Less commonly, the trunk and extremities are involved and lesions may be associated with limb defects, epidermolysis bullosa, and chromosomal abnormalities

Neonatal Lupus Erythematosus

Annular erythematous plaques with a central scale

Transplacentally aquired ssA (Ro) and ssB (La) Ab is thought to play role in pathogenesis

May be triggered or exacerbated by sun exposure

Associated with heart block, hepatosplenomegaly, anemia, leukopenia, thrombocytopenia, and/or lymphadenopathy

Except for cardiac involvement, usually resolves in 6-12 months

May need topical steroids, rarely requires systemic steroids