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NewbornRashes-Qamar

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					                                Newborn Skin Rashes

COMPETENCY – The resident should be able to:
  • Distinguish between noninfectious self-limiting disease versus potentially life-
     threatening disease
  • Identify the most common benign and life-threatening dermatoses
  • Know when laboratory testing is indicated
  • Know which lesions warrant therapy
  • Know what history should be obtained when evaluating a neonate with
     vesiculopustular lesions
  •
QUESTIONS:
  1. What are the frequencies of occurence, physical exam findings, distribution and
     causes of various newborn dermatoses?
  2. Which lesions warrant testing?
  3. Which dermatoses warrant therapy and which are self-limited diseases?
  4. What are the laboratory tests available?
  5. What questions should be asked in the history when evaluating a neonate with
     vesiculopustular lesions?


Case:

A mother brings in her three week old baby with the complaint of a rash. The baby
appears well, has had no fevers, and has been feeding well. There is no family history of
atopy or eczema. On exam you find waxy scaly lesions over the scalp, neck and axilla.
What is your diagnosis? What treatment if any is recommended?


Introduction:

As a pediatrician one of the most common presenting complaints is that of an infant with
a rash and with the large number of possible diagnoses (on the order of more than 30!) it
is essential to be able to recognize the characteristic appearance of common lesions.
Furthermore, it is imperative to be able to identify life-threatening disease processes
involving systemic signs (hyperthermia, hypothermia, irritability, lethargy, respiratory
distress, sepsis) from benign, self-limiting disease.
                         COMMON BENIGN DERMATOSES

                                   Acne Neonatorum:




Frequency            Extremely common
History              Usually occurs around 2-4 weeks of age
Physical exam        Comedones, papules. Resembles acne vulgaris seen in adolescents
Distribution         Cheeks, chin, forehead, upper chest, shoulders
Causes               Maternal adrogenic hormonal stimulation of sebaceous glands
Evaluation/testing   Lab studies not indicated in non-toxic appearing child (if one has any
                     suspicion of bacterial, viral or fungal disease this warrants work up).
                     Under Wright stain lesion reveals numerous eosinophils.
Treatment               • Benign, self-limited condition, no treatment required
                        • Resolves by 3 months of age; mother’s hormones have waned
                        • Severe cases mild keratolytic agents (3% salicylic acid)



                           Erythema Toxicum Neonatorum:




Frequency            30-70% of newborns with no racial or gender tendency
History              Term neonates 3-14 days. 90% of cases occur after 48 hours of age
Physical exam        1-3mm white/yellow papules, vesicles, and pustules surrounded by a
                     blotchy erythematous halo
Distribution       Spread centripetally from trunk to extremities and face, sparing
                   palms and soles. Lesions seem to migrate by disappearing within
                   hours and then reappearing elsewhere.
Causes             Unknown
Evaluation/testing Lab studies not indicated in non-toxic appearing child (if one has any
                   suspicion of bacterial, viral or fungal disease this warrants work up).
                   Wright stain reveals eosinophils. 15% have peripheral eosinophilia.
Treatment             • Benign, self-limited condition
                      • Resolves within 2 weeks
                      • No treatment is required


                                         Milia:




Frequency          40-50% of newborns with no racial or gender tendency
History            Presents in term neonates after 4-5 days. Can be delayed from days
                   to weeks in preterm infants. Limited to the neonatal period.
Physical exam      1-2 mm popular pearly white lesions
Distribution       Chin, nose, forehead and cheeks. Known as Epstein pearls if located
                   on the soft or hard palate
Causes             Unknown
Evaluation/testing Lab studies not indicated in non-toxic appearing child (if one has any
                   suspicion of bacterial, viral or fungal disease this warrants work up).
                   Histology shows multiple superficial keratin-filled inclusion cysts
                   with no visible opening
Treatment              • Benign, self-limited condition
                       • Resolves within 1-2 months
                       • No treatment is required
                       Transient Neonatal Pustular Melanosis:




Frequency          0.2-4% of newborns. Twice as prevalent in African Americans than in
                   Caucasian infants
History            Present at birth. Limited to the neonatal period
Physical exam      3 stages of lesions:
                   1. 2-4mm nonerythematous pustules with milky fluid
                   2. Ruptured vesiculopustules with collarettes of scale
                   3. Hyperpigmented macules
Distribution       Clustered under chin, forehead, nape of neck, lower back, cheeks,
                   trunk, extremities
Causes             Unknown
Evaluation/testing Important to differentiate from pustulovesicles of staphylococcal,
                   candidal, or herpetic origin. Lab studies not indicated in non-toxic
                   appearing child (if one has any suspicion of bacterial, viral or fungal
                   disease this warrants work up). Histology shows sterile lesions with
                   few neutrophils.
Treatment              • Benign, self-limited condition, no treatment required
                       • Vesiculopustular lesions disappear in 24-48 hours
                       • Hyperpigmented macules regress by 3 months of age

                         Seborrheic Dermatitis (Cradle Cap):
Frequency          Unknown
History            Begins in 1st 12 weeks of age and can last up to 3 years of age
Physical exam      Greasy, scaling with patchy redness, fissuring & occasional weeping.
Distribution       Scalp is the most common site but can also appear on the face, ears,
                   forehead, eyebrows, trunks and flexural areas
Causes             Inflammatory process related to maternal androgens
Evaluation/testing Lab studies not indicated. Histology is not specific and shows
                   features of psoriasis and chronic dermatitis.
Treatment              • Benign, self-limited condition
                       • Treatment of scalp with shampoo (such as Selsun blue) to
                           soften the greasy scale followed with gentle combing with a
                           fine toothed comb to remove them
                       • For thick and adherent scales mineral oil (baby oil) or
                           Vaseline can be applied and a fine toothed comb can be used
                           to remove the scale
                       • Resolves by 8-12 months of age

                                  Mongolian spots:




Frequency          Most commonly encountered pigmented lesion in the newborn
                       • 85 to 100 percent in Asian neonates
                       • >60 percent in African American neonates
                       • 46 to 70 percent in Hispanic neonates
                       • <10 percent in White neonates
History            Present at birth
Physical exam      Blue-grey pigmented macules with indefinite borders OR
                   Greenish-blue or brown.
Distribution       Most common location is sacro-gluteal region, then the shoulders.
                   Very rarely on the face or flexor surface of extremities.
Causes             Delayed disappearance of dermal melanocytes. The sacral area and
                   medial buttocks are areas where active dermal melanocytes are still
                   present at birth.
Evaluation/testing Biopsy not usually indicated but shows widely spaced dermal
                   melanocytes in the deep dermis
Treatment          None required. Fade during the first or second year of life. Most
                   disappear by 6 to 10 years of age. About 3 percent remain into
                   adulthood, especially those in extrasacral locations.

                             Nevus Simplex (Stork Bite):




Frequency          Common – 40-60% of newborns
History            Present at birth or may appear in the first few months of life. May
                   become darker when the child cries.
Physical exam      Pink red macules.
Distribution       Midline of the nape of the neck, forehead, eyelid, glabella
Causes             Dilation of blood vessels
Evaluation/testing None needed
Treatment          None. Most fade away in about 1-2 years. The ones on the back of the
                   neck generally do not.


                           INFECTIOUS DERMATOSES:

                                    Herpes Simplex:




Frequency           1 in 1000 to 1 in 5000 deliveries per year
History                 • 75% of disease caused by HSV-2
                       •    Transmitted to an infant during birth through infected
                            maternal genital tract or via ascending infection
Physical exam      Vesicles occur in 90% of children with HSV. Vesicles develop from
                   an erythematous base and are 1-2mm in diameter. New lesions form
                   adjacent to old vesicles sometimes forming bullae.
Distribution       Vesicles can appear anywhere on the body. Can occur on the scalp at
                   the site of where an electrode was applied for fetal monitoring. May
                   occur in the oropharynx as well as a corneal infection.
Causes                 1. Vertical transmission at or near birth
                       2. HSV-1 transmitted by contact with infected saliva
                       3. HSV-2 transmitted sexually
                       4. Mucocutaneous infection follows inoculation of the virus into
                            mucosal surfaces (oropharynx, cervix, conjunctiva) or
                            through breaks in the skin (scalp electrode)
Evaluation/testing     • Cultures of skin lesions
                       • Culture of mouth/nasopharynx, eyes, rectum
                       • Urine culture
                       • Blood culture
                       • CSF culture and stain
                       • Scraping of lesion will show multinucleated giant cells and
                            epithelial cells containing intranuclear inclusion bodies.
Treatment              • IV acyclovir 60mg/kg/day divided TID for 14 days if
                            confined to skin, eyes and mouth
                       • IV acyclovir 60mg/kg/day divided TID for 21 days for
                            disseminated or CNS infection
                       • Ocular involvement should receive topical ophthalmic drug
                            in addition to parenteral IV therapy

                                 Congenital Syphilis:

Frequency          Rare
History            Infants can be normal at birth and can become symptomatic during
                   the first 5 weeks of life
Physical exam      Hemorrhagic bullae and petechiae
Distribution       Pathognomonic sign is that of lesions starting on the palms and soles
                   and spreading to trunk and extremities
Causes             Spirochete treponema pallidum transmitted during pregnancy to fetus
Evaluation/testing     • Serologic testing with RPR and FTA-ABS
                       • Direct visualization: darksfield microscopy of lesion exudate
                       • Direct fluorescent antibody tests of lesion exudate or tissue
Treatment          Penicillin G 100,000 to 150,000 units/kg per day IV divided BID for
                   seven days and then every eight hours to complete a 10-day course
                                                     OR
                   Procaine penicillin G 50,000 U/kg per day IM in a single dose for 10
                   days
                                  Bacterial infections:

                       Staphylococcal Scalded Skin Syndrome:




Frequency          Not common
History            Usually occurs at 3 to 7 days of age and is not present at birth. Infants
                   are often febrile and irritable
Physical exam          • Diffuse blanching erythema often beginning around the mouth
                       • Flaccid blisters one to two days later
                       • + Nikolsky’s sign (gentle pressure causes skin to separate and
                           slough)
Distribution           • Blisters are most commonly in areas of mechanical stress such
                           as flexural areas, buttocks, hands, and feet
                       • Often conjunctivitis is present
                       • Mucous membranes are not involved but may be hyperemic
Causes                 • Dissemination of S. aureus epidermolytic toxins
                       • Toxin acts at the zona granulosa of the epidermis
                       • Causes cleavage of desmoglein 1 complex, a protein in
                           desmosomes
                       • Desmosomes no longer can anchor the keratinocytes
                           rendering formation of fragile, tense bullae
Evaluation/testing     • Blood culture, urine culture
                       • Culture nasopharynx, umbilicus, abnormal skin or other
                           suspected focus of infection
                       • Intact bullae are sterile
                       • Diagnosis is clinical but skin biopsy shows a cleavage plane in
                           the lower stratum granulosum
Treatment              • Prompt initiation of IV penicillinase-resistant penicillin, such
                           as nafcillin or Vancomycin in areas where there is a high
                          prevalence of MRSA
                      •   Emollients, creams or ointments to create a barrier
                      •   Fluid support may be required


                                 Fungal infections:

                               Neonatal Candidiasis:




Frequency          Common
History            Usually develops after the first week of life
Physical exam         • Candidal diaper dermatitis: erythematous rash in the inguinal
                          region. Areas of confluent erythema with multiple tiny
                          pustules or discrete erythematous papules and plaques with
                          superficial scales.
                      • Oropharyngeal candidiasis:white plaques on the buccal
                          mucosa, palate, tongue, or the oropharynx.
Distribution       Affects moist, warm regions and skin folds (diaper area) or mucous
                   membranes in the mouth (thrush)
Causes             Candida albicans
Evaluation/testing No testing indicated
Treatment             • Candidal diaper dermatitis: Topical antifungal
                      • Oropharyngeal candidiasis: Nystatin
What questions should be asked in the history when evaluating a neonate with
vesiculopustular lesions?

A thorough maternal history should be taken including history of HSV or other STDs,
maternal fever, rashes, or lesions during delivery, and prolonged rupture of membranes.
Is there a history of primary bullous or autoimmune disease that could have been passed
transplacentally to the neonate? Is there a family history of chronic blistering (could
suggest epidermolysis bullosa)?

What laboratory tests are available?

KOH                Fungi and yeast: pseudohyphae and spores
Tzanck Prep           • Multinucleated giant cells: herpes simplex, varicella/zoster
                      • Eosinophils: erythema toxicum neonatorum
Gram stain         Bacteria
PCR                HSV


References:

   1. Johr, R.H and Schachner, L.A. “Neonatal Dermatologic Challenges.” Pediatrics in
      Review. March 1997; 18(3): 86-94.
   2. O’Connor, Nina et al. “Newborn Skin: Part I. Common Rashes” American Family
      Physician. January 1, 2008; 77(1): 47-52.
   3. Schwab, Joel. “Common Skin Lesions in Neonates and Infants.”
      http://pedclerk.bsd.uchicago.edu/
   4. Salman, Sawsan. “Newborn Rashes”
      http://pediatrics.uchicago.edu/chiefs/ClinicCurriculum/documents/NewbornRashe
      s-SueS.pdf
   5. Pielop, J.A. “Vesiculobullous and pustular lesions in the newborn” Uptodate.com
      Accessed on 6/3/09
   6. Pielop, J.A. “Benign skin and scalp lesions in the newborn and young infant.”
      Uptodate.com Accessed on 6/4/09.
   7. Wirth, F.A. and Lowitt, M.H. “Diagnosis and Treatment of Vascular Lesions”
      American Family Physician. February 15, 1998.

Author: Nashmia Qamar, DO
Reviewed by: Kyran Quinlan, MD

				
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posted:3/1/2013
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