Neonatal Dermatologic Findings

Common and Usually Benign Dermatologic Findings

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

Erythema Toxicum Neonatorum Central papule or pustule surrounded by area of erythema Benign, self-limiting, asymptomatic disorder of unknown etiology Occurs in up to 50% of infants Presents 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 etiology Occurs more frequently in black males Usually presents at birth Pustule 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 Spot Flat, slate-gray to bluish-black, poorly circumscribed macules/patches Most commonly located over the lumbosacral area and buttocks Common in black, asian, and hispanic infants Usually fade by 7 years of age

Does this mottling mean this newborn is ill?

Cutis Marmorata Transient, netlike, reddish-blue mottling Caused by variable vascular constriction and dilation Response to chilling, resolves with warming Benign 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 skin Recurrence unusual after 1 month of age

What is this and is this benign?

Hemangiomas Congenital vascular malformation Occur in 10% of all newborns Presents in first few months of life Marked vascular overgrowth resulting in bright red discoloration and definite elevation Rapid growth for the first 6-12 months, then a plateau period, then slow involution 50% involute by age 5, 90% by age 9 Refer 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 malformation Seen in 60% of infants Fades in first year of life Usually 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 newborns Maternal and endogenous androgens play a role in the pathogenesis Lesions 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?

Milia Pearly yellow papules usually on the face Occur in 50% of newborns Usually resolve during the 1st month of life

Are these rashes the same?

Miliaria Results 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 stress Usually 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 familial Asymptomatic Can usually be tied off as long as no bone is palpated

Rare and Abnormal Dermatologic Findings

Collodian Baby Born encased in thick cellophane-like membrane Most 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 disorders Blisters form after mild friction or trauma Three types: epidermolytic EB, junctional EB, dermolytic EB Skin biopsy distinguishes types and determines prognosis Prenatal diagnosis is now possible for a number of variants for which gene markers are available Treatment is symptomatic and supportive

Incontinentia Pigmenti Neurocutaneous syndrome X-linked dominant, lethal in males Starts 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 Syphilis Mucocutaneous lesions usually appear between 2-6 weeks of age Most 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 Rubella Blueberry muffin lesions Seen 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 testing Treatment: 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 lesion Treat with acyclovir as soon as infection is suspected to prevent disseminated disease and morbidity/mortality

Neonatal Varicella Early 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 life Dissemination can lead to pneumonitis, encephalitis, purpura with hemorrhage, hypotension, and death If newborn at risk, should consider Varicella-zoster immune globulin or IVIG Start acyclovir early if lesions are suspicious for varicella Confirm diagnosis with DFA or PCR of lesion

Aplasia Cutis Congenita Often inherited as AD trait Absence/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