1. Common Rashes in the Newborn
Spencer Copland, MD
CMC Family Medicine
Newborn Nursery
Modified by Marsha Rhodes, MD
CMC Pediatrics
2/13/09

2. Genetic Differences in Skin Color
Don’t assume that a light-skinned baby is Caucasian
Some AA infants are quite light at birth
Most darker skinned babies get darker over time
For clues to the eventual skin tones look at the top of the pinnae, at the base of fingernails, and at genitalia

3. Vernix Caseosa Cheesy coating on term babies at delivery
In utero waterproofing
Current trend is to not remove it
May have antibacterial (via pH) and emollient benefits
Nursing debates re timing of first bath

4. Dry, peeling skin

5. Acrocyanosis Persistent blue-purple color of distal extremities Normal
Is not really cyanosis
Normal
Resolves with maturation of autonomic system

6. Vacuum delivery bruising
Somewhat well-defined circular area of erythema of scalp in infants delivered by vacuum (or attempted delivery)
At increased risk for hyperbilirubinemia as result of hemolysis
At increased risk for subgaleal hemorrhage
Diffuse or localized subgaleal bleed
Palpable fluid wave

7. Cutis Marmorata Sometimes called “livedo reticularis”
Venous mottling of skin in young children
More prominent when cool
Classically improves with warming
Benign
Resolves in a few months as autonomic control of vasculature matures
Appearance later in life associated is generally not good
The very pronounced form of this is “cutis mamorata telangiectasia congenita”
It looks more purpuric and brownish in color

8. Sebaceous Hyperplasia
These are frequently called “milia” but they’re really not so please don’t call them that
Most newborns have sebaceous hyperplasia
Slightly dome-shaped yellowish-white plugs in typical sebaceous gland locations (nose & chin)
Benign & resolve in a few weeks
No treatment needed
Question: does this baby have retinoblastoma?
Probably not but ….

9. Milia These are the real milia!
They are tiny white superficial cysts (check the right cheek and the left chin)
Most common on face but can be seen anywhere on the body
Benign and self- limited
Resolves in days to weeks
No treatment needed

10. Epstein Pearls Very common
Yellow-white epithelial cysts on roof of mouth
One to several
Benign epithelial cysts
No treatment needed
Resolve spontaneously in 2-3 wks

11. Bohn's Nodules
Comparable to Epstein Pearls but occur on buccal surface of gums
May be single or multiple
May be missed if you don’t use a tongue blade
Benign
Resolve spontaneously in 2-3 wks
Parents think they’re teeth … but they’re not!

12. Preauricular Pits or Sinuses
Fairly common
Tend to run in families
Do not resolve but no need for intervention unless swell, drain, and/or infected (occurs after NB period)
Risk of hearing loss is minimal but all babies have hearing tested

13. Accessory Tragi
Aka preauricular skin tags but “accessory tragi” is a better term if there is a complex grouping
Range from mounds to peduculated appendages
Increased risk of hearing loss and associated syndromes including branchial cleft defects

14. Skin Tags

15. “Sacral Dimples”
What the nurses call sacral dimples and sinuses are actually intergluteal, not sacral, lesions
They are within the buttock crease
These are quite common and are at very low risk for underlying spinal deformities and tethered cords
Imaging is rarely indicated
True sacral and lumbosacral area lesions above the intergluteal crease do warrant concern
The one pictured here is quite unusual
Ultrasound at birth is fine but it’s best to MRI sinus tracts at ~ 6 wks
Skin dimples in general are benign
Thought to originate in areas of in utero compression
“Y” shaped intergluteal creases are a normal variation (though there is some controversy about these)

16. Slate Grey Patches Aka “Congenital dermal melanosis”
Collection of melanocytes deep in the dermis
Most common in LS area and over buttocks, but can be anywhere
More common in darker skinned infants
Macular, blue-black or blue-green patches with a sheen to the skin
Usually fade in 5-10 years in part because skin tends to darken
They are so common and normal than routine documentation not truly essential but unusual mongolian spots (distribution or location) should certainly be documented
Sometimes mistaken for bruises by parents, babysitters, daycare personnel
Should be mentioned to parents so that they understand that they are not bruises

17. Mongolian Spots There is a large faint one in the photo
While we’re here …
LANUGO at the top of the intergluteal crease is frequently directed down into the crease … and can be misinterpreted as a “hair tuff”
It’s not!
Hair tufts are well-defined patches of coarse hairs in the true LS area (b/w the iliac crests where an LP would be done)
Fortunately they are quite rare
But when present are clues to underlying neural problems

18. Café au lait Lesion A very common birthmark Questions Bonus question
May be inconspicuous at birth then darken over time
Hard to see in darker skin
Questions
What disorders are associated with multiple café au lait lesions?
How many are needed to inspire you to think of them?
How big do they need to be?
Bonus question
Is the Bandaid necessary?

19. Answers about Café au lait Lesions
What disorders are associated with multiple café au lait lesions?
Neurofibromatosis
Tuberous sclerosus
How many are needed to inspire you to think of them?
6 or more for NF
How big do they need to be?
0.5 cm or larger
No, the ACIP doesn’t recommend Bandaids after injections but acknowledges that everyone expects them
Remove before discharge or you’ll see them still on there at the newborn visit

20. What is the difference between a nevus simplex and a nevus flammeus?

21. Nevus Simplex Very common
Aka “Angel’s kiss” (glabella) or “salmon patches” (eyelids) but we use the terms interchangeably
Known as “stork bite” when it’s on the nape
Flat, erythematous patch(es) that blanches with pressure
Usually on eyelid, glabella, naso-labial area, forehead, nape but can be anywhere
Not a vascular malformation
Benign & no treatment needed
Most resolve on their own over several months
When the ones on the face first fade away, they “light” back up with overheating and crying before fading completely
~50% of those on nape persist throughout life

22. Nevus Flammeus Aka “port wine stain”
Is a vascular malformation: a type of hemangioma
Prominent flat, pink, red, or purple mark that does not blanch
Continues to grow with the child
Permanent disorder (does not resolve)
If in V1-3 trigeminal distribution needs cranial MRI, neuro & ophthamology consults
Possible Sturge Weber Syndrome and/or glaucoma
Laser therapy used for cosmesis

23. Hemangioma Usually not apparent at birth
You might see a hypopigmented area with a subtle vascular component (telangietatic)
Types: cherry, strawberry, cavernous
Will become more prominent and raised
Due to proliferation of vasculature
Grow rapidly during 1st yr then most atrophy and regress over several years
Can cause bleeding problems
Hemangiomatosis (diffuse lesions may be internal and external)
Kasselbach-Merritt Syndrome (platelet consumption)
Tx:
None unless extensive, interfering with vision, breathing, etc
Laser therapy is best
Excision usually has less than optimal results
Occasionally steroids used
Derm consult may be helpful
Note: many insurers including Medicaid do not pay for cosmetic procedures. For serious lesions, you may have to build a medical argument for intervention. MOST will do fine without intervention since most resolve spontaneously.

24. Hemangiomas

25. What disorders are in the differential for pustular disorders in neonates?

26. Diff Dx of NB Pustular Disorders
Erythema toxicum
Not really pustules, erythematous flare, healthy term infants
Transient neonatal pustular melanosis
Hyperpigmented macules, pustules, collarette of fine scale, present at delivery, in health term infants
Cutaneous candidiasis
Thousands on pustules in otherwise healthy infant
Uncommon
Neonatal acne and neonatal cephalic pustulosis
Pustules on cheeks
HSV
Usually preterm and very sick when skin symptoms present at birth, otherwise lesions typically appear in 2-4 days
The most worrisome of course
Varicella
Maternal history of recent infection
Folliculitis
Pustules associated with hair follicles, should not be present at birth
Bullous disorders
Usually are large and flaccid with clear fluid

27. Erythema Toxicum Very common
Affects 30-70% of newborns
More common in term infants
Small papules, vesicles, and pustules with erythematous flare
Spares palms and soles
Parents always think they are flea bites
Can be confused with miliaria rubra
They present a few hours after birthand are evanescent (change location over a matter of hours)
Suspected allergic and/or immunologic etiology but no one really knows
Do contain eosinophils
Possibly related to immaturity of pilosebaceous follicles
Benign, no w/u or tx needed
Resolve spontaneously in 2-3 weeks

28. Pustular form of ETN

29. Transient Neonatal Pustular Melanosis
Yes, it’s a mouthful
We sometimes just say “melanosis” or “pustular melanosis”
Hallmark is ~2 mm hyperpigmented macules
May also have few to many thin-walled pustules which rupture easily leaving fine collarette of scale
Lack erythematous flare
Consider “lentiginoses” if only the macules are present
More common in darker skinned term infants (incidence ~5%)
Cause unknown
Gram stain: neutrophils
Benign
No w/u or tx needed if you know that’s one it is
Resolves spontaneously in a few weeks

30. Transient Neonatal Pustular Melanosis vs Lentiginoses

31. Neonatal Varicella
1-3 mm vesicles and erythematous papules -> pustules, crusts, erosions
Typically begin on scalp or face
Appear in crops down body
Crust in same order
Trunk or buttocks especially w/ breech presentation
Lesions develop around 6-13 days of age
Lesions at birth are from intrauterine infection

32. Neonatal Herpes

33. Cutaneous Candidiasis
Thousands of pustules
Healthy, vigorous infant
Do KOH and fungal culture
Tx with topical nystatin

34. Folliculitis Bacterial infection of hair follicles
Unusual in newborns but it’s in the differential of pustules
A few to multiple lesions
Gram stain and C&S
Confer with ID

35. What is the difference between milia and miliaria
What is the difference between milia and miliaria? What types of miliaria are there?

36. Miliaria Crystallina
Profuse tiny superficial vesicles similar to what can happen with sunburns
Not seen often but you need to know what it is
Benign
No treatment needed
Avoid lotion/creams
Keep infant more lightly dressed

37. Miliaria Rubra Aka “prickly heat”
Related to overheating
Is related to miliaria crystallina; it just occurs in deeper stratum corneum
Scattered vesiculo-pustular lesions frequently in patches with surrounding erythema
Easy to confuse with erythema toxicum
Benign
Avoid lotions/creams
Keep infant lightly dressed
Miliaria sudamina
Lesions are even deeper

38. Is it Neonatal Acne? Neonatal acne is overdiagnosed
Actual pimples and comedones
Tx usually not needed
Can consider Retin-A if severe
No association with acne later in life
Neonatal cephalic pustulosis
More common
This is probably what most people think is neonatal acne
No comedones
Caused by Malazzemia sp.
Benign
If severe can use topical antifungal (ketoconazole)

39. Sucking Blister
Raw or blistered area on fingers, hand, or distal forearm (look under ID bracelet!)
DDx includes bullous disorders but there are usually multiple bullae with those
Sucking blisters on the hands/arms are clear evidence of in utero sucking behavior
Usually heal without scarring
Treatment not usually needed
Sucking blisters (or pad) can also form on upper lip
Noticed after feeding for a few weeks
Do not rupture !
Check for ankyloglossia

40. Scalp Bruising

41. Forceps delivery marks
On face or scalp
Linear or curvilinear bruising
Can cause eye injury and facial palsy

42. Scalp Electrode Lesions
Typically linear or curvilinear abrasion
May become infected
Confused with aplasia cutis
History of monitor
Location
Appearance
Rapidity of healing

43. Aplasia Cutis Raw area of skin Most common in the scalp Hairless
Variable depth of involvement
Eventually fills in
Midlline lesions may be associated with underlying defects
Confused with scalp electrode lesions and Nevus of Jadassohn

44. Nevus of Jadassohn Frequently confused with aplasia cutis
Elevated orange-yellow plaque with an “orange peel” appearance
Aka “Nevus sebaceous”
Hairless
Usually in scalp but can be elsewhere
Initially benign but has potential for malignant transformation in adolescence and adulthood
Excision recommended in late childhood, early adolescence

45. Harlequin color change
Line of color change in the midline of the body
Dependent half of body is reddish
Uncommon but fun to see
Benign & resolves spontaneously with time
Not to be confused with a Harlequin fetus
Severe disruption of the skin

46. Jaundice
Yellow-orange hue to skin and sclerae associated with hyperbilirubinemia
Some degree of it occurs in >60% of infants
Contributing factors:
Relative polycytemia
Enterohepatic circulation
Relative dehydration in first few days especially if breastfeeding
Most often mild and physiologic
ABO incompatibility is next most common then extensive bruising
Then there are many other causes …
Note: infants with biliary atresia usually have a greenish hue to their skin

47. Jaundice

48. Spina bifida Don’t palpate LS lesions Keep moisturized
Transfer to NICN
Neurosurgery needed

49. Amniotic bands

50. Sprengle’s lines Horizontal crease across calves
Thought to be due to amniotic bands
It’s the same Sprengle who described Sprengle’s deformity (winging of scapula)

51. Congenital nevi

52. Amniocentesis marks
A random skin pit

53. Brachial Cleft Cysts and Sinuses
Congenital lesions typically located just anterior to SCM muscle
Check for sinus tracts especially at base of skin tags on neck

54. Thyroglossal Duct Cysts
Midline cyst that moves with swallowing
Congenital defect but usually doesn’t present until ~15 months of age
Need to be excised by ENT

55. Congenital Syphilis Rash starts on palms/soles May be present at birth
Bullae are highly infectious
May have blueberry muffin rash (peteciae)

56. Newborn Hair Poliosis = white hair patch
Is lost by ~ 2-3 months of age
Can come in as a different color
Some babies “go bald” all over
In others it’s never obvious that they lost their hair at all
Loss of hair on back of head is from rubbing
Development, allow to sit up more, tummy time

57. Hypopigmented Lesions
Piebaldism
Congenital depigmentation of skin and/or hair (poliosis)
Does not progress
Usually benign
Classic: Waardenburg Syndrome with white forelock and hearing loss
Vitiligo
Acquired depigmentation
Likely to progress
Associated with autoimmune disorders
Nevus achromicus
Lesion disappears with the glass test because it’s actually a less vascularized area of the skin
Benign
Tuberous sclerosis

58. How many ash leaf spots should make you concerned about tuberous sclerosis?

59. You should be concerned about tuberous sclerosis if there are 3 or more hypopigmented lesions.

60. What other skin lesions are associated with TS?

61. Shagreen patches. Sebaceous adenomas, café au lait and ash leaf spots are other markers of TS

62. Uncommon disorders Tuberous schlerosis Bullous disorders
Incontinentia pigmenti
Epidermal nevus
Subcutaneous fat necrosis
Blueberry muffin rashes
Syphilis, rubella

63. Vestigial Tail Rare but now you’ve seen one
Neurosurgery consult needed