1. Common pediatric rashes JFK pediatric core curriculum
MGH Center for Global Health
Pediatric Global Health Leadership Fellowship
Credits:
Brett Nelson, MD, MPH
Sohil Patel, MD

2. Discussion outline Dermatology terminology
Common benign newborn rashes
Common infectious newborn rashes
Newborn vascular lesions
Various other pediatric rashes

3. Common dermatology terms
Macule: circumscribed change in skin color without elevation or depression
Papule: solid elevated lesion usually <0.5 cm in diameter
Plaque: raised lesion >0.5cm in diameter
Wheal (hive): rounded or flat-topped elevated lesion formed by local dermal edema
Purpura: non-blanching erythema or violaceous color due to extravasation of blood
Nodule: palpable solid lesion of varying size
Vesicle: circumscribed elevated lesion which contains free fluid and is <0.5 cm in diameter
Bulla (blister): same as vesicle but with diameter >0.5 cm
Cyst: sac containing liquid or semisolid material usually in the dermis
Pustule: circumscribed elevated lesion which contains pus
Abscess: collection of pus in the dermis or subcutis

4. Benign newborn rashes Erythema toxicum neonatorum Miliaria
Neonatal acne
Milia
Seborrheic dermatitis
Benign pustular melanosis of the newborn
Sucking blisters
Presented in random order….
Some other ones not covered are:
-- mongolian spots
-- nappy rash (diaper dermatitis)

6. Miliaria Due to obstruction and rupture of exocrine sweat duct
Commonly seen secondary to thermal stress, particularly with crops of lesions over face, scalp, and trunk
Important to ensure infant is not over-wrapped
Once heat stress is removed, lesions usually resolve quickly

8. Neonatal acne
Can be present at birth or develop in first 2-4 weeks of life
Consists of pustules over the cheeks primarily, but also involves other areas of face and scalp
No comedones in neonatal form
Resolves spontaneously and without scarring
There is controversy over whether it is truly acne or whether it represents a form of pustular disorder in the newborn period.  As a result, the term neonatal cephalic pustulosis has been mooted.
As opposed to infantile acne (which develops after 2 months) and acne of adolescence, there are no comedomes in the neonatal form.
It may be difficult to differentiate between acne and miliaria rubra.

11. Benign pustular melanosis of the newborn
Lesions present at birth
Superficial pustules which rupture easily without pus content, leaving spot of hyperpigmentation
Pustules last 1-2 days but pigmented spots may persist for a while
Any area of the body may be involved
Smears from pustules reveal polymorphonuclear leukocytes with absence of organisms
Etiology is unknown.

13. Seborrheic dermatitis
Primarily affects scalp and intertriginous areas
Involvement of scalp is frequently termed "cradle cap“ and manifests as greasy, yellow plaques on scalp
Most common in first 6 weeks of life, but can occur in children up to 12 months of age
Usually clears up without treatment in 3-4 weeks
If needed, treatment can include mild tar shampoo, oatmeal baths, avoidance of soaps, and occasional use of mild topical steroid
Involvement of skin creases can lead to secondary candidal infections
Etiology unknown
Other commonly affected areas include the forehead and eyebrows (as in the photo to the left), nasolabial folds, and external ears.

15. Erythema toxicum neonatorum
Onset on day 2-3 of life, mostly in term babies
Lesions wax and wane over ensuing 3-6 days
Lesions may intensify or coalesce particularly in response to local heat
Central white-yellow papule surrounded by a halo of erythema, mainly over trunk (but also on limbs and face)
Scrapings of lesions would reveal eosinophils
Etiology unknown

18. Milia Tiny, white, usually discrete papules
Inclusion cysts that contain trapped keratinised stratum corneum
Commonly occur on face and scalp
Usually resolve within a few months without treatment
Rarely associated with dermatologic syndromes
Epidermolysis bullosa, oro-facial-digital syndrome (type 1)
Similar lesions may occasionally be seen in mouth
When on hard palate, called Epstein's pearls
When on alveolar ridges, called alveolar cysts or Bohn's nodules

20. Sucking blisters
Present at birth, most often over dorsal and lateral aspect of wrist
Either bilateral or unilateral
May appear like well-demarcated bruises or vesicles
Infant is noted to exhibit excessive sucking activity
In the lower image, the blister present on the dorsal surface of the second finger burst open discharging yellow serous fluid. Such a lesion may be confused with bullous impetigo but the time of onset, the location and the examination should differentiate the two.

21. Infectious newborn lesions
Staphylococcal pustules
Herpes simplex
Generalized in utero infection
Paronychia
Bullous impetigo
Omphalitis
Congenital syphilis
Candida Dermatitis
Presented in random order….

23. Paronychia Localized inflammation with infection of nail fold
Relatively common in infants
Treat most infections with oral antibiotics and severe cases with IV antibiotics
First line treatment is usually flucloxacillin/floxacillin for Staphylococcus aureus or Streptococcus pyogenes
For chronic lesions, consider Gram-negative organisms or Candida as potential causes
This SEPARATION may be exacerbated by the baby sucking their fingers or by overzealous trimming of the infant's finger nails.

25. Bullous impetigo
Skin infection typically caused by Staphylococcus aureus
Lesions tend to appear DOL 5-10
Any body site may be involved, with predilection to diaper area
Bullae are flaccid, containing straw colored or turbid fluid
Rupture easily leaving moist denuded area (“honey-crusted lesions”)
Treatment with systemic antibiotics, particularly for lesions around umbilicus

27. Staphylococcal pustule
Typically seen first few days of life
Predilection to neck, axilla, and inguinal areas
Nearly always caused by Staphylococcus aureus
If one lesion, may be treated "expectantly" with application of chlorhexidine (mainly to prevent spread)
However, if more than one lesion, oral antibiotics are indicated after culture is taken
For pustules in periumbilical area, consider systemic antibiotics

30. Herpes simplex May involve skin, mouth, or eye
Lesions typically develop DOL 5-10
Grouped vesicles may be seen, often in linear distribution if affecting limbs (1st slide)
If vesicle eroded, shallow ulcer with erythematous base may be seen (2nd slide)
May have associated lesions on lips -- similar to those of "cold sore" in an adult
… and when they do, they provide valuable clues to the possibility of associated disseminated or CNS herpes
However, there are exceptions to the rule and occasionally lesions may be present at birth and presumably such infants would have been exposed to the virus several days prior to delivery.

31. Herpes Simplex: SEM
HSV infection develops in one of three patterns, with roughly equal frequency
Localized to the skin, eyes, and mouth (SEM)
Localized CNS disease
Disseminated disease involving multiple organs
Can develop anytime between birth and four weeks
Patients with disseminated disease present earliest, often within the first week after delivery, although CNS symptoms usually occur during the second or third week

32. Discussion point: How do you differentiate HSV from impetigo from staph from millia?

34. Omphalitis Infection of umbilical stump
Erythematous, edematous, +/- exudative
Most commonly occurs after day 3
Infective organisms are variable, but S.aureus, S.pyogenes, and Gram-negative organisms are common
If cultures available, swab affected area for Gram-stain and culture to guide treatment
Initiate IV antibiotics
There may be signs of cellulitis ("cord flare") and, very rarely, fasciitis.
It is important to differentiate omphalitis (or funisitis - infection of the cord itself) from other causes of serous or exudative umbilical discharges, such as a persistent vitelline duct, umbilical papilloma, or urachal remnant.

36. Congenital syphilis Dermatological findings quite variable
Classically involve palmar/plantar, perioral, and anogenital regions
Early lesions include petechiae, hemorrhagic vesicles, and bullae
Lesions extremely infectious
May have extracutaneous findings
Hepatomegaly, low birth weight, thrombocytopenia, anaemia, jaundice, respiratory distress, osteochondritis, hydrops fetalis, meningitis, chorioretinitis, and pseudoparalysis
Older infants may present with "snuffles" (syphylitic rhinitis) which, in early stages, may be mistaken for URI
Because of the variable lesions and clinical symptoms seen with CS, it has frequently been termed "the great imitator", and it is important to consider alternative diagnoses or vesiculobullous diseases that involve the palms and soles.

37. Candida Dermatitis A common condition of young infants
Most commonly caused by C. albicans
Characteristically appears as an erythematous rash in the inguinal region
Classically has areas of confluent erythema with discrete erythematous papules and plaques with superficial scales
Satellite lesions are typically noted

38. Candida Dermatitis

39. Newborn vascular lesions
Harlequin phenomenon
Cutis marmorata

41. Cutis marmorata
Reticulated pattern of constricted capillaries and venules
Often called "mottling“
Due to vasomotor instability in immature infants
Generally resolves with increasing age and for most infants is of no significance
However, may reflect underlying poor perfusion
Infants who develop mottling and are unwell need to be clinically evaluated for sepsis and other illnesses

43. Harlequin phenomenon
Striking reddening of one side of body and blanching of other half
Each episode may last from seconds to minutes
Episodes occur most often during first few days of life
Thought to be vascular manifestation of changes occurring in newborn’s autonomic system

44. Various other pediatric rashes
Adapted from:
Paul Geltman, MD, MPH and
Johns Hopkins DermAtlas
The following are ~80 slides to be used as time permits – possibly during a second lecture session. Some photos may contain nude anatomy and would not be appropriate for openly public display.

45. Measles Description: red confluent papular eruption Comments:
A 5 year old boy developed fever, headache, and sore throat followed several days later by a red papular rash on the face. Five days later the rash was confluent on his face and disseminated over the trunk and extremities including the palms and soles.

46. [The remainder of these ~80 slides have been temporarily removed from this lecture due to space limitations. The full lecture (25MB) is available from