1. Neonatal Dermatologic Findings

2. Common and Usually Benign Dermatologic Findings

3. 24 hour old female with this rash, what is it?

4. 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 hours of life, fades within 5-7 days, but recurrences may occur for several weeks
Smear of pustule reveals eosinophils

5. What is this rash noted on this baby immediately after birth?

6. 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

7. Is this bruising from birth trauma or something else?

8. 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

9. Does this mottling mean this newborn is ill?

10. 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

11. Is this lesion benign?

12. 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

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

14. Acrocyanosis Hands and feet become variably and symmetrically blue
Resolves with warming of the skin
Recurrence unusual after 1 month of age

15. What is this and is this benign?

16. 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

17. Can you guess the name for this rash?

18. 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

19. What syndrome can be related to this vascular malformation?

20. 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

21. Can babies get pimples?

22. 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

23. What’s on this baby’s nose?

24. 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

25. Is this the same as the previous rash?

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

27. Are these rashes the same?

28. 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

29. Is this polydactyly?

30. 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

31. Rare and Abnormal Dermatologic Findings

33. 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

35. 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

37. 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

39. 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

41. 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

43. 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

45. 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

47. 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

49. 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