Newborn Skin Rashes COMPETENCY – The resident should be able to:

Newborn Skin Rashes
COMPETENCY – The resident should be able to:
• Distinguish between noninfectious self-limiting disease versus potentially lifethreatening 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
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?
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?
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.
Acne Neonatorum:
Physical exam
Extremely common
Usually occurs around 2-4 weeks of age
Comedones, papules. Resembles acne vulgaris seen in adolescents
Cheeks, chin, forehead, upper chest, shoulders
Maternal adrogenic hormonal stimulation of sebaceous glands
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.
• 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:
Physical exam
30-70% of newborns with no racial or gender tendency
Term neonates 3-14 days. 90% of cases occur after 48 hours of age
1-3mm white/yellow papules, vesicles, and pustules surrounded by a
blotchy erythematous halo
Spread centripetally from trunk to extremities and face, sparing
palms and soles. Lesions seem to migrate by disappearing within
hours and then reappearing elsewhere.
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.
• Benign, self-limited condition
• Resolves within 2 weeks
• No treatment is required
40-50% of newborns with no racial or gender tendency
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
Chin, nose, forehead and cheeks. Known as Epstein pearls if located
on the soft or hard palate
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
• Benign, self-limited condition
• Resolves within 1-2 months
• No treatment is required
Transient Neonatal Pustular Melanosis:
0.2-4% of newborns. Twice as prevalent in African Americans than in
Caucasian infants
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
Clustered under chin, forehead, nape of neck, lower back, cheeks,
trunk, extremities
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.
• 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):
Physical exam
Begins in 1st 12 weeks of age and can last up to 3 years of age
Greasy, scaling with patchy redness, fissuring & occasional weeping.
Scalp is the most common site but can also appear on the face, ears,
forehead, eyebrows, trunks and flexural areas
Inflammatory process related to maternal androgens
Evaluation/testing Lab studies not indicated. Histology is not specific and shows
features of psoriasis and chronic dermatitis.
• 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:
Physical exam
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
Present at birth
Blue-grey pigmented macules with indefinite borders OR
Greenish-blue or brown.
Most common location is sacro-gluteal region, then the shoulders.
Very rarely on the face or flexor surface of extremities.
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
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):
Common – 40-60% of newborns
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.
Midline of the nape of the neck, forehead, eyelid, glabella
Dilation of blood vessels
Evaluation/testing None needed
None. Most fade away in about 1-2 years. The ones on the back of the
neck generally do not.
Herpes Simplex:
1 in 1000 to 1 in 5000 deliveries per year
• 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.
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.
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)
• 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.
• 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:
Infants can be normal at birth and can become symptomatic during
the first 5 weeks of life
Physical exam
Hemorrhagic bullae and petechiae
Pathognomonic sign is that of lesions starting on the palms and soles
and spreading to trunk and extremities
Spirochete treponema pallidum transmitted during pregnancy to fetus
• Serologic testing with RPR and FTA-ABS
• Direct visualization: darksfield microscopy of lesion exudate
• Direct fluorescent antibody tests of lesion exudate or tissue
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
Procaine penicillin G 50,000 U/kg per day IM in a single dose for 10
Bacterial infections:
Staphylococcal Scalded Skin Syndrome:
Not common
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
• 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
• 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 no longer can anchor the keratinocytes
rendering formation of fragile, tense bullae
• 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
• 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:
Physical exam
Usually develops after the first week of life
• 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.
Affects moist, warm regions and skin folds (diaper area) or mucous
membranes in the mouth (thrush)
Candida albicans
Evaluation/testing No testing indicated
• 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?
Tzanck Prep
Gram stain
Fungi and yeast: pseudohyphae and spores
• Multinucleated giant cells: herpes simplex, varicella/zoster
• Eosinophils: erythema toxicum neonatorum
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.”
4. Salman, Sawsan. “Newborn Rashes”
5. Pielop, J.A. “Vesiculobullous and pustular lesions in the newborn”
Accessed on 6/3/09
6. Pielop, J.A. “Benign skin and scalp lesions in the newborn and young infant.” 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