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 • QUESTIONS: 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? Case: 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? Introduction: 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. COMMON BENIGN DERMATOSES Acne Neonatorum: Frequency History Physical exam Distribution Causes Evaluation/testing Treatment 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: Frequency History 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 Distribution Spread centripetally from trunk to extremities and face, sparing palms and soles. Lesions seem to migrate by disappearing within hours and then reappearing elsewhere. Causes Unknown 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. Treatment • Benign, self-limited condition • Resolves within 2 weeks • No treatment is required Milia: Frequency History 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 Distribution Chin, nose, forehead and cheeks. Known as Epstein pearls if located on the soft or hard palate Causes Unknown 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 Treatment • Benign, self-limited condition • Resolves within 1-2 months • No treatment is required Transient Neonatal Pustular Melanosis: Frequency 0.2-4% of newborns. Twice as prevalent in African Americans than in Caucasian infants History 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 Distribution Clustered under chin, forehead, nape of neck, lower back, cheeks, trunk, extremities Causes Unknown 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. Treatment • 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): Frequency History Physical exam Distribution Unknown 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 Causes Inflammatory process related to maternal androgens Evaluation/testing Lab studies not indicated. Histology is not specific and shows features of psoriasis and chronic dermatitis. Treatment • 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: Frequency History Physical exam Distribution Causes 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 Treatment 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): Frequency History 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. Distribution Midline of the nape of the neck, forehead, eyelid, glabella Causes Dilation of blood vessels Evaluation/testing None needed Treatment None. Most fade away in about 1-2 years. The ones on the back of the neck generally do not. INFECTIOUS DERMATOSES: Herpes Simplex: Frequency History 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. Distribution 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. Causes 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) Evaluation/testing • 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. Treatment • 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: Frequency History Rare Infants can be normal at birth and can become symptomatic during the first 5 weeks of life Physical exam Hemorrhagic bullae and petechiae Distribution Pathognomonic sign is that of lesions starting on the palms and soles and spreading to trunk and extremities Causes Spirochete treponema pallidum transmitted during pregnancy to fetus Evaluation/testing • Serologic testing with RPR and FTA-ABS • Direct visualization: darksfield microscopy of lesion exudate • Direct fluorescent antibody tests of lesion exudate or tissue Treatment 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 OR Procaine penicillin G 50,000 U/kg per day IM in a single dose for 10 days Bacterial infections: Staphylococcal Scalded Skin Syndrome: Frequency History 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 slough) Distribution • 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 Causes • 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 • Desmosomes no longer can anchor the keratinocytes rendering formation of fragile, tense bullae Evaluation/testing • 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 Treatment • 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: Frequency History Physical exam Common 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. Distribution Affects moist, warm regions and skin folds (diaper area) or mucous membranes in the mouth (thrush) Causes Candida albicans Evaluation/testing No testing indicated Treatment • 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? KOH Tzanck Prep Gram stain PCR Fungi and yeast: pseudohyphae and spores • Multinucleated giant cells: herpes simplex, varicella/zoster • Eosinophils: erythema toxicum neonatorum Bacteria HSV References: 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.” http://pedclerk.bsd.uchicago.edu/ 4. Salman, Sawsan. “Newborn Rashes” http://pediatrics.uchicago.edu/chiefs/ClinicCurriculum/documents/NewbornRashe s-SueS.pdf 5. Pielop, J.A. “Vesiculobullous and pustular lesions in the newborn” Uptodate.com Accessed on 6/3/09 6. Pielop, J.A. “Benign skin and scalp lesions in the newborn and young infant.” Uptodate.com 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