1. science
2. medicine
3. surgery

AFP Journal Review:
January 1, 2008
John W. Hariadi, M.D.
Newborn Skin: Part I.
Common Rashes







Rashes extremely common in 1st 4 weeks of
life
Mostly benign and self-limited
Transient Vascular phenomenon
Erythema Toxicum
Acne Neonatorum
Milia, Miliaria
Seborrheic Dermatitis
Clinical Recommendation
Evidence
ratin
g
Infants who appear sick and have vesiculopustular rashes should be tested for Candida, viral,
and bacterial infections.
C
Acne neonatorum usually resolves within four months without scarring. In severe cases, 2.5%
benzoyl peroxide lotion can be used to hasten resolution.
C
Miliaria rubra (also known as heat rash) responds to avoidance of overheating, removal of
excess clothing, cool baths, and air conditioning.
C
Infantile seborrheic dermatitis usually responds to conservative treatment, including petrolatum,
soft brushes, and tar-containing shampoo.
C
Resistant seborrheic dermatitis can be treated with topical antifungals or mild corticosteroids.
B
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi
= consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information
SORT evidence rating system
Transient Vascular Phenomena


Normal Newborn Physiology rather than true
“rashes”
Cutis Marmorata and Harlequin Color
Change
Cutis Marmorata





Normal reticulated
Mottling of skin
Trunks and extremities
Vascular response to
cold
May persist for weeks
or months
Generally resolves
when skin is warmed
Harlequin Color Change







?Caused by immaturity of hypothalamic center that
controls dilation of peripheral blood vessels
Occurs when newborn lies on side
Erythema of dependent side with blanching of
contralateral side
Persists for 30 seconds to 20 minutes
Resolves with crying or increased muscle activity
Up to 10% of full term infants
From 2nd-5th day of life, may continue up to 3 weeks
Erythema Toxicum Neonatorum






Most common pustular eruption
in newborns (40-70%)
Common in term infants and
those >5.5 lbs
Present at birth, 2nd-3rd DOL
Erythematous 2-3 mm macules
& papules pustules
Pustule surrounded by blotchy
area of erythema –”flea bitten”
Face, trunk, proximal
extremities-spares palms/soles
Erythema Toxicum Neonatorum






Generally clinical diagnosis
Cytologic exam of pustuleeosinophilia with
Gram, Wright, Giemsa Stain
Etiology is unknown
Fade over 5-7 days, may recur for several
weeks
No treatment needed
If sick appearing, need to r/o infectious cause
Table 1. Infectious Causes of Vesicles or Pustules in the
Newborn
Class
Cause
Distinguishing features
Bacterial
Group A or B
Streptococcus
Listeria monocytogenes
Pseudomonas aeruginosa
Staphylococcus aureus
Other gram-negative
organisms
Other signs of sepsis usually present
Elevated band count, positive blood culture; Gram stain of intralesional contents shows polymorphic
neutrophils
Fungal
Candida
Presents within 24 hours after birth if congenital, after one week if acquired during delivery
Thrush is common
Potassium hydroxide preparation of intralesional contents shows pseudohyphae and spores
Spiroche
tal
Syphilis
Rare
Lesions on palms and soles
Suspect if results of maternal rapid plasma reagin or venereal disease research laboratory test positive
or unknown
Viral
Cytomegalovirus
Herpes simplex
Varicella zoster
Crops of vesicles and pustules appear on erythematous base
For herpes simplex and varicella zoster, Tzanck test of intralesional contents shows multinucleated
giant cells
Transient Neonatal Pustular Melanosis








Vesiculopustular rash
5% Black, ,1% White
Lesions lack surrounding
erythema
Pigmented macules within
the vesiculopustules
Rupture easilyleave
behind scales & pigmented
macules
All areas affected including
palms/soles
Fade over 3-4 weeks
Cytology: PMNs
Acne Neonatorum







20% of newborns
Closed comedones on
forehead, nose, cheeks
Open comedones, inflammatory
papules
Stimulation of sebaceous
glands by maternal androgens
Resolve within 4 months
without scarring
Treatment usually not required;
can use 2.5% benzoyl peroxide
Persistent/Severe need to
look for underlying causes
Milia





1-2 mm pearly white/yellow papules
Retention of keratin within dermis
Up to 50% of newborns
Forehead, nose, cheeks, chin but can also:
trunk, penis, limbs, mucous membranes
Resolve within 1st month, can last till 2nd or
3rd month
Miliaria



Sweat retention by partial
closure of eccrine structures
40% of infants-1st MOL
Miliaria Crystallina
–
–

Miliaria Rubra-”Heat Rash”
–
–

1-2mm vesicles without
surrounding erythema
Hours to days
Erythematous papules, in
covered portions of skin
Deeper level of sweat gland
obstruction
Avoid overheating, remove
excess clothing, cooling baths,
air conditioning
Seborrheic Dermatitis





Extremely common
“Cradle Cap”-may
include face, ears, neck
Erythema in flexural
folds, scaling on scalp
Often involves diaper
area
Can be difficult to
distinguish from atopic
dermatitis
Table 2. Distinguishing Features of Seborrheic and Atopic
Dermatitis in Infancy
Feature
Seborrheic dermatitis
Atopic dermatitis
Age at
onse
t
Usually within first
month
After three months of age
Course
Self-limited, responds to
treatment
Responds to treatment, but
frequently relapses
Distributi Scalp, face, ears, neck,
on
diaper area
Scalp, face, trunk, extremities,
diaper area
Pruritus
Ubiquitous
Uncommon
Seborrheic Dermatitis



Etiology unknown-? Malassezia furfur,
hormonal fluctuations
Self limited- resolves several weeks to
months
Conservative approach
–
–
–
Watchful waiting
Soft Brush after shampooing
Emollient
Table 3. Treatment Options for Infantile Seborrheic
Dermatitis
Medication
Directions
Cost
(generic)*
White petrolatum
Apply daily
$3 for 30 g
May soften scales, facilitating
removal with soft brush
Tar-containing shampoo
Use several times per
week
$13 to $15 for
240 mL
Use when baby shampoo has
failed
Safe, but potentially irritating
Ketoconazole (Nizoral, brand no
longer available in the United
States), 2% cream or 2%
shampoo
Cream: apply to scalp
three times weekly
Shampoo: lather, leave on
for three minutes, then
rinse. Use three times
weekly
Cream: ($16
to $37 for
15 g)
Shampoo: $30
to $33 for
120 mL
($16 to
$38)
Small trial showed no systemic
drug levels or change in
liver function after one
month of use
Hydrocortisone 1% cream
Apply every other day or
daily
$2 to $4 for 30
g
Limit surface area to reduce
risk of systemic absorption
and adrenal suppression
May be especially effective for
rash in flexural areas
Notes
Newborn Skin: Part II
Birthmarks

3 Main groups
–
Pigmented


–
Vascular


–

Congenital melanocytic Nevi
Dermal Melanosis
Hemangiomas
Nevus Flammeus, Nevus Simplex
Abnormal development
Most do not require immediate treatment
Clinical recommendation
Patients with large congenital melanocytic nevi should be
referred to a surgeon and followed for recurrence.
Evidence
C
Uncomplicated hemangiomas that are not near the eyes,
lips, nose, or perineum do not require treatment.
C
Infants with port-wine stains near the eyes should be
referred for glaucoma testing.
C
Patients with multiple midline lumbosacral skin lesions or a C
single high-risk lesion should undergo magnetic
resonance imaging or ultrasonography to rule out occult
spinal dysraphism.
Congenital Melanocytic Nevi






0.2-0.4% infants at birth
Disrupted migration of
melanocytic precursors in
neural crest
Color: Brown to black
Mostly flat, can be raised
Potential for malignancybased on size
Nevus that changes in color,
shape or thickness need
further evaluation
Table 1. Management of Congenital Melanocytic Nevi by Size
Size
Projected
size in
Size during infancy
adulthood Management strategy
Giant
>14 cm
> 40 cm
Remove nevus, observe for
recurrence in original or
distal sites
Large
> 7 cm on torso,
buttocks or
extremities;
>12 cm on head
20 to 40 cm
Remove nevus, observe for
recurrence in original or
distal sites
Medium
0.5 to 7 cm
1.5 to 20 cm
Consider referral to
dermatologist for
observation
Small
< 0.5 cm
< 1.5 cm
Observe in primary care
setting
Dermal Melanosis






“Mongolian Spots”
Flat, most often in back or
buttocks
Arise when melanocytes
trapped deep in the skin
Common in Non-white
populations
Should be documented in
newborn exam
Most fade by 2 years of age
Hemangiomas






1.1-2.6% of newborns
Can develop anytime in 1st few months
of life, 10% at 1 year
50% involute by 5 years, 70% by 7
years and 90% by age 10
May leave scars
Can treat with pulse dye laser—unsure
long term cosmetic outcome
Eye, airway or organ compression
require immediate treatment & referral
–
Prednisone 3mg/kg x 6-12 weeks
Nevus Flammeus







“Port Wine Stain”
0.3% of newborns
Flat,dark red to purple lesions
Do not fade over time
May develop varicosities,
granulomas, nodules
Do not require treatment—Pulse
dye laser before age1
Opthalmic (V1) distribution
associated with glaucoma
–
5-8% with Sturge-Weber Syndrome


–
glaucoma/seizures/port-wine stain,
angioma of brain/meninges
Mental retardation & hemiplegia
Refer to Ophthalmology
Nevus Simplex





“Stork bites” ,“Angel Kisses” , “Salmon patch”
Flat, salmon colored lesions-telengectasias
in dermis
Eyes, scalp, neck—blanch when compressed
Occur on both sides of face in symmetric
pattern
40% resolve in neonatal period, most by 18
months
Supernumerary Nipples





Arise from mammary ridges along ventral
body wall
May contain areola, nipple or both
May be unilateral/bilateral
Up to 5.6% of children
Mostly benign
Skin Markers of Spinal Dysraphism

Spinal dysraphism:
–
–

diverse congenital spinal anomalies caused by incomplete
fusion of midline elements of the spine
Tethered Cord Syndrome-need surgical release
Midline lumbosacral skin lesions are often cutaneous
markers of spinal dysraphism
–
–
High or intermediate risk lesions should undergo imaging
MRI is most sensitive. Spinal ultrasonography also used
Table 2. Cutaneous Markers and Risk of Occult Spinal Dysraphism
Risk of occult spinal
dysraphism
Suggested evaluation
Any one of the
following:
Dermal sinus
Lipoma
Tail
High
MRI
Any one of the
following:
Aplasia cutis
congenita
Atypical dimple
Deviation of
gluteal
furrow
Intermediate
MRI or ultrasonography
Any one of the
following:
Hemangioma
Hypertrichosis
Mongolian spot
Nevus simplex
Port-wine stain
Simple dimple
Low
No evaluation needed in most cases; may consider ultrasonography
depending on local standard of care
Two or more
lesions
of any type
High
MRI
Skin lesion
Clavicle Fractures



5-10% of all fractures
Most in men<25 yrs, men >55 & women >75
Allman Classification
–
–
–
Group I (midshaft/middle third) ->75-80%, young
Group II (lateral/distal)-> 15-25%
Group III (medial/proximal)-> 5%
Clinical recommendation
Nonoperative treatment is preferred for nearly all acute, nondisplaced
midshaft clavicle fractures.
Evide
nc
e
B
Treatment with an arm sling is preferred over a figure-of-eight dressing for B
acute midshaft clavicle fractures because it is better tolerated and
leads to similar outcomes.
Displaced midshaft clavicle fractures may be managed nonoperatively,
but plate fixation should be considered.
B
Nonoperative treatment is preferred for distal clavicle fractures because
outcomes are the same whether or not bony union is achieved.
B
Anatomy





Midshaft is thinnest, least
medullous area
AC & SC joints have robust
ligamentous support
Sternal ossification center
fuses with shaft by age 30
Malunion can impair mobility
to upper extremity
Callus formation/
displacement can lead to
thoracic outlet obstruction
Evaluation





Mechanism of injury: fall directly on shoulder
with arm at side, often in contact sports
Hold affected arm adducted close, support
with opposite hand
Exam: ecchymosis, edema,focal tenderness
and crepitus on palpation of clavicle
Need to perform neurovascular & lung exam
Radiographs should be performed
Midshaft Clavicle Fractures
Midshaft Clavicle Fractures

Nondisplaced
–
–
–

Sling /Figure of eight dressing
Can discontinue in 1-2 weeks
when pain subsides
Pendulum exercises as soon
as pain allows, active ROM &
strengthening 4-8 weeks
Displaced
–
–
Higher rates of nonunion
Can consider operative
treatment in patients with
multiple risk factors
Table 1. Risk Factors for Nonunion of Midshaft Clavicle
Fractures
Clavicle shortening > 15-20 mm
Female sex
Fracture comminution
Fracture displacement
Greater extent of initial trauma
Older age
Midshaft Clavicle Fractures

Operative options:
–
–



Open/closed reduction with plate fixation
Intramedullary fixation->smaller incisions, avoids plate
pressure but risk of device migration
Complications rare->pneumothorax, vascular injury
Long term Sequelae: Pain, weakness, parasthesias
Displacement of > one bone width is strongest
radiographic risk factor for symptoms & sequealea
Return To Activity Considerations







Full Range of motion
Normal shoulder strength
Clinical & radiographic evidence of bone healing
No tenderness
Can return to noncontact sports in 6 weeks
Contact sports in 2-4 months
If surgical case->may need removal of hardware
Midshaft Clavicle Fractures in Children





88 percent of clavicle fractures
Nearly all heal well due to great periosteal
regenerative potential
Often have significant callus formation
Healing within 4-6 weeks
If no history of trauma, need to consider
malignancy, rickets, osteogenesis imperfecta
and physical abuse
Distal Clavicle Fractures

5 Types:
–
–
–
–
–



Type I Coracoclavicular ligament intact
Type II Conoid (medial) torn, trapezoid intact
Type III Extension into AC joint
Type IV Disruption in periosteal sleeve (children)
Type V Avulsion of ligaments with small cortical fragment
Type I & III-stable nonoperative
Type II->high rate of nonunion
Type IV-often occurs through distal physis with
ligaments attached-> “pseudodislocation”
–
Operative treatment only with sever displacement
Proximal Clavicle Fractures




Very uncommon
Typically nondisplaced
If displaced, need to evaluate for
neurovascular compromise
May need CT scan for better visualization
Herbal and Dietary Supplement-Drug
Interactions in Patients with Chronic
Diseases



Herbs, Vitamins and supplements may augment or
antagonize actions of drugs
Deleterious effects are most pronounced with
anticoagulants, cardiovascular medications, oral
hypoglycemics and antiretrovirals
St. John’s Wort
–

Reduction in INR with warfarin, reduced levels of verapamil,
statins, digoxin, antiretrovirals
Physicians should routinely ask patients about use of
supplements