Neonatal Dermatologic Findings

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Neonatal Dermatologic Findings
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Common and Usually Benign Dermatologic Findings
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24 hour old female with this rash, what is it?
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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 24-48 hours of life, fades within 5-7
  days, but recurrences may occur for several weeks
• Smear of pustule reveals eosinophils

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

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Is this bruising from birth trauma or something
else?
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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

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Does this mottling mean this newborn is ill?
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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

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Is this lesion benign?
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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

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Whats wrong with this newborns hands and feet?
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Acrocyanosis

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

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What is this and is this benign?
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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

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Can you guess the name for this rash?
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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

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What syndrome can be related to this vascular
malformation?
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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

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Can babies get pimples?
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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

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Whats on this babys nose?
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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

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Is this the same as the previous rash?
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Milia

• Pearly yellow papules usually on the face
• Occur in 50 of newborns
• Usually resolve during the 1st month of life

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Are these rashes the same?
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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

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Is this polydactyly?
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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

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Rare and Abnormal Dermatologic Findings
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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 -gt 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

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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

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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) -gt warty plaques by several
  weeks to months -gt increasing pigmentation at 2-6
  months that look like marble cake swirls -gt fade
  to hypopigmented patches in late childhood
• Associated defects in the CNS, eye, dentition,
  heart, skeletal system

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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

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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

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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

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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

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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

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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