Download Neonatal Dermatology 2010

Neonatal Dermatologic Findings
Common and Usually Benign
Dermatologic Findings
24 hour old female with this rash,
what is it?
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
What is this rash noted on this
baby immediately after birth?
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
Is this bruising from birth trauma or
something else?
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
Does this mottling mean this
newborn is ill?
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
Is this lesion benign?
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
What’s wrong with this newborn’s
hands and feet?
Acrocyanosis
 Hands and feet become variably and symmetrically blue
 Resolves with warming of the skin
 Recurrence unusual after 1 month of age
What is this and is this benign?
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
Can you guess the name for this
rash?
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
What syndrome can be related to
this vascular malformation?
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
Can babies get pimples?
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
What’s on this baby’s nose?
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
Is this the same as the previous
rash?
Milia
 Pearly yellow papules usually on the face
 Occur in 50% of newborns
 Usually resolve during the 1st month of life
Are these rashes the same?
Miliaria
 Results from obstruction to the flow of sweat and rupture of
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the eccrine sweat gland
Miliaria crystallina - superficial 1-2mm vesicles on noninflamed 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
Is this polydactyly?
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
Rare and Abnormal Dermatologic
Findings
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
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
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
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
Congenital Rubella
 Blueberry muffin lesions
 Seen in severe disseminated disease with jaundice, pneumonitis,
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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
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
Neonatal Varicella
 Early exposure in utero during 1st trimester can rarely lead to
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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
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
Neonatal Lupus Erythematosus
 Annular erythematous plaques with a central scale
 Transplacentally aquired ssA (Ro) and ssB (La) Ab is thought to
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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