Neonatal Dermatologic Findings

1. Neonatal Dermatologic Findings

2. Common and Usually Benign Dermatologic Findings

3. 24 hour old female with this rash, what is it?

4. 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

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

6. 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

7. Is this bruising from birth trauma or something else?

8. 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

9. Does this mottling mean this newborn is ill?

10. 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

11. Is this lesion benign?

12. 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

13. What’s wrong with this newborn’s hands and feet?

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

15. What is this and is this benign?

16. 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

17. Can you guess the name for this rash?

18. 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

19. What syndrome can be related to this vascular malformation?

20. 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

21. Can babies get pimples?

22. 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

23. What’s on this baby’s nose?

24. 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

25. Is this the same as the previous rash?

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

27. Are these rashes the same?

28. 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

29. Is this polydactyly?

30. 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

31. Rare and Abnormal Dermatologic Findings

33. 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

35. 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

37. 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

39. 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

41. 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

43. 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

45. 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

47. 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

49. 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