Neonatal Dermatologic Findings
Common and Usually Benign Dermatologic Findings
24 hour old female with this rash, what is it?
Erythema Toxicum NeonatorumCentral papule or pustule surrounded by
area of erythemaBenign, self-limiting, asymptomatic
disorder of unknown etiologyOccurs in up to 50% of infantsPresents 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 etiologyOccurs more frequently in black malesUsually presents at birthPustule 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 SpotFlat, slate-gray to bluish-black, poorly
circumscribed macules/patchesMost commonly located over the
lumbosacral area and buttocksCommon in black, asian, and hispanic
infantsUsually fade by 7 years of age
Does this mottling mean this newborn is ill?
Cutis MarmorataTransient, netlike, reddish-blue mottlingCaused by variable vascular constriction
and dilationResponse to chilling, resolves with warmingBenign 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?
AcrocyanosisHands and feet become variably and
symmetrically blue Resolves with warming of the skinRecurrence unusual after 1 month of age
What is this and is this benign?
HemangiomasCongenital vascular malformationOccur in 10% of all newbornsPresents in first few months of lifeMarked vascular overgrowth resulting in
bright red discoloration and definite elevationRapid growth for the first 6-12 months, then a
plateau period, then slow involution50% involute by age 5, 90% by age 9Refer 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 malformationSeen in 60% of infantsFades in first year of lifeUsually located nape of neck, forehead and
upper eyelids
What syndrome can be related to this vascular
malformation?
Port Wine StainPurplish-red vascular malformation present at
birthLesions do not enlarge but remain flat and
persistWhen 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 AcneDevelops in up to 20% of newbornsMaternal and endogenous androgens play a
role in the pathogenesisLesions involute within 1-3 months,
treatment usually unnecessary
What’s on this baby’s nose?
Sebaceous Gland HyperplasiaYellow 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?
MiliaPearly yellow papules usually on the faceOccur in 50% of newbornsUsually resolve during the 1st month of life
Are these rashes the same?
MiliariaResults 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 stressUsually erupt in crops in the intertriginous
areas, scalp, face, and trunk
Is this polydactyly?
Supernumerary DigitsMost commonly occur as rudimentary
structures at the base of the ulnar side of the 5th finger
Usually familialAsymptomaticCan usually be tied off as long as no bone
is palpated
Rare and Abnormal Dermatologic Findings
Collodian BabyBorn encased in thick cellophane-like
membraneMost 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 BullosaGroup of inherited mechanobullous disordersBlisters form after mild friction or traumaThree types: epidermolytic EB, junctional EB,
dermolytic EBSkin biopsy distinguishes types and
determines prognosisPrenatal diagnosis is now possible for a
number of variants for which gene markers are available
Treatment is symptomatic and supportive
Incontinentia PigmentiNeurocutaneous syndromeX-linked dominant, lethal in malesStarts 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 SyphilisMucocutaneous lesions usually appear
between 2-6 weeks of ageMost 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 RubellaBlueberry muffin lesionsSeen 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 testingTreatment: isolation and supportive care
Herpes Simplex InfectionOf 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 lesionTreat with acyclovir as soon as infection is
suspected to prevent disseminated disease and morbidity/mortality
Neonatal VaricellaEarly 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 lifeDissemination can lead to pneumonitis, encephalitis,
purpura with hemorrhage, hypotension, and deathIf newborn at risk, should consider Varicella-zoster
immune globulin or IVIGStart acyclovir early if lesions are suspicious for
varicellaConfirm diagnosis with DFA or PCR of lesion
Aplasia Cutis CongenitaOften inherited as AD traitAbsence/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 healedLeaves an atrophic, hairless scar that can be
excised later in lifeLess 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 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