Approach to the Problem
Concerns about the skin are a common chief complaint during the initial newborn visit in the hospital and the outpatient setting. A recent study of hospitalized neonates found that only 4.3% of the newborns had no dermatological findings. Most newborn skin findings are transient and very rarely require treatment, but it is important to distinguish benign skin lesions from cutaneous manifestations of more serious disorders, such as infections. Therefore, a thorough inspection of the skin for rashes and skin abnormalities is an essential part of the newborn examination.
New parents are often concerned about their baby’s skin. Knowledge and recognition of common, benign lesions of the newborn are important for counseling parents about the natural course of these dermatological lesions.
Key Points in the History
• A maternal history of primary active genital herpes simplex virus infection perinatally puts the infant at the highest risk of developing herpes neonatorum. A negative maternal history does not exclude the possibility of this diagnosis.
• A history of cyanosis of the hands and feet is often benign, while cyanosis of the lips and mouth is a sign of hypoxia.
• A rare condition involving transient erythema on one half of the body with a sharp demarcation down the midline is called harlequin color change. It is thought to be benign and subsides after the third week of life.
• Physiologic cutis marmorata, a transient rash brought on by exposure to cold or distress, resolves once the baby is warmed.
• Cutis marmorata telangiectatica is always visible.
• Dermal melanocytosis (a.k.a Mongolian spot) is present at birth in more than 90% of African Americans, 80% of Asians, and rarely in Caucasians.
• Pigmentation is first noted in the periungual and genital areas, which will often appear hyperpigmented at birth in dark-skinned newborns.
• The lesions of epidermolysis bullosa heal slowly, whereas sucking blisters often heal within 48 hours.
Key Points in the Physical Examination
• Infants who appear ill should have skin lesions cultured to rule out viral, bacterial, or yeast infections.
• Dermal melanocytosis consists of nontender, gray-blue macular lesions primarily located on the lumbosacral area, but may be seen over the entire back and on the shoulders and extremities. Familiarity with these lesions will enable a clinician to distinguish these from ecchymoses.
• Miliaria crystallina are pinpoint vesicles containing clear fluid. The lesions are easily denuded with pressure.
• The lesions of erythema toxicum, the most common transient rash in healthy term newborns, are often absent at birth and will often appear during the first few days of life.
• Erythema toxicum spares the palms and soles, while clusters of pustular melanosis may appear on pressure areas.
• Pustular melanosis may present at birth with small hyperpigmented macular lesions if the pustular phase occurred in utero.
• Neonatal pustulosis of transient myeloproliferative disorder has been reported in neonates with Trisomy 21. It presents with pustules and vesicles on a red base predominantly on the face, as part of congenital leukemia or transient myeloproliferative disorder. The lesions also occur at sites of trauma or adhesive usage. There is an associated leukocytosis. Pustules resolve over a few weeks as the leukocytosis resolves.
• Milia are isolated or scattered white pinhead-sized papules that usually occur on the face.
• Sebaceous hyperplasia is often found on the tip of the nose and is often mistaken as milia.
• Initially, neonatal acne may resemble milia, but the lesions become larger and more pustular in the first month of life.
• Acropustulosis of infancy consists of extremely pruritic lesions concentrated on the palms and soles.
• Neonatal seborrhea usually involves the ears, back of the neck, and shoulders. Neonatal eczema spares these areas.
• The vesicles of herpes simplex virus infection often occur on the presenting body part of the infant during birth.
• Cultures of pustular or vesicular lesions can help distinguish benign cutaneous lesions from those of infectious etiology.
PHOTOGRAPHS OF SELECTED DIAGNOSES
Figure 7-1 Erythema toxicum. Note the central papule with surrounding erythema. (Courtesy of Esther K. Chung, MD, MPH.)
Figure 7-2 Dermal melanocytosis. Bluish-gray macular pigmentation on the back of a neonate. (Courtesy of George A. Datto, III, MD.)
Figure 7-3 Pustular melanosis. Hyperpigmented macules with adherent white scale seen after the pustular lesions have ruptured. (Courtesy of Paul S. Matz, MD.)
Figure 7-4 Pustular melanosis. Pustular phase of pustular melanosis located on the chin of a newborn. (Courtesy of Denise A. Salerno, MD, FAAP and Hanah Raverby, MD, BS.)
Figure 7-5 Sucking blister. The lesion on the left hand of this newborn is the result of sucking that occurred in utero. (Courtesy of Denise A. Salerno, MD, FAAP.)
Figure 7-6 Sucking blister. The lesion on the right arm of this newborn resulted from sucking in utero. (Courtesy of Denise A. Salerno, MD, FAAP and Hanah Raverby, MD, BS.)
Figure 7-7 Jaundice. Physiologic jaundice. (Courtesy of Denise A. Salerno, MD, FAAP.)
Figure 7-8 Milia. Milia on the cheek and chin of a newborn. (Courtesy of Denise A. Salerno, MD, FAAP.)
Figure 7-9 Miliaria crystallina alba. (Used with permission from Fletcher MA. Physical diagnosis in neonatology. Philadelphia, PA: Lippincott Williams & Wilkins; 1998:124.)
Figure 7-10 Neonatal acne. Erythematous pustular rash on cheeks of a 3-week-old neonate. (Courtesy of George A. Datto, III, MD.)
Figure 7-11 Seborrhea. Greasy, scaly lesions of scalp and eyebrows. (Courtesy of the Benjamin Barankin Dermatology Collection.)
Other Diagnoses to Consider
• Herpes simplex neonatorum
• Blue nevus
• Bug bites
• Staphylococcal skin infection
• Bullous impetigo
• Candidal skin infection
• Infantile atopic dermatitis
When to Consider Further Evaluation or Treatment
• Elevated bilirubin levels in the first 24 hours of life, or above the recommended American Academy of Pediatrics algorithm, should promptly be identified and when indicated treated with phototherapy and/or exchange transfusion.
• When neonatal herpes infection is suspected, cultures from multiple sites should be obtained, including any blisters, mucosal surfaces, serum, and cerebrospinal fluid (if indicated). Liver function tests should be obtained as well.
• Infants with bullous impetigo or suspected staphylococcal infections should be promptly treated with antibiotics. Strong consideration should be given to obtaining blood cultures and giving parenteral antibiotics pending culture results.
American Academy of Pediatrics, Committee on Fetus and Newborn. Technical report: phototherapy to prevent severe neonatal hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2011;128(4):e1046–e1052.
American Academy of Pediatrics, Committee on Infectious Disease, Committee of Fetus and Newborn. Clinical report: Guidance on management of asymptomatic neonates born to women with active genital herpes lesions. Pediatics. 2013;131(2):e635–e646.
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