Common Rashes in the Newborn

1. Common Rashes in the Newborn Spencer Copland, MD CMC Family Medicine Newborn Nursery Modified by Marsha Rhodes, MD CMC Pediatrics 2/13/09

2. Don’t assume that a light-skinned baby is Caucasian Some AA infants are quite light at birth Most darker skinned babies get darker over time For clues to the eventual skin tones look at the top of the pinnae, at the base of fingernails, and at genitalia Genetic Differences in Skin Color

3. Cheesy coating on term babies at delivery In utero waterproofing Current trend is to not remove it May have antibacterial (via pH) and emollient benefits Nursing debates re timing of first bath Vernix Caseosa

4. Dry, peeling skin

5. Persistent blue-purple color of distal extremities Is not really cyanosis Normal Resolves with maturation of autonomic system Acrocyanosis

6. Somewhat well-defined circular area of erythema of scalp in infants delivered by vacuum (or attempted delivery) At increased risk for hyperbilirubinemia as result of hemolysis At increased risk for subgaleal hemorrhage Diffuse or localized subgaleal bleed Palpable fluid wave Vacuum delivery bruising

7. Sometimes called “livedo reticularis” Venous mottling of skin in young children More prominent when cool Classically improves with warming Benign Resolves in a few months as autonomic control of vasculature matures Appearance later in life associated is generally not good The very pronounced form of this is “cutis mamorata telangiectasia congenita” It looks more purpuric and brownish in color Cutis Marmorata

8. These are frequently called “milia” but they’re really not so please don’t call them that Most newborns have sebaceous hyperplasia Slightly dome-shaped yellowish-white plugs in typical sebaceous gland locations (nose & chin) Benign & resolve in a few weeks No treatment needed Question: does this baby have retinoblastoma? Probably not but …. Sebaceous Hyperplasia

9. Milia • These are the real milia! • They are tiny white superficial cysts (check the right cheek and the left chin) • Most common on face but can be seen anywhere on the body • Benign and self- limited • Resolves in days to weeks • No treatment needed

10. Very common Yellow-white epithelial cysts on roof of mouth One to several Benign epithelial cysts No treatment needed Resolve spontaneously in 2-3 wks Epstein Pearls

11. Comparable to Epstein Pearls but occur on buccal surface of gums May be single or multiple May be missed if you don’t use a tongue blade Benign Resolve spontaneously in 2-3 wks Parents think they’re teeth … but they’re not! Bohn's Nodules

12. Fairly common Tend to run in families Do not resolve but no need for intervention unless swell, drain, and/or infected (occurs after NB period) Risk of hearing loss is minimal but all babies have hearing tested Preauricular Pits or Sinuses

13. Aka preauricular skin tags but “accessory tragi” is a better term if there is a complex grouping Range from mounds to peduculated appendages Increased risk of hearing loss and associated syndromes including branchial cleft defects Accessory Tragi

14. Skin Tags

15. What the nurses call sacral dimples and sinuses are actually intergluteal, not sacral, lesions They are within the buttock crease These are quite common and are at very low risk for underlying spinal deformities and tethered cords Imaging is rarely indicated True sacral and lumbosacral area lesions above the intergluteal crease do warrant concern The one pictured here is quite unusual Ultrasound at birth is fine but it’s best to MRI sinus tracts at ~ 6 wks Skin dimples in general are benign Thought to originate in areas of in utero compression “Y” shaped intergluteal creases are a normal variation (though there is some controversy about these) “Sacral Dimples”

16. Slate Grey Patches • Aka “Congenital dermal melanosis” • Collection of melanocytes deep in the dermis • Most common in LS area and over buttocks, but can be anywhere • More common in darker skinned infants • Macular, blue-black or blue-green patches with a sheen to the skin • Usually fade in 5-10 years in part because skin tends to darken • They are so common and normal than routine documentation not truly essential but unusual mongolian spots (distribution or location) should certainly be documented • Sometimes mistaken for bruises by parents, babysitters, daycare personnel • Should be mentioned to parents so that they understand that they are not bruises

17. There is a large faint one in the photo While we’re here … LANUGO at the top of the intergluteal crease is frequently directed down into the crease … and can be misinterpreted as a “hair tuff” It’s not! Hair tufts are well-defined patches of coarse hairs in the true LS area (b/w the iliac crests where an LP would be done) Fortunately they are quite rare But when present are clues to underlying neural problems Mongolian Spots

18. A very common birthmark May be inconspicuous at birth then darken over time Hard to see in darker skin Questions What disorders are associated with multiple café au lait lesions? How many are needed to inspire you to think of them? How big do they need to be? Bonus question Is the Bandaid necessary? Café au lait Lesion

19. What disorders are associated with multiple café au lait lesions? Neurofibromatosis Tuberous sclerosus How many are needed to inspire you to think of them? 6 or more for NF How big do they need to be? 0.5 cm or larger No, the ACIP doesn’t recommend Bandaids after injections but acknowledges that everyone expects them Remove before discharge or you’ll see them still on there at the newborn visit Answers about Café au lait Lesions

20. What is the difference between a nevus simplex and a nevus flammeus?

21. Nevus Simplex • Very common • Aka “Angel’s kiss” (glabella) or “salmon patches” (eyelids) but we use the terms interchangeably • Known as “stork bite” when it’s on the nape • Flat, erythematous patch(es) that blanches with pressure • Usually on eyelid, glabella, naso-labial area, forehead, nape but can be anywhere • Not a vascular malformation • Benign & no treatment needed • Most resolve on their own over several months • When the ones on the face first fade away, they “light” back up with overheating and crying before fading completely • ~50% of those on nape persist throughout life

22. Nevus Flammeus • Aka “port wine stain” • Is a vascular malformation: a type of hemangioma • Prominent flat, pink, red, or purple mark that does not blanch • Continues to grow with the child • Permanent disorder (does not resolve) • If in V1-3 trigeminal distribution needs cranial MRI, neuro & ophthamology consults • Possible Sturge Weber Syndrome and/or glaucoma • Laser therapy used for cosmesis

23. Hemangioma • Usually not apparent at birth • You might see a hypopigmented area with a subtle vascular component (telangietatic) • Types: cherry, strawberry, cavernous • Will become more prominent and raised • Due to proliferation of vasculature • Grow rapidly during 1st yr then most atrophy and regress over several years • Can cause bleeding problems • Hemangiomatosis (diffuse lesions may be internal and external) • Kasselbach-Merritt Syndrome (platelet consumption) • Tx: • None unless extensive, interfering with vision, breathing, etc • Laser therapy is best • Excision usually has less than optimal results • Occasionally steroids used • Derm consult may be helpful • Note: many insurers including Medicaid do not pay for cosmetic procedures. For serious lesions, you may have to build a medical argument for intervention. MOST will do fine without intervention since most resolve spontaneously.

24. Hemangiomas

25. What disorders are in the differential for pustular disorders in neonates?

26. Diff Dx of NB Pustular Disorders • Erythema toxicum • Not really pustules, erythematous flare, healthy term infants • Transient neonatal pustular melanosis • Hyperpigmented macules, pustules, collarette of fine scale, present at delivery, in health term infants • Cutaneous candidiasis • Thousands on pustules in otherwise healthy infant • Uncommon • Neonatal acne and neonatal cephalic pustulosis • Pustules on cheeks • HSV • Usually preterm and very sick when skin symptoms present at birth, otherwise lesions typically appear in 2-4 days • The most worrisome of course • Varicella • Maternal history of recent infection • Folliculitis • Pustules associated with hair follicles, should not be present at birth • Bullous disorders • Usually are large and flaccid with clear fluid

27. Erythema Toxicum • Very common • Affects 30-70% of newborns • More common in term infants • Small papules, vesicles, and pustules with erythematous flare • Spares palms and soles • Parents always think they are flea bites • Can be confused with miliaria rubra • They present a few hours after birthand are evanescent (change location over a matter of hours) • Suspected allergic and/or immunologic etiology but no one really knows • Do contain eosinophils • Possibly related to immaturity of pilosebaceous follicles • Benign, no w/u or tx needed • Resolve spontaneously in 2-3 weeks

28. Pustular form of ETN

29. Yes, it’s a mouthful We sometimes just say “melanosis” or “pustular melanosis” Hallmark is ~2 mm hyperpigmented macules May also have few to many thin-walled pustules which rupture easily leaving fine collarette of scale Lack erythematous flare Consider “lentiginoses” if only the macules are present More common in darker skinned term infants (incidence ~5%) Cause unknown Gram stain: neutrophils Benign No w/u or tx needed if you know that’s one it is Resolves spontaneously in a few weeks Transient Neonatal Pustular Melanosis

30. Transient Neonatal Pustular Melanosis vs Lentiginoses

31. Neonatal Varicella • 1-3 mm vesicles and erythematous papules -> pustules, crusts, erosions • Typically begin on scalp or face • Appear in crops down body • Crust in same order • Trunk or buttocks especially w/ breech presentation • Lesions develop around 6-13 days of age • Lesions at birth are from intrauterine infection

32. Neonatal Herpes

33. Cutaneous Candidiasis • Thousands of pustules • Healthy, vigorous infant • Do KOH and fungal culture • Tx with topical nystatin

34. Folliculitis • Bacterial infection of hair follicles • Unusual in newborns but it’s in the differential of pustules • A few to multiple lesions • Gram stain and C&S • Confer with ID

35. What is the difference between milia and miliaria?What types of miliaria are there?

36. Profuse tiny superficial vesicles similar to what can happen with sunburns Not seen often but you need to know what it is Benign No treatment needed Avoid lotion/creams Keep infant more lightly dressed Miliaria Crystallina

37. Aka “prickly heat” Related to overheating Is related to miliaria crystallina; it just occurs in deeper stratum corneum Scattered vesiculo-pustular lesions frequently in patches with surrounding erythema Easy to confuse with erythema toxicum Benign Avoid lotions/creams Keep infant lightly dressed Miliaria sudamina Lesions are even deeper Miliaria Rubra

38. Neonatal acne is overdiagnosed Actual pimples and comedones Tx usually not needed Can consider Retin-A if severe No association with acne later in life Neonatal cephalic pustulosis More common This is probably what most people think is neonatal acne No comedones Caused by Malazzemia sp. Benign If severe can use topical antifungal (ketoconazole) Is it Neonatal Acne?

39. Raw or blistered area on fingers, hand, or distal forearm (look under ID bracelet!) DDx includes bullous disorders but there are usually multiple bullae with those Sucking blisters on the hands/arms are clear evidence of in utero sucking behavior Usually heal without scarring Treatment not usually needed Sucking blisters (or pad) can also form on upper lip Noticed after feeding for a few weeks Do not rupture ! Check for ankyloglossia Sucking Blister

40. Scalp Bruising

41. On face or scalp Linear or curvilinear bruising Can cause eye injury and facial palsy Forceps delivery marks

42. Typically linear or curvilinear abrasion May become infected Confused with aplasia cutis History of monitor Location Appearance Rapidity of healing Scalp Electrode Lesions

43. Raw area of skin Most common in the scalp Hairless Variable depth of involvement Eventually fills in Midlline lesions may be associated with underlying defects Confused with scalp electrode lesions and Nevus of Jadassohn Aplasia Cutis

44. Frequently confused with aplasia cutis Elevated orange-yellow plaque with an “orange peel” appearance Aka “Nevus sebaceous” Hairless Usually in scalp but can be elsewhere Initially benign but has potential for malignant transformation in adolescence and adulthood Excision recommended in late childhood, early adolescence Nevus of Jadassohn

45. Line of color change in the midline of the body Dependent half of body is reddish Uncommon but fun to see Benign & resolves spontaneously with time Not to be confused with a Harlequin fetus Severe disruption of the skin Harlequin color change

46. Yellow-orange hue to skin and sclerae associated with hyperbilirubinemia Some degree of it occurs in >60% of infants Contributing factors: Relative polycytemia Enterohepatic circulation Relative dehydration in first few days especially if breastfeeding Most often mild and physiologic ABO incompatibility is next most common then extensive bruising Then there are many other causes … Note: infants with biliary atresia usually have a greenish hue to their skin Jaundice

47. Jaundice

48. Spina bifida • Don’t palpate LS lesions • Keep moisturized • Transfer to NICN • Neurosurgery needed

49. Amniotic bands

50. Sprengle’s lines • Horizontal crease across calves • Thought to be due to amniotic bands • It’s the same Sprengle who described Sprengle’s deformity (winging of scapula)