Dermatologic Conditions of the Neonate

1. Dermatologic Conditions of the Neonate Stacy Wong, MSIII University of Nevada School of Medicine

2. Objectives

3. Dermatologic Definitions • Primary lesions • Macule: pigmented, non-palpable • Patch: ≥6 mm • Papule: palpable, discrete lesions ≤5 mm in diameter • Pustule: small, circumscribed skin papules containing purulent material • Nodule: palpable, discrete lesions measuring ≥6 mm diameter 

4. Dermatologic Definitions • Primary lesions • Vesicle: papule <5 mm containing serous material • Bulla: vesicles that are ≥6 mm • Plaque: >5 mm superficial flat lesions, often formed by a confluence of papules

5. Birthmarks • Congenital melanocytic nevi • Dermal melanosis • Hemangioma • Nevus flammeus

6. Congenital Melanocytic Nevi • Epidemiology • 0.2 to 2.1% of infants at birth • Mechanism of Action • disrupted migration of melanocyte precursors in the neural crest • Clinical features • Brown to black • Most are macules, but hyperpigmented papules or nodules are possible

7. Congenital Melanocytic Nevi • Potential for malignancy • Size • Satellite lesions • Giant congenital melanocytic nevi

8. Congenital Melanocytic Nevi • Management

9. Birthmarks • Congenital melanocytic nevi • Dermal melanosis • Hemangioma • Nevus flammeus

10. Dermal Melanosis • AKA “mongolian spot” • Epidemiology • incidence varies widely among racial and ethnic groups = most common in black, Native American, Asian, and Hispanic populations • Mechanism of Action • melanocytes are trapped deep in the skin

11. Dermal Melanosis • Clinical features • Blue to black patches • Typically on back or buttock • May look like a bruise, but does not blanch • Management • Because the “bruise” appearance may raise suspicion for child abuse in some settings, dermal melanosis should be documented in the medical record. • Most fade by 2 yo and do not require tx

12. Birthmarks • Congenital melanocytic nevi • Dermal melanosis • Hemangioma • Nevus flammeus

13. Hemangioma • AKA “strawberry hemangioma” • Epidemiology • 1.1 to 2.6% of newborns • Can develop anytime in the first few months of life; present in 10% of infants at 1 yo • Mechanism of action currently unknown • Clinical features • Self-involuting, vascular tumor-like structure • Superficial or deep (internal organs)

14. Hemangioma • Management • Hemangiomas of infancy tend to involute and disappear after infancy • 50% resolve by 5 yo, 70% by 7 yo, and 90% by 10 yo • Do not need tx, UNLESS they compress the eye, airway, or vital organs  immediate referral in the neonatal period! • Tx: Prednisone 3 mg/kg qday for 6 to 12 weeks • Large or multiple may lead to high-output cardiac failure (rare)

15. Birthmarks • Congenital melanocytic nevi • Dermal melanosis • Hemangioma • Nevus flammeus

16. Nevus Flammeus • AKA “port-wine stain” • Epidemiology • 0.3 to 0.5% of newborns • Mechanism of Action • Capillary malformation due to abnormal morphogenesis • Clinical features • Pink to red to purple macule/patch; usually blanching • Most commonly on the face or upper trunk • In infancy and childhood, the color darkens with crying, fever, or overheating

17. Nevus Flammeus • Management • If occurs in the ophthalmic division of trigeminal nerve often associated with ipsilateral glaucoma • Referral to ophthalmology • 5-8% of those with ophthalmic port-wine stain are associated with Sturge-Weber syndrome • Triad: glaucoma, seizures, and port-wine stain • Angiomas of the brain and meninges • ↑Risk of mental retardation and hemiplegia • Cosmetic tx: pulsed dye laser therapy

18. Papular and Pustular Rashes • Erythema Toxicum Neonatorum • Transient Neonatal Pustular Melanosis • Acne Neonatorum • Milia • Miliaria

19. Erythema ToxicumNeonatorum • Epidemiology • Most common pustular eruption in newborns • Incidence 40-70% • Term infants, weighing >2500 g • Mechanism of action not known • Clinical features • Erythematous, 2- to 3-mm macules and papules that evolve into pustules (on a bed of erythema) • “flea-bitten” • Typically on face, trunk, and proximal extremities; does not affect palms/soles

20. Erythema ToxicumNeonatorum

21. Erythema ToxicumNeonatorum • Diagnosis • Initial dx made clinically • Can be confirmed by cytologic examination of a pustular smear  eosinophilia with Gram, Wright, or Giemsa staining • Management • Lesions fade over 5-7 days, but may recur over several weeks

22. Papular and Pustular Rashes • Erythema Toxicum Neonatorum • Transient Neonatal Pustular Melanosis • Acne Neonatorum • Milia • Miliaria

23. Transient Neonatal PustularMelanosis • Epidemiology • 5% of black newborns, but <1% of white newborns • Mechanism of action – idiopathic • Clinical Features • Vesiculopustular rash; unlike erythema toxicum, there is no bed of erythema • Lesions rupture easily  pigmented macule that fades over 3-4 weeks • Can affect all areas of the body including palms and soles

24. Transient Neonatal PustularMelanosis • Management • Clinical recognition to avoid unnecessary tests/tx for infection • Macules within the vesicopustules are unique to this condition = NOT infectious!

25. Papular and Pustular Rashes • Erythema Toxicum Neonatorum • Transient Neonatal Pustular Melanosis • Acne Neonatorum • Milia • Miliaria

26. Acne Neonatorum • Epidemiology • Up to 20% of newborns • Mechanism of Action • Maternal or infant androgens stimulate sebaceous glands • Clinical features • Closed comedones • Typically on the forehead, nose, and cheeks • Also possible: open comedones, inflammatory papules, and pustules

27. Acne Neonatorum • Management • Usually resolve spontaneously within 4 months without scarring = tell the parents! • Tx usually not warranted; if extensive and persists for months; use 2.5% benzoyl peroxide lotion 

28. Papular and Pustular Rashes • Erythema Toxicum Neonatorum • Transient Neonatal Pustular Melanosis • Acne Neonatorum • Milia • Miliaria

29. Milia • Epidemiology • Up to 50% of newborns • Mechanism of Action • superficial inclusion cysts involving the follicular infundibulum (upper part of the hair follicle • Due to retention of keratin in the dermis • Clinical features • 1- to 2-mm pearly white or yellow papules • Located on forehead, cheeks, nose, and chin, but they may also occur on the upper trunk, limbs, penis, or mucous membranes

30. Milia • Management • Parents are often concern; provide reassurance • Lesions disappear spontaneously, usually within the first month of life; may persist into the second or third month

31. Papular and Pustular Rashes • Erythema Toxicum Neonatorum • Transient Neonatal Pustular Melanosis • Acne Neonatorum • Milia • Miliaria

32. Miliaria • Epidemiology • Up to 40% of infants • Mechanism of Action • sweat retention caused by partial closure of eccrinestructures • Immaturity of glands • Clinical features • Usually appears first mo of life • 2 of the most common types: • Miliariacrystallina: 1- to 2-mm vesicles without surrounding erythema, most commonly on the head, neck, and trunk

33. Miliaria • 2 of the most common types: • Miliaria rubra: erythematous papules and vesicles; NON-coalescing • Management • Avoidance of overheating • Removal of excess clothing • Give cooling baths and air conditioning

34. References • Goldstein BG. Approach to dermatologic diagnosis. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2012. • Morelli, JG. Diseases of the Neonate. In: Kliegman RM, et al. Nelson Textbook of Pediatrics.19th Edition. Philadelphia PA: W.B. Saunders; 2011. • McLaughlin MR, O'Connor NR, Ham P. Newborn skin: part II. Birthmarks. Am Fam Physician. 2008;77(1):56–60. • O'Connor NR, McLaughlin MR, Ham P. Newborn skin: part I. Common rashes. Am Fam Physician. 2008;77(1):47–52. • Liu C, Feng J, Qu R, et al. Epidemiologic study of the predisposing factors in erythema toxicumneonatorum. Dermatology. 2005;210(4):269–272.