Dermatologic Conditions of the Neonate

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Dermatologic Conditions of the Neonate. Stacy Wong, MSIII University of Nevada School of Medicine. Objectives. Dermatologic Definitions. Primary lesions Macule : pigmented, non-palpable Patch : ≥6 mm Papule : palpable, discrete lesions ≤ 5 mm in diameter
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Dermatologic Conditions of the Neonate Stacy Wong, MSIII University of Nevada School of Medicine Objectives 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 
  • 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
  • Birthmarks
  • Congenital melanocytic nevi
  • Dermal melanosis
  • Hemangioma
  • Nevus flammeus
  • 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
  • Congenital Melanocytic Nevi
  • Potential for malignancy
  • Size
  • Satellite lesions
  • Giant congenital melanocytic nevi
  • Congenital Melanocytic Nevi
  • Management
  • Birthmarks
  • Congenital melanocytic nevi
  • Dermal melanosis
  • Hemangioma
  • Nevus flammeus
  • 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
  • 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
  • Birthmarks
  • Congenital melanocytic nevi
  • Dermal melanosis
  • Hemangioma
  • Nevus flammeus
  • 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)
  • 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)
  • Birthmarks
  • Congenital melanocytic nevi
  • Dermal melanosis
  • Hemangioma
  • Nevus flammeus
  • 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
  • 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
  • Papular and Pustular Rashes
  • Erythema Toxicum Neonatorum
  • Transient Neonatal Pustular Melanosis
  • Acne Neonatorum
  • Milia
  • Miliaria
  • 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
  • Erythema ToxicumNeonatorum 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
  • Papular and Pustular Rashes
  • Erythema Toxicum Neonatorum
  • Transient Neonatal Pustular Melanosis
  • Acne Neonatorum
  • Milia
  • Miliaria
  • 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
  • Transient Neonatal PustularMelanosis
  • Management
  • Clinical recognition to avoid unnecessary tests/tx for infection
  • Macules within the vesicopustules are unique to this condition = NOT infectious!
  • Papular and Pustular Rashes
  • Erythema Toxicum Neonatorum
  • Transient Neonatal Pustular Melanosis
  • Acne Neonatorum
  • Milia
  • Miliaria
  • 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
  • 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 
  • Papular and Pustular Rashes
  • Erythema Toxicum Neonatorum
  • Transient Neonatal Pustular Melanosis
  • Acne Neonatorum
  • Milia
  • Miliaria
  • 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
  • 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
  • Papular and Pustular Rashes
  • Erythema Toxicum Neonatorum
  • Transient Neonatal Pustular Melanosis
  • Acne Neonatorum
  • Milia
  • Miliaria
  • 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
  • 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
  • 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.
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