Transcript SBH Peds Res

Jenna Scholnick, MD
January 21, 2011
Goals
 Identify common benign skin conditions
 Describe skin disorders characterized by papules and
pustules
 Recognize vascular, hyperpigmented, and
hypopigmented birthmarks
 Identify and treat various types of diaper rashes
Cutis Marmorata
 Clinical Features: When infants become cold,
capillaries in the extremities constrict, causing
characteristic violaceous, reticulated mottling of the
skin.
Treatment: No treatment needed. Resolves
spontaneously with warming. May persist in patients
with Down syndrome, trisomy 18, or Cornelia de Lange
syndrome.
When to Refer: Localized or exaggerated mottling may
represent a related disorder referred to as cutis
marmorata telangiectatica congenita
Harlequin color change
 Occurs when newborn lies on side
 Erythema of dependent side of body with simultaneous
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blanching of contralateral side.
Develops suddenly and persists for 30 sec to 20 minutes
Resolves with increased muscle activity or crying
Affects up to 10% of full term infants but often goes
unnoticed due to bundling.
2nd to 5th day until three weeks
Thought to be caused by immatturity of hypothalamic
center
Erythema Toxicum Neonatorum
Cause: Inflammatory disorder of unknown etiology.
Clinical Features: Blotchy, erythematous macules and patches
are present and often have a central papule, vesicle, or pustule.
Fluid from vesicles contains eosinophils.
Lesions appear within 24 to 48 hours of birth.
Occurs in up to 50% of term infants (all races) and is uncommon
in premature infants.
Treatment: No treatment is required. Lesions typically resolve
within 4 to 5 days, although the process may begin later or
persist longer in some infants.
Milia
• Cause: Epidermal inclusion cysts.
Clinical Features: Tiny (1- to 2-mm) white papules
most commonly located on the forehead, nose, and
cheeks.
The lesions may be present at birth or develop during
the first few months of life.
Treatment: No therapy is necessary. Milia generally
resolve spontaneously over several weeks to months
Miliaria
 Cause: Miliaria is caused by obstruction of the eccrine
ducts, which may be superficial (resulting in miliaria
crystallina) or deep (resulting in miliaria rubra or
pustulosa)
Miliaria occurs primarily during hot, humid weather
or febrile illness. It may also occur if an infant is
dressed too warmly.
Miliaria rubra (“prickly heat”)
 Clinical Features: Most common form of miliaria
Obstruction of the eccrine ducts leads to dilation and
rupture, producing swelling and inflammation.
Characterized by tiny erythematous macules or papules
often concentrated on areas of skin covered by clothing.
 Treatment: Best management is prevention, avoiding
excessive environmental heat, overdressing, and
application of thick emollients (which may occlude
eccrine ducts).
Infants with established miliaria may benefit from a low-
humidity air-conditioned environment. Cool baths or
sponge baths may be helpful.
Miliaria Crystallina
 Clinical Features: Characterized by clear, thin-walled
vesicles without surrounding erythema. The vesicles
rupture easily.
Treatment: Management and prevention are as
described for miliaria rubra.
Mongolian spots
 Cause: Arrested migration of melanocytes from the neural crest
to the skin.
Clinical Features:
Brown to gray-blue macules and patches most commonly
distributed over the lumbosacral spine and buttocks but may
also occur on the trunk or extremities.
Differential Diagnosis: Mongolian spots are sometimes
confused with melanocytic nevi, vascular lesions, and bruises.
Treatment: No treatment is necessary, as there is no potential
for malignant change, and the lesions usually fade spontaneously
by adolescence.
Neonatal acne
Cause: Obstruction and inflammation within pilosebaceous
follicles. Attributed to androgens.
Clinical Features: occurs in approximately 20% of all neonates
during first few weeks of life and consists of papules, pustules,
and closed comedones located primarily on the face. Rarely,
larger papulonodular or scarring lesions may occur.
Treatment: Treatment usually unnecessary. As androgen levels
decline during the first months of life, the condition resolves.
When to Refer: Infants with persistent or unusually severe acne
should be evaluated for signs of androgen excess (eg,
virilization).
Neonatal cephalic pustulosis
 Cause: A recently described condition that may be result of an
inflammatory response to yeasts of the Malassezia species. May
represent disorder in the spectrum of neonatal acne.
Clinical Features: Characterized by an erythematous papular and
pustular eruption that usually affects the face, although scalp and
upper part of chest may be involved. Lesions begin to appear at 2 to 3
weeks of age.
Closely resembles neonatal acne but does not produce comedones
(blackheads and whiteheads) and often involves the scalp.
Treatment: Resolves spontaneously over several weeks. Treatment
with an imidazole cream twice daily may hasten resolution
Sebaceous gland hyperplasia
• Cause: Hypertrophy of sebaceous glands caused by
elevated androgen levels present during the first
months of life.
Clinical Features: Pinpoint, yellow macules and
papules (enlarged sebaceous glands) are commonly
located on the nose, forehead, cheeks, and upper lip.
The condition is often present in term newborns.
Treatment: No therapy is necessary. The condition
resolves as androgen levels decline
Postdates desquamation
• Cause: Thought to be the result of loss of vernix and the
transition from the aqueous intrauterine environment to the dry
extrauterine environment.
Clinical Features: Desquamation or cracking of the skin is most
pronounced in acral locations (eg, the wrists, hands, ankles, and
feet) but may be generalized.
The degree of desquamation increases proportionately with the
degree of postmaturity.
Treatment: No treatment is required, but an emollient may be
applied. The condition usually resolves during the first weeks of
life.
Sucking blister
 Cause: Vigorous sucking in utero.
Clinical Features: Present at birth in 0.5% of newborns.
Appear as shallow erosions or intact bullae, most commonly on
the fingers, wrists, lips, or forearms.
Differential Diagnosis: Occasionally mimic other blistering
disorders (eg, epidermolysis bullosa) and infections (eg, bullous
impetigo and herpes simplex virus infection). However, their
characteristic appearance and location suggest the diagnosis.
Treatment: The condition is self-limited, and treatment is
supportive. A topical antibiotic and dressing may be applied as
needed.
Pseudo ingrown nails
• Cause: Hypoplasia and soft consistency of the
infantile nail plate.
Clinical Features: Most commonly affects the great
toenails and presents as swelling or redness of the
lateral nail fold, simulating an ingrown nail.
Treatment: Intervention is rarely required. With age,
the nail plates grow and assume the appearance of
mature nails
Seborrheic dermatitis
 Cause: Unknown but possibly related to increased sebaceous gland function
due to elevated androgen levels during the first months of life.
Some believe that it may be the result of an inflammatory response to the yeast
Pityrosporum ovale.
Clinical Features: Characterized by scaling and/or erythematous patches
concentrated in areas where sebaceous glands are most numerous, such as the
scalp, face, and postauricular and intertriginous areas. The umbilicus is
frequently involved.
Treatment: The condition usually resolves spontaneously by 8 to 12 months of
age.
For scaling of the scalp ("cradle cap”): small amount of mineral oil applied to
affected area followed by gentle brushing with a soft brush may be effective.
Alternatively, an antiseborrheic shampoo may be used.
For lesions on the skin: a low-potency topical corticosteroid (eg,
hydrocortisone 1%) may be applied twice daily as needed.
Transient neonatal pustular melanosis
 Cause: Benign pustular disorder of unknown etiology.
Clinical Features: Present at birth and occurs in approximately 5% of
African-American newborns; it is rare in other races.
Pustules and vesiculopustules that rupture easily (often before birth),
leaving small hyperpigmented macules, each with a rim (collarette) of
scale. Polymorphonuclear leukocytes are present in the fluid from
pustules.
The lesions are concentrated on the forehead, chin, neck, and trunk.
The palms and soles also may be affected.
Treatment: No treatment is required. The pustules resolve within a
few days, and the hyperpigmented macules fade completely by 3 to 4
months of age.
Acropustulosis of infancy
 Cause: An uncommon disorder of unknown etiology,
although some believe it may represent a postscabies
hypersensitivity phenomenon.
Clinical Features: May be present at birth but more often
presents in the first months of life.
Characterized by a rash composed of tense, pruritic
vesiculopustules concentrated on the hands and feet,
including the palms and soles. In some patients, a few
lesions may be present on the trunk, proximal extremities,
or scalp.
The lesions persist for 5 to 10 days, but crops of new lesions
appear every 2 to 4 weeks.
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Acropustulosis of infancy
 Differential Diagnosis: Most often confused with
scabies. However, scabies does not recur with
regularity, and a scraping of lesions will reveal mites,
eggs, or fecal material.
Dyshidrotic eczema may cause vesicles on the hands or
feet but rarely has its onset in infancy.
Treatment: The condition resolves spontaneously
over 1 to 2 years. Flares may be managed with a potent
topical corticosteroid used cautiously or an oral
antihistamine
Scabies
 Cause: Infestation with the mite, Sarcoptes scabiei, which
rarely occurs during the first month of life.
Clinical Features: Unlike in older children, in whom
lesions are concentrated in skin flexures, in infants, scabies
causes a generalized rash composed of erythematous
papules, vesicles, or pustules.
The rash may involve the palms, soles, and scalp.
Diagnosis: The diagnosis may be confirmed by
microscopic examination of scrapings from several papules
placed in immersion oil on a glass slide. Mites, eggs, or
fecal material may be observed.
Scabies
 Differential Diagnosis: When vesicles are present,
scabies may be confused with acropustulosis of
infancy. However, the latter condition can be
differentiated by its recurrence every 2 to 4 weeks and
the concentration of lesions on the hands and feet.
Treatment: Treatment is topical permethrin 5%,
applied to the infant and to all close contacts and
rinsed 8-14 hours later. Treatment is often repeated in 1
week for infested individuals.
Infant birthmarks
 Vascular birthmarks are the most common of all
birthmarks and include hemangiomas, port-wine
stains, and nevus simplex.
 Hyperpigmented birthmarks include congenital
melanocytic nevi (increased risk of malignant
transformation), and café au lait spots (macules).
 Hypopigmented birthmarks are common in
infancy.
Do not have malignant potential, but may represent
a cutaneous marker of systemic disease. Examples
include ash-leaf spots and nevus depigmentosus
Hemangiomas
 Cause: Benign, self-limited vascular tumors of unknown etiology.
Development may be related to placental factors. Risk factors include
prematurity and advanced maternal age and, possibly, pregnancy-induced
hypertension and placenta previa.
Clinical Features: Typically appear at 2 to 4 weeks of age and affect 2.6% of
newborns and 10% to 12% of 1-year-old infants.
 More common in females and preterm infants.
Appear as enlarging erythematous papules, nodules, or plaques, most
commonly on the head or neck. They can be superficial, deep, or mixed.
Deeper lesions have a blue color.
Grow rapidly in the first 4 to 6 months of age. Between 6 and 12 months of age,
growth slows and involution begins (appearance of areas of gray mottling on
the surface of the lesion)
Hemangiomas
 Treatment: Half of all hemangiomas resolve by age 5 years, and
90% resolve by age 9 years.
 If small and does not threaten a vital structure, no treatment is
required. If redundant skin or telangiectasias remain after
involution, patients may be referred to a pediatric dermatologist
or plastic surgeon for pulsed dye laser treatment.
 Patients should be referred to a pediatric dermatologist if the
hemangioma compromises a vital structure (eg, the eye or
airway); ulcerates; is located on the tip of the nose, lip, or
midline of the back; or is large, particularly if it involves the face
or head.
Hemangiomas
 Hemangiomas of the eyelids or periorbital skin may obstruct the
visual axis (leading to amblyopia) or may compress the globe (resulting
in glaucoma or astigmatism)
 Any hemangioma that obstructs the visual axis or causes ptosis should
be evaluated immediately by a dermatologist and an ophthalmologist.
May extend into the orbit, imaging (eg, magnetic resonance imaging
[MRI]) should be considered
 Hemangiomas located on the tip of the nose or lip often cause
permanent distortion. Early referral is indicated. These lesions may be
treated with intralesional or oral corticosteroids or propranolol. Lifethreatening or treatment-resistant hemangiomas may be treated with
vincristine, interferon alfa, or other agents
Nevus simplex
 Cause: A nevus simplex (“salmon patch”) represents
an area of superficially dilated capillaries.
Clinical Features: These erythematous lesions
occur in 30% to 40% of newborns and are commonly
located at the glabella, on the eyelids, or at the nape
of the neck.
Treatment: Most lesions on the face resolve during
the first 2 years of life. Those at the nape of the neck
may persist.
Port wine stain
 Cause: Vascular malformation of unknown etiology.
Clinical Features: These erythematous or violaceous patches are
present in 0.5% of newborns. They tend to be permanent, although
some may fade slightly with time. Many of these lesions become darker
and thicker with time, and they may develop vascular nodules that
bleed.
Most port-wine stains are not associated with underlying disease.
However, a facial port-wine stain may be associated with Sturge-Weber
syndrome (SWS); those involving the extremities or trunk rarely are
associated with Klippel-Trénaunay or Proteus syndromes.
Treatment: Early treatment with pulsed dye laser improves the
appearance of facial port-wine stains and may prevent later local
complications.
Congenital melanocytic nevi
 Cause: Unknown.
Clinical Features: Congenital melanocytic nevi (CMN) are
hyperpigmented macules or thin plaques present at birth. The lesion
may exhibit hypertrichosis.
All CMN have an increased risk of malignant transformation; the larger
the nevus, the greater the risk. Risk of transformation is 2% to 3% in
small lesions (< 1.5 cm) but may be as high as 4% to 8% in large or
"giant" nevi (> 20 cm). The presence of hair does not imply a poor
prognosis (ie, risk for malignancy). The risk of malignant
transformation in African-American patients is much lower.
Treatment: Management of CMN remains controversial.
Small lesions may be observed or electively excised at puberty;
malignant change before puberty is extraordinarily rare.
Acrodermatitis enteropathica
 Cause: Rare autosomal recessive disorder
Defective gastrointestinal transport protein results in
impaired absorption of zinc. Because human milk contains
a protein that facilitates zinc absorption, clinical
manifestations often appear after an infant is weaned from
human milk to formula or cow’s milk.
An acrodermatitis enteropathica-like presentation may
occur with zinc deficiency occurring in full-term, breastfed infants, in which case it has been ascribed to defects in
maternal mammary zinc secretion. In these patients, zinc
replacement is only required until the time of weaning.
Acrodermatitis enteropathica
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Clinical Features: In addition to a scaling erythematous eruption located
around the mouth and in the diaper area, infants may have sparse hair,
diarrhea, or failure to gain weight.
Diagnosis: The diagnosis is suggested by a low serum zinc concentration.
Treatment: Treatment is zinc supplementation. While awaiting improvement
from supplementation, affected areas may be treated with a low-potency
topical corticosteroid (eg, hydrocortisone 1%) twice daily.
Candidal diaper dermatitis
• Cause: C albicans infection of the diaper area may be primary or,
more often, secondary to an existing irritant diaper dermatitis.
Clinical Features: Characterized by erythematous patches
involving the convex skin surfaces as well as skin creases.
Satellite papules and pustules are present, as is scaling at the
margin of the involved area.
Treatment: Treatment consists of application of a topical
antifungal preparation (eg, nystatin, clotrimazole, or
miconazole). Severe cases occasionally require treatment with an
oral antifungal agent (eg, fluconazole) for 2 to 4 weeks.
Irritant diaper dermatitis
 Cause: Multiple factors may contribute to irritant diaper dermatitis,
including moisture (which reduces the skin's ability to withstand
frictional forces), friction (applied by the diaper), and enzymes in stool
(which act as irritants).
Clinical Features: The rash consists of erythematous patches
involving the lower abdomen, buttocks, and thighs.
Convex skin surfaces are involved, whereas the inguinal folds are often
spared (suggesting that contact with the diaper is partly responsible).
Treatment: Initial management includes frequent diaper changes and
the application of a barrier cream or ointment that protects the skin
from moisture and further trauma.
Low-potency topical corticosteroids (eg, hydrocortisone 1% or
alclometasone 0.05% ointment) may be used adjunctively to reduce
inflammation
Psoriasis
 Cause: unknown
 Clinical Features: In infant is characterized by erythematous scaling papules
or plaques. Scaling of the scalp and umbilicus may be present
 May manifest as diaper dermatitis, although lesions in the diaper area often
lack the scale characteristic of psoriatic lesions located elsewhere. Lesions in
the diaper area often are the result of the Koebner phenomenon (eg, the
appearance of lesions at sites of trauma
 Treatment: emollients and low potency corticosteroid twice daily
 When to Refer: Referral is useful to confirm the diagnosis (skin biopsy may be
helpful) and to design a treatment plan for infants with recalcitrant disease.
 You are asked by a nursery nurse to check a 3 day old
newborn with a rash. The infant was delivered by csection, has been feeding well, and has had normal
vital signs. The rash is scattered on the trunk and
consists of individual white, 1-2 mm papules on
blanching erythematous base. Six to eight such
lesions are evident.
 Your diagnosis would likely be:
 A. Milia
 B. Impetigo
 C. Herpes simplex virus infection
 D. Erythema toxicum neonatorum
References
 AAP Pedialink Pediatric Dermatology-Newborn Skin
 Pediatric Dermatology, Mancini
 http://newborns.stanford.edu/PhotoGallery
 American Academy of Family Physicians