Nevus flammeus, or port-wine stain, when present in the area innervated by the ophthalmic branch of the facial nerve, is associated with Sturge–Weber syndrome, a neurocutaneous disorder with vascular malformations of the brain and intractable seizures.
Multiple or clustered capillary hemangiomas may be associated with deep tissue and parenchymal involvement, and further evaluation is necessary.
Dermal melanosis, or Mongolian spots, are dark blue–grey patches of melanocytes located in the dermis. Mongolian spots should not be confused with bruising.
Seborrheic dermatitis can be recognized clinically by the presence of greasy scales and erythematous plaques.
Diaper dermatitis is usually caused by irritation of the skin from prolonged contact with feces and urine. Sparing of the skin folds is diagnostic.
Candida skin or oral infections may be secondary to excessive use of oral antibiotics. Treatment includes antifungal agents such as nystatin, ketoconazole, or clotrimazole as well as consideration of probiotics and hygiene.
Multiple café-au-lait spots of neurofibromatosis increase the risk for auditory and central nervous system (CNS) tumors.
Vascular malformations in a “beard distribution” on the face are associated with airway hemangiomas.
Macules are nonpalpable lesions ≤1cm
Patches are nonpalpable lesions >1cm
Papules are palpable lesions ≤5mm
Plaques are palpable lesions >5mm
Nodules are palpable lesions, >5mm in both width and depth1
Telangiectasias are dilated superficial blood vessels
Vesicles are clear fluid-filled lesions, ≤5mm
Bullae are clear fluid-filled lesions, >5mm
Pustules are pus-filled lesions, ≤5mm
With the urgent need for adjustment to the extrauterine environment that the newborn faces, many different adaptive changes occur across all organ systems, including the skin. Skin lesions, or rashes, commonly occur, many of which are benign, but which usually are a cause of considerable concern for parents.
Milia are tiny white-yellow discrete pearly papules, 1 to 2 mm, frequently occurring on the face and scalp. They are superficial inclusion cysts of the pilosebaceous units that contain laminated keratinized material of sebaceous origin.2 The lesions resolve spontaneously and no treatment is necessary.
Miliaria are lesions caused by obstruction of eccrine sweat gland ducts, especially in warm climates. Very superficial sweat gland obstruction results in miliaria crystallina, which results from sweat being trapped in the stratum corneum of the skin, producing tiny clear vesicles. Miliaria rubra, or heat rash, is common in febrile or overheated infants. These are erythematous small papules that are most commonly found on the upper trunk and head, caused when obstructed sweat leaks into the dermis, inciting an inflammatory response (Fig. 93-1).
Neonatal acne presents as open or closed comedones concentrated on the face and upper chest, thought to be related to excess maternal or exogenous androgens, or due to an inflammatory response to skin colonization by Malassezia furfur in severe cases.3 It is self-limiting, but application of topical ketoconazole or hydrocortisone may speed clearance of the lesions.
Erythema toxicum is the most common newborn rash, and is present in up to 50% of newborn infants. The lesions usually appear by the second day of life, last approximately 1 week, and resolve spontaneously. The rash presents as pinpoint, papulopustular lesions on an erythematous base that appear on the face, trunk, and extremities, sparing the palms and soles. The lesions are at the opening of sebaceous ducts, thought to be secondary to an inflammatory reaction to microbial colonization at birth.4,5 Characteristic findings with Wright stain will reveal collections of eosinophils with absence of infectious organisms.2
Transient pustular melanosis is found almost exclusively in African American infants, and the lesions are usually present at birth. It presents with a combination of fine pustules, areas of fine scale, and hyperpigmented macules where prior pustules were located.2 A Wright stain of the contents will show a predominance of neutrophils (as opposed to erythema toxicum), and absence of bacteria. A variety of vesiculopustular lesions which could be confused with pustular melanosis, but that may have serious complications are shown in Table 93-1.
| Condition | Etiology | Diagnosis | Sequelae |
|---|---|---|---|
| Neonatal herpes | Herpes simplex 1 Herpes simplex 2 | Viral culture PCR for DNA Direct immunofluorescence assay | Sepsis DIC Hepatic dysfunction |
| Neonatal varicella | Varicella zoster virus | Clinical Direct fluorescence assay PCR | Pneumonia Hepatitis Meningoencephalitis |
| Bacterial infections | Staphylococcus aureus Streptococcus spp Listeria monocytogenes | Gram stain Blood culture | Sepsis Meningitis |
| Congenital syphilis | Treponema pallidum | Darkfield microscopy Serology Silver stain | Interstitial keratitis Saber shins |
| Incontinentia pigmenti | X-linked dominant | Skin biopsy | Dental abnormalities Neurological complications (seizures, cerebral infarctions) |
| Cutaneous mastocytosis | Excessive mast cell accumulation and mediator release | Clinical Skin biopsy | Anaphylaxis Cachexia Chronic GI symptoms Bone marrow/hepatic fibrosis |
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