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Neonatal dermatology – the rashes you shouldn’t ignore


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Neonates have rashes of all shapes and sizes. It’s important for us to be able to reassure parents where appropriate and act when we need to. This two part series deals with neonatal dermatology. In Part 1, we looked at the benign conditions, but in Part 2 we will look at the conditions that you shouldn’t ignore.

Epidermolysis bullosa



  • —Group of inherited mechanobullous disorders
  • —Blisters form after mild friction or trauma
  • —Three types: epidermolytic EB, junctional EB, dermolytic EB
  • —Skin biopsy distinguishes types and determines prognosis
  • —Prenatal diagnosis is now possible for a number of variants for which gene markers are available
  • —Treatment is symptomatic and supportive

Congenital syphillis



  • —Mucocutaneous lesions usually appear between 2-6 weeks of age
  • —Most common finding = papulosquamous eruption beginning in the palms and soles and spreading over extremities, face and trunk (pemphigus syphiliticus)
  • —Diagnosis confirmed with serological studies of the serum and CSF
  • —Early diagnosis and treatment with high dose penicillin prevents late complications
  • —Newborns with disease can also be born premature, have poor growth, and develop hepatosplenomegaly and rhinorrhea

Congenital rubella



  • —Blueberry muffin lesions
  • —Seen in severe disseminated disease with jaundice, pneumonitis, meningitis, bony abnormalities, thrombocytopenia
  • —Congenital rubella associated with cataracts, microphthalmia, glaucoma, congenital heart disease
  • —Blueberry muffin lesions can also be seen in congenital CMV and toxoplasmosis
  • —Can confirm diagnosis with serologic testing

Herpes simplex

neonatal herpes



  • —Of infected babies, 70% develop the skin rash and 90% of these children go on to develop systemic disease
  • —Clustered red papules and vesicles, then become pustular, denuded, crusted, and hemorrhagic over the following 2-3 days
  • —Diagnose by PCR of the lesion
  • —Treat with acyclovir as soon as infection is suspected to prevent disseminated disease and morbidity/mortality

Neonatal varicella



  • —Early exposure in utero during 1st trimester can rarely lead to neonatal varicella syndrome: linear scars, limb anomalies, ocular defects, and CNS involvement
  • —Late exposure in 3rd trimester increases the risk of baby acquiring the disease during the neonatal period (the closer to delivery, the higher the risk)
  • —Vesicles usually develop over the first 3-10 days of life
  • —Dissemination can lead to pneumonitis, encephalitis, purpura with hemorrhage, hypotension, and death
  • —If newborn is at risk, should consider varicella-zoster immune globulin or IVIG
  • —Start acyclovir early if lesions are suspicious for varicella
  • —Confirm diagnosis with DFA or PCR of lesion

Aplasia cutis congenita

aplasia cutis


  • —Often inherited as AD trait
  • —Absence/failure of formation of a localized area of scalp or skin, usually single lesion located over vertex of the scalp
  • —Treatment is supportive until lesion is healed
  • —Leaves an atrophic, hairless scar that can be excised later in life
  • —Less commonly, the trunk and extremities are involved and lesions may be associated with limb defects, epidermolysis bullosa, and chromosomal abnormalities

Neonatal lupus erythematosus



  • —Annular erythematous plaques with a central scale
  • —Transplacentally aquired ssA (Ro) and ssB (La) Ab is thought to play role in pathogenesis
  • —May be triggered or exacerbated by sun exposure
  • —Associated with heart block, hepatosplenomegaly, anemia, leukopenia, thrombocytopenia, and/or lymphadenopathy
  • —Except for cardiac involvement, usually resolves in 6-12 months
  • —May need topical steroids, rarely requires systemic steroids

Incontinentia pigmenti



  • —Neurocutaneous syndrome
  • —X-linked dominant (IKBKG gene), lethal in males
  • —Starts out with patches of erythema and blisters that follow the lines of Blaschko -> warty plaques by several weeks to months -> increasing pigmentation at 2-6 months that look like marble cake swirls -> fade to hypopigmented patches in late childhood
  • —Associated defects in the CNS, eye, dentition, heart, skeletal system

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