MIAMI BEACH Fla. Although minor evanescent lesions in newborn infants are fairly common, most are not harmful and do not require treatment, according to Patricia A. Treadwell, MD.
--- Erythema toxicumneonatorum often resemble flea bites.
Several types of benign dermatoses often occur, including erythema toxicum neonatorum, which occurs in 30% to 70% of infants. This disorder develops because of the immaturity of the follicles and occurs usually 24-48 hours after birth. The symptoms can last up to 2 weeks of age, but will disappear without treatment.
The yellowish papules with surrounding erythema resemble flea bites and occur primarily on the trunk and extremities, but do not occur on the palms and soles because of an absence of follicles. Erythema toxicum neonatorum is less frequent in preterm babies.
This disorder does not have open sores and must be distinguished from other more severe forms of dermatosis, said Treadwell, chief of pediatric dermatology, Riley Children's Hospital, Indianapolis, and associate professor of dermatology and pediatrics, Indiana University.
Treadwell recently spoke here at the 32nd Annual Pediatric Postgraduate Course sponsored by Miami Children's Hospital. More than 900 attended the conference and approximately 6,000 more viewed the meeting in 20 countries by satellite.
--- Transient neonatal pustular melanosis is characterized by large pustula lesions.
Transient neonatal pustular melanosis is a common disorder seen more in black infants (4.4%) and is usually present at birth. It is characterized by sometimes large pustular lesions which create hyperpigmented macules when they rupture, a later form of the disorder.
This type of dermatosis can occur on all areas of the body, especially on the chin, neck, upper chest and lower back, but can also occur on the palms and soles. The macules disappear without treatment in a few weeks.
"The important distinction is looking at the pustular lesions," Treadwell said. "If these are cultured, they are negative for any organism."
This helps distinguish from other dermatoses, she said.
--- Sucking blisters are caused by the infant sucking on the skin in utero.
Sucking blisters are also common and can occur anywhere. They normally appear on the upper limbs and are caused by the infant sucking on the skin in utero. The blister is produced when pressure from the sucking separates the epidermis from the dermis and fluid collects there.
There can be some bleeding into the lesion, depending what part of the body the child sucks on. The lesions are usually solitary and appear symmetrical, or if multiple lesions appear, they are asymmetrical and can present as crusted lesions, Treadwell said.
Treadwell noted that these blisters are not associated with erythema.
--- Subcutaneous fat necrosis is usually painless.
Often seen in infants with a history of difficult labor and delivery is subcutaneous fat necrosis. This inflammatory disorder tends to occur on cheeks, posterior trunk, arms and legs, and can appear in children up to 1 month of age. It is characteristically painless, but tenderness can occur, Treadwell said.
This disorder combines necrosis and inflammation of the fat, but will resolve on its own, and no treatment is recommended. Uncomplicated lesions resolve spontaneously within weeks to months, usually without scarring or atrophy. Needle aspiration is recommended for fluctuant lesions and may prevent rupture and subsequent scarring. This condition is rarely associated with hypercalcemia.
--- Smooth muscle hamartoma consists of a raised lesion.
Smooth muscle hamartoma usually consists of a raised lesion with an increased growth of hair overlying the lesion. It is important to distinguish from congenital pigmented nevus, because the hamartoma lesions have no associated risk of melanoma and need not be removed. Hyperpigmentation sometimes occurs over the firm nodular lesion, which may ripple with stroking.
The lesions are composed of smooth muscle fiber bundles of arrector pili muscles, which produce goose bumps. They will become less prominent as the child becomes older and the skin matures.
--- Nevus sebaceous of Jadassohn usually occurs on the face and scalp.
Nevus sebaceous of Jadassohn appears as a lesion typically on the scalp and face area and has a 10% to 15% associated risk of cutaneous carcinoma. This occurs in 0.3% of births and appears as a yellowish, hairless plaque in newborns and remains hairless throughout the child's life.
It regresses at childhood and be comes more yellow and raised at puberty because of hormonal influences. During adolescence the lesions commonly may studded with large rubbery nodules.
"I usually recommend removal around puberty, based on the fact that most of the cutaneous carcinomas that have been reported have been late adolescent or early twenties onset," she said.
--- Aplasia cutis congenita is most often seen on the scalp.
Aplasia cutis congenita also appears in about 0.03% births and is most often seen on the scalp. The appearance of the lesions varies, depending on when they occurred during intrauterine development. Larger lesions may require surgical excision, but in general, this form of dermatosis does not require treatment, Treadwell said.
Infants can have lesions with absence of epidermis, dermis and subcutaneous tissue, which usually heal and leave a parchment scar as the child gets older.
Major complications include hemorrhage, secondary local infection and meningitis. Some cases may be associated with ectodermal or neurological defects.
--- Neonatal herpes can affect each child differently.
Herpes simplex virus (HSV) infection and congenital syphilis are important infectious neonatal disorders. When diagnosing HSV infection, remember the type, the transmission and that it can affect each child differently is important, Treadwell said.
Herpes can be transmitted transplacentally, at delivery and during the post-partum period. Children who contracted herpes infection transplacentally tend to be more seriously infected, particularly if the mother has an initial HSV-2 infection during the pregnancy, she said. This is because the mother develops viremia and doesn't have antibodies, so the infant develops viremia without antibodies. The vesicular lesions are often grouped with erythema surrounding them, a helpful sign when diagnosing herpes, Treadwell noted.
Fifty percent of infants with neonatal herpes infections will also have mucocutaneous lesions.
Herpes can also be transmitted at delivery if the mother has visual lesions or viral shedding during labor. If it is a recurrent outbreak, the child probably has some antibodies and will not be as likely to have a serious infection, she said.
Post-partum transmission can occur if the child is in close contact with an adult with active herpes labialis. Under these circumstances, transmission can occur if an infant is kissed by a caregiver who has active recurrent oral herpes, even if the person is asymptomatic.
--- Congenital syphilis may feature vesiculobullous lesions.
Syphilis is another disease transmitted transplacentally and the risk of congenital syphilis depends on the state of maternal illness. Untreated pregnant women with primary and secondary syphilis and spirochetemia are more likely to transmit infection to the unborn infant than are women with latent infection.
As the incidence of syphilis increases in women of child-bearing age, the incidence will also increase in children born to these mothers, Treadwell explained.
Most infants may be asymptomatic at birth, but if they are untreated, symptoms develop within weeks or months. Symptoms vary but may include desquamation on the palms, mucous patches, rhinitis and condylomatous lesions are highly characteristic features of syphilis, which can be evidence of the infection. Congenital syphilis is the one form of syphilis where vesiculobullous lesions may be present, she said.
Although the symptoms may seem quite evident when discussing them, Treadwell said, diagnosing the problem is not as easy. "The point to be made is that if you don't think about syphilis, you won't make the diagnosis, so it's very important to think about," Treadwell said.
For more information:
- Drolet B. et. al. "Membranous aplasia cutis" with hair collars. Congenital absence of skin or neuroectodermal defect? Arch Dermatol. 1995;131:1427-31.
- Treadwell PA. Sexually transmitted disease in neonates and infants. Sem Dermatol 1994;13:256-61.
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