Frequent newborn skin diseases

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82 Clinical Dermatology 2016; 4 (3-4):82-86
Annalisa Patrizi
Iria Neri
Annalucia Virdi
Carlotta Gurioli
Dermatology Division, Department of Experimental,
Diagnostic and Specialty Medicine, University of
Bologna, Bologna, Italy
Address for correspondence:
Carlotta Gurioli
Dermatology Division, Department of Experimental,
Diagnostic and Specialty Medicine
University of Bologna
Bologna, Italy
Phone: 0039 0512144847 - Fax: 0039 0512143474
E-mail: guriolicarlotta@gmail.com
Summary
Dermatological diseases in neonates are commonly
benign and self-limiting, but, in some cases, they
may be the first sign of serious conditions, such as
complexes syndromes or severe infective disorders
requiring an additional work-up. Therefore, an
accurate and prompt diagnosis is mandatory. This
article presents a short overview of transient
neonatal skin conditions, with their differential
diagnoses and treatments.
KEY WORDS: neonatal; transient; skin disease.
Introduction
The majority of the dermatologic findings in neonates
are physiological and transient so no treatment is
required; parents can therefore be reassured about
the good prognosis. However, in some cases, serious
conditions must be excluded such as complexes
syndromes (epidermolysis bullosa, incontinentia
pigmenti, etc.), or severe infective disorders (con -
genital varicella syndrome and disseminated neonatal
herpes simplex virus, neonatal candidiasis, Staphy -
lococcal Scalded Skin Syndrome-SSSS, etc.).
Sebaceous gland hyperplasia
Sebaceous gland hyperplasia represents a physiolo -
gical phenomenon of the newborn due to high sebum
secretion rates (1, 2). This sebaceous gland activity
may reflect the stimulation by placentally transferred
maternal androgens, particularly dehydroepiandroste -
rone (1). Sebaceous hyperplasia is characterized by
multiple, yellow to flesh-colored tiny papules occuring
on the nose, cheeks and chin where the density of
sebaceous glands is high est (Figure 1) ( 2, 3).
Sometimes the papules are grouped into plaques
without surrounding erythema (3). Sebaceous gland
hyperplasia most commonly affects full-term infants,
constituting nearly half of all cases, whereas pre -
mature infants are less frequently affected (2, 3). It is
a temporary disorder that spontaneously resolves
usually within the first few weeks of life (2, 3). The
papules differ from milia, which are epider mal
inclusion cysts, usually solitary and whiter in color (3).
Milia
Milia affects about 40-50% of newborns (2). They
appear as tiny, white or yellow, smooth-surfaced
papules, 1-2 mm in diameter most commonly located
over the cheeks, forehead, nose, nose-labial folds, but
they may be found anywhere: on the upper trunk,
limbs, penis, or mucous membranes (2, 3). Milia may
be few or numerous and are frequently grouped (2, 3).
These skin lesions are small cysts, resulting from
retention of keratin within the dermis (2).
They may be present at birth or appear later in infancy
and usually disappear spontaneously during the first 3
or 4 weeks of life. No therapy is required, although
Review
Frequent newborn skin diseases
Figure 1 - Sebaceous gland hyperplasia of the nose in a
newborn (Maiani Hospital, Sheraro, Ethiopia).
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Frequent newborn skin diseases
Clinical Dermatology 2016; 4 (3-4):82-86 83
sometimes milia may persist over the second or third
month (3). The most important differential diagnosis of
milia is from sebaceous hyperplasia, which tends to
be slightly more yellow (3). Clinicians must be aware
that persistent and widespread milia may be present
in association with other defects, such as oral-facial-
digital syndrome type I, which has several craniofacial
and limb features, hereditary trichodysplasia (Marie-
Unna hypotrichosis), and junctional and dystrophic
epidermolysis bullosa (where milia appear in sites of
healing erosions (2, 3).
Oral mucosal cysts of the newborn: Epstein’s
pearls and Bohn’s nodules
Epstein’s pearls (palatal microkeratocysts of the
newborn) are whitish-yellow cysts (1 to 3 mm in size)
typically seen on the median palatal mouth raphe and
represent epithelial tissue trapped during the palatal
fusion. They occur in 64-89% of neonates and are
more common in Caucasians (3).
Similar cysts on in the alveolar ridges or on the
periphery of the palate are called Bohn’s nodules.
Although Bohn’s nodules are thought to be mucous
gland cysts, more recent studies have shown them to
be keratin cysts derived from the dental lamina. The
diagnosis is clinical. They do not require treatment
because they spontaneously resolve over the first few
months of life (3).
Erythema toxicum neonatorum
Erythema Toxicum Neonatorum (ETN) usually appears
in the first to fourth day of life and occurs in ap -
proximately half of term newborns (3). No sexual or
racial predilection is reported. Congenital lesions can
occur, but, in the majority of cases, the onset varies
between 24 and 48 hours of life (3).
ETN is characterized by papules surrounded by an
erythematous halo, and somet imes vesic les o r
pustules of 2-4 mm in diame ter (star ry sky
appearance) (Figure 2). Lesions appear first on the
face then spread to the trunk and extremities, without
involving the palms. Histologically, the lesions are
eosinophilic subcorneally intrafollicular pustules. The
etiology of ETN is unknown and the diagnosis is
clinical. Blood eosinophilia may be present. ETN is
also called flea-bite rash and spontaneously resolves
in 2-7 days without permanent sequelae, so clinicians
must only reassure parents.
The differential diagnosis of ETN includes first
transient neonatal pustular melanosis (TNPM) and
other pustular dermatoses of the newborn.
Transient neonatal pustular melanosis
Transient Neonatal Pustular Melanosis (TNPM) is a
vesiculopustular rash that occurs at birth, in 5% of
black newborns, but in less than 1% of white
newborns (4). In contrast with ETN, the lesions of
TNPM lack surrounding erythema and rupture easily,
leaving a collarette of scale and a pigmented macule.
Moreover ETN appears a few days after birth and
clinically manifests with more inflammatory vesicles
containing primarily eosinophils (Figure 3). Although
in TNPM these macules have been called ‘lentigines’,
they are not true lentigines but appear to represent
transient post-inflammatory hyperpigmen tation. They
may last for up to several months before they resolve
(4). All areas of the body may be affected, under the
chin, on the forehead, at the nape, and on the lower
back and shins, the trunk, palms, and soles. The
etiology of TNPM is unknown. Although the pustules
of TNPM resolve rapidly, the pigmented macules may
take weeks to months to fade away. No treatment is
needed except parental reassurance (3).
Principal differential diagnosis of pustular ETN
and TNPM
Pustular disorders of newborn such as ETN and
TNPM must be differentiated from other inflammatory
diseases such as miliaria rubra and infantile
acropustulosis, but infantile acropustolosis is a rare
disease clinically characterized by red papules and
vesiculo-pustules involving both hands and feet. This
relapsing episodes may last until 2-3 years of life.
Some infective diseases must be ruled out, such as
staphylococcal impetigo, herpes simplex infection and
neonatal candid iasis. The lesion s of impetigo
neonatorum develops in the first days to weeks of life
and usually are caused by staphylococcus aureus.
Figure 2 - Erythema toxicum neonatorum of the face.
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Lesions consist on vesicles, pustules and tense,
fragile bullae easily to rupture, leaving superficial
erosions on an erythematous base with a peripheral
collarette of scales (2, 3). The more common involved
skin areas are: skin folds (neck, axillae, etc.) diaper
region and periorificial areas (perioral, periumbilical,
etc.). Infants are usually otherwise healthy, without
signs of systemic disease, even if, sometimes, a more
extensive clinical skin involvement may be seen and,
in these cases, impetigo could be interpreted as a
localized form of staphylococcal scalded skin
syndrome (2, 3). Usually topical antibiotical treatment
is sufficient to control mild and localized disease,
while in more severe cases a more aggressive
antibiotic treatment is required to avoid potential
systemic complications.
Considering fungal infections, candida is the most
frequent pathogen in newborn. It may be transmitted
vertically from the mother, in utero or during the passage
through the infected birth canal or horizontally by
nosocomial transmission. Therefore two types of
candidiasis have been described: a congenital form
and a neonatal form, with respectively skin lesions
present at birth or within the first week of life, and after
the 1st week of life (2). There is a broad spectrum of
clinical settings, f rom localized to diffuse s kin
eruptions with or without systemic involvement or, in
most severe cases, life-threatening diseases without
skin lesions, usually seen in extremely low birthweight
neonates. Localized neonatal candida infection
presents with red scaly patches with satellite papules
and pustules involving the diaper area and other
intertriginous areas. Also the oral mucous membranes
may be affected especially in infants after intubation.
In immunocompetent newborns, topical therapy with
imidazole or nystatin is usually sufficient to avoid
dissemination (3).
Diffuse type of candida infection corresponds to
congenital cutaneous candidiasis. First, the neonates
develop a fine erythematous papular rash evolving in
disseminated erythematous macules, papules, and
pustules and sometimes bullae. Any skin site may be
involved, even if the trunk, extremities and skin folds,
with the exception of the diaper area, are the most
frequently affected. Clinically, pustules on the palms
and soles may help the diagnosis (2). In immu -
nocompetent infants, this kind of candidiasis is often
limited to the skin and heals in 1-2 weeks (3).
Miliaria
Miliaria is a common neonatal dermatosis caused by
obstruction of sweat and rupture of the eccrine sweat
duct. It is a frequent benign disease (15% of neo -
nates) occurring in the first few weeks of life owing to
the relative immaturity of the eccrine ducts, which
favor poral closure and sweat retention. It appears as
a vesicular eruption with subsequent maceration and
obstruction of the eccrine ducts involving the face,
scalp, and trunk (2). In neonates, there are two forms:
miliaria crystallina and miliaria rubra. Miliaria
crystallina (sudamina) consists of clear superficial
pinpoint vesicles without an inflammatory areola,
while miliaria rubra represents a deeper level of sweat
gland obstruction, and is characterized by small
discrete erythematous papules, vesicles, or papulo -
vesicles sometimes with pustules (Figures 4, 5).
Therapy for miliaria is directed at avoidance of
excessive heat and humidity. Therefore, lightweight
cotton clothing, cool baths, and air conditioning may
be helpful in the management of this disorder.
Seborrheic dermatitis
Infantile Seborrheic Dermatitis (ISD) is a common,
self-limiting condition characterized by greasy scaling
Figure 3 - Transient neona-
tal pustular melanosis.
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Frequent newborn skin diseases
Clinical Dermatology 2016; 4 (3-4):82-86 85
on a red base involving the scalp and the face. Many
parents know this rash as “cradle cap” because it
occurs most commonly on the scalp (4). Sometimes
ISD may spread to the intertriginous zones, such as
the umbilicus and ano genital region.
ISD shows a marked predilection for the for so-called
“seborrheic” areas where there is a high density of
sebaceous glands (i.e. forehead, ears, eyebrows, and
nose) but the exact etiology of seborrheic dermatitis is
unknown (4). Probably hormonal fluctuations and the
colonization by Malassezia furfur may explain the
distribution of the lesions, playing a role in the patho -
genesis of this disease (4).
Differential diagnosis between ISD and atopic der -
matitis can be difficult above all in infants in the first
months of life, but the two conditions mainly differ for
the high risk of relapses and the presence of itch in
atopic patients.
Infantile seborrheic dermatitis is usually self-limited
and generally resolves within weeks to months.
Therefore, conservative management is indicated and
parents must be reassured. In severe cases scales
can be removed with a soft brush after shampooing or
after applying an emollient with white petrolatum or
antifungal. Shampoos may contain antifungal agents.
Acne neonatorum
Acne neonatorum is a benign condition occurring in up
to 20% of newborns (4) (Figure 6). In the classical
form, it consists of comedones usually involving the
cheeks (5). However, the presence of inflammatory
papules and pustules, sometimes spreading to the
forehead, may be found.
Neonatal acne results from hormonal stimulation of
sebaceous glands by maternal or infant androgens.
Figure 4 - Miliaria rubra of the dorsum.
Figure 6 - Acne neonatorum in a male patient.
Figure 5 - Miliaria rubra with pustules.
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Acne neonatorum may be confused with neonatal
cephalic pustulosis, a facial eruption associated with a
fungal sapro phyte belonging to the Pityrosporum
(Malassezia) spe cies, both M. furfur and M.
sympodialis. Clinically it manifests with papules,
papulopus tules, or larger pustules, surrounded by an
erythematous halo, located on the cheeks, chin,
forehead and trunk. In these cases, a topical anti -
fungal treatment may lead to resolution of lesions.
Neonatal acne has to be distinguished from infantile
acne. First, the neonatal form develops earlier from birth
to the first 2-3 weeks of life, while infantile acne occurs
later. Moreover in the infantile type, the acne appears
with more inflamed acneiform lesions, including open
and closed comedones, as well as papules, pustules,
and occasionally nodules. Also, infantile acne is related
to androgen-driven hyperplasia of sebaceous glands.
Like neonatal acne, infantile acne usually undergoes
spontaneous resolution in the first 6-12 months of life.
In some cases infantile acne may be more persistent
and even cause scarring, so a treatment must be
administered. Papules and pustules respond well to
topical benzoyl peroxide or erythromycin or topical
tretinoin in low concentrations (0.01% gel or 0.025%
cream) (2, 4, 5).
Diaper dermatitis
Diaper Dermatitis (DD), also known as diaper rash, is
a common irritative skin condition involving the diaper
area. DD can range from mild erythema to skin
erosion or open wounds with considerable discomfort
for the child and concern for parents. DD is one of the
most common reasons for dermatologic consultations
in infancy in the United States (6). Diaper dermatitis is
strictly associated to the occlusion, warmth and
friction caused by the napkin and to the direct
exposure of the skin to urine, feces and micro -
organisms. Moreover, the frequency of diaper soiling,
diarrhea, prolonged wetness due to a low frequency of
diaper changes and lack of barrier cream, may
increase the risk of skin disease. Premature neonates
are at higher risk because of the immaturity of the skin
(6). Prevalence in infants (1-12 months of age) ranges
from 7 to 35%. Prevalence surveys in US and UK
hospitals found a prevalence of 16% in diaper-
wearing children (7).
The most effective management for DD is prevention,
so parents should be aware of the correct manage -
ment aimed at supporting skin barrier function and
protecting the area from u rine and f eces (8).
Unfortunately, to date, no international guidelines
about available evidence and recommendations for
DD prevention practice, have been published. The
first line therapy consists of products containing zinc
oxide since it is inexpensive, not burning, antiseptic
and astringent, with a low risk of contact dermatitis
and with significant role in wound healing.
Omphalitis
Neonates are particularly prone to infection of the
umbilicus, occasionally developing into omphalitis.
The incidence is between 0.5-2% in US, but the
incidence rates depend on the geographic distribution
and the hygienic conditions. The mean age of
developing omphalitis is 3.2 days, therefore most
cases occur outside the hospital. After birth, the
devitalized umbilical cord represents an ideal
substrate for bacterial growth and also provides direct
access to the bloodstream of the neonate. Bacterial
colonization of the cord causing omphalitis may vary
from erythema with or without purulent discharge and
surrounding indurations, to thrombophlebitis, cellulitis,
and necrotizing fascitiis with increased mortality rates.
Omphalitis requires systemic antibiotic treatment and,
in the most severe cases, surgical omphalectomy.
Different topical substances are indicated for cord
care to reduce the risk of infection (8). More recent
papers assess that the application of select anti -
microbial agents to the umbilical cord does not
provide clear benefit in the hospital setting or in high-
resource cou ntries, because reducing b acteria l
colonization may have the unintended consequence
of selecting more virulent bacterial strains. However, it
may be beneficial for infants born at home in resource
limited countries where the risks of omphalitis and
associated sequelae are high (8).
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