1Common pediatric rashes JFK pediatric core curriculum MGH Center for Global HealthPediatric Global Health Leadership FellowshipCredits:Brett Nelson, MD, MPHSohil Patel, MD
2Discussion outline Dermatology terminology Common benign newborn rashesCommon infectious newborn rashesNewborn vascular lesionsVarious other pediatric rashes
3Common dermatology terms Macule: circumscribed change in skin color without elevation or depressionPapule: solid elevated lesion usually <0.5 cm in diameterPlaque: raised lesion >0.5cm in diameterWheal (hive): rounded or flat-topped elevated lesion formed by local dermal edemaPurpura: non-blanching erythema or violaceous color due to extravasation of bloodNodule: palpable solid lesion of varying sizeVesicle: circumscribed elevated lesion which contains free fluid and is <0.5 cm in diameterBulla (blister): same as vesicle but with diameter >0.5 cmCyst: sac containing liquid or semisolid material usually in the dermisPustule: circumscribed elevated lesion which contains pusAbscess: collection of pus in the dermis or subcutis
4Benign newborn rashes Erythema toxicum neonatorum Miliaria Neonatal acneMiliaSeborrheic dermatitisBenign pustular melanosis of the newbornSucking blistersPresented in random order….Some other ones not covered are:-- mongolian spots-- nappy rash (diaper dermatitis)
6Miliaria Due to obstruction and rupture of exocrine sweat duct Commonly seen secondary to thermal stress, particularly with crops of lesions over face, scalp, and trunkImportant to ensure infant is not over-wrappedOnce heat stress is removed, lesions usually resolve quickly
8Neonatal acneCan be present at birth or develop in first 2-4 weeks of lifeConsists of pustules over the cheeks primarily, but also involves other areas of face and scalpNo comedones in neonatal formResolves spontaneously and without scarringThere is controversy over whether it is truly acne or whether it represents a form of pustular disorder in the newborn period. As a result, the term neonatal cephalic pustulosis has been mooted.As opposed to infantile acne (which develops after 2 months) and acne of adolescence, there are no comedomes in the neonatal form.It may be difficult to differentiate between acne and miliaria rubra.
11Benign pustular melanosis of the newborn Lesions present at birthSuperficial pustules which rupture easily without pus content, leaving spot of hyperpigmentationPustules last 1-2 days but pigmented spots may persist for a whileAny area of the body may be involvedSmears from pustules reveal polymorphonuclear leukocytes with absence of organismsEtiology is unknown.
13Seborrheic dermatitis Primarily affects scalp and intertriginous areasInvolvement of scalp is frequently termed "cradle cap“ and manifests as greasy, yellow plaques on scalpMost common in first 6 weeks of life, but can occur in children up to 12 months of ageUsually clears up without treatment in 3-4 weeksIf needed, treatment can include mild tar shampoo, oatmeal baths, avoidance of soaps, and occasional use of mild topical steroidInvolvement of skin creases can lead to secondary candidal infectionsEtiology unknownOther commonly affected areas include the forehead and eyebrows (as in the photo to the left), nasolabial folds, and external ears.
15Erythema toxicum neonatorum Onset on day 2-3 of life, mostly in term babiesLesions wax and wane over ensuing 3-6 daysLesions may intensify or coalesce particularly in response to local heatCentral white-yellow papule surrounded by a halo of erythema, mainly over trunk (but also on limbs and face)Scrapings of lesions would reveal eosinophilsEtiology unknown
18Milia Tiny, white, usually discrete papules Inclusion cysts that contain trapped keratinised stratum corneumCommonly occur on face and scalpUsually resolve within a few months without treatmentRarely associated with dermatologic syndromesEpidermolysis bullosa, oro-facial-digital syndrome (type 1)Similar lesions may occasionally be seen in mouthWhen on hard palate, called Epstein's pearlsWhen on alveolar ridges, called alveolar cysts or Bohn's nodules
20Sucking blistersPresent at birth, most often over dorsal and lateral aspect of wristEither bilateral or unilateralMay appear like well-demarcated bruises or vesiclesInfant is noted to exhibit excessive sucking activityIn the lower image, the blister present on the dorsal surface of the second finger burst open discharging yellow serous fluid. Such a lesion may be confused with bullous impetigo but the time of onset, the location and the examination should differentiate the two.
21Infectious newborn lesions Staphylococcal pustulesHerpes simplexGeneralized in utero infectionParonychiaBullous impetigoOmphalitisCongenital syphilisCandida DermatitisPresented in random order….
23Paronychia Localized inflammation with infection of nail fold Relatively common in infantsTreat most infections with oral antibiotics and severe cases with IV antibioticsFirst line treatment is usually flucloxacillin/floxacillin for Staphylococcus aureus or Streptococcus pyogenesFor chronic lesions, consider Gram-negative organisms or Candida as potential causesThis SEPARATION may be exacerbated by the baby sucking their fingers or by overzealous trimming of the infant's finger nails.
25Bullous impetigoSkin infection typically caused by Staphylococcus aureusLesions tend to appear DOL 5-10Any body site may be involved, with predilection to diaper areaBullae are flaccid, containing straw colored or turbid fluidRupture easily leaving moist denuded area (“honey-crusted lesions”)Treatment with systemic antibiotics, particularly for lesions around umbilicus
27Staphylococcal pustule Typically seen first few days of lifePredilection to neck, axilla, and inguinal areasNearly always caused by Staphylococcus aureusIf one lesion, may be treated "expectantly" with application of chlorhexidine (mainly to prevent spread)However, if more than one lesion, oral antibiotics are indicated after culture is takenFor pustules in periumbilical area, consider systemic antibiotics
30Herpes simplex May involve skin, mouth, or eye Lesions typically develop DOL 5-10Grouped vesicles may be seen, often in linear distribution if affecting limbs (1st slide)If vesicle eroded, shallow ulcer with erythematous base may be seen (2nd slide)May have associated lesions on lips -- similar to those of "cold sore" in an adult… and when they do, they provide valuable clues to the possibility of associated disseminated or CNS herpesHowever, there are exceptions to the rule and occasionally lesions may be present at birth and presumably such infants would have been exposed to the virus several days prior to delivery.
31Herpes Simplex: SEMHSV infection develops in one of three patterns, with roughly equal frequencyLocalized to the skin, eyes, and mouth (SEM)Localized CNS diseaseDisseminated disease involving multiple organsCan develop anytime between birth and four weeksPatients with disseminated disease present earliest, often within the first week after delivery, although CNS symptoms usually occur during the second or third week
32Discussion point: How do you differentiate HSV from impetigo from staph from millia?
34Omphalitis Infection of umbilical stump Erythematous, edematous, +/- exudativeMost commonly occurs after day 3Infective organisms are variable, but S.aureus, S.pyogenes, and Gram-negative organisms are commonIf cultures available, swab affected area for Gram-stain and culture to guide treatmentInitiate IV antibioticsThere may be signs of cellulitis ("cord flare") and, very rarely, fasciitis.It is important to differentiate omphalitis (or funisitis - infection of the cord itself) from other causes of serous or exudative umbilical discharges, such as a persistent vitelline duct, umbilical papilloma, or urachal remnant.
36Congenital syphilis Dermatological findings quite variable Classically involve palmar/plantar, perioral, and anogenital regionsEarly lesions include petechiae, hemorrhagic vesicles, and bullaeLesions extremely infectiousMay have extracutaneous findingsHepatomegaly, low birth weight, thrombocytopenia, anaemia, jaundice, respiratory distress, osteochondritis, hydrops fetalis, meningitis, chorioretinitis, and pseudoparalysisOlder infants may present with "snuffles" (syphylitic rhinitis) which, in early stages, may be mistaken for URIBecause of the variable lesions and clinical symptoms seen with CS, it has frequently been termed "the great imitator", and it is important to consider alternative diagnoses or vesiculobullous diseases that involve the palms and soles.
37Candida Dermatitis A common condition of young infants Most commonly caused by C. albicansCharacteristically appears as an erythematous rash in the inguinal regionClassically has areas of confluent erythema with discrete erythematous papules and plaques with superficial scalesSatellite lesions are typically noted
41Cutis marmorataReticulated pattern of constricted capillaries and venulesOften called "mottling“Due to vasomotor instability in immature infantsGenerally resolves with increasing age and for most infants is of no significanceHowever, may reflect underlying poor perfusionInfants who develop mottling and are unwell need to be clinically evaluated for sepsis and other illnesses
43Harlequin phenomenonStriking reddening of one side of body and blanching of other halfEach episode may last from seconds to minutesEpisodes occur most often during first few days of lifeThought to be vascular manifestation of changes occurring in newborn’s autonomic system
44Various other pediatric rashes Adapted from:Paul Geltman, MD, MPH andJohns Hopkins DermAtlasThe following are ~80 slides to be used as time permits – possibly during a second lecture session. Some photos may contain nude anatomy and would not be appropriate for openly public display.
45Measles Description: red confluent papular eruption Comments: A 5 year old boy developed fever, headache, and sore throat followed several days later by a red papular rash on the face. Five days later the rash was confluent on his face and disseminated over the trunk and extremities including the palms and soles.
46[The remainder of these ~80 slides have been temporarily removed from this lecture due to space limitations. The full lecture (25MB) is available from