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MOCA Time: Neonatal Rashes

Solomon Behar, MD and Joanna Parga-Belinkie, MD

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Sol sits down with neonatologist Dr. Joanna Parga-Belinke to discuss how to evaluate and manage common neonatal skin disorders. The most common neonatal skin disorders include dermal melanocytosis (mongolian spots), sebaceous hyperplasia, nevus simplex (salmon patch), erythema toxicum neonatorum, and milia. Most neonatal skin conditions resolve spontaneously.

Generalized Skin Changes 

  • Acrocyanosis or peripheral cyanosis: 
    • Bluish discoloration of the extremities; sometimes also periorally
      • Should improve with warming
    • Should never be central (lips and mouth; i.e. the mucous membranes)
  • Cutis marmorata
    • Patchy, reticular erythema that also can resolve with warming
      • Cutis marmorata telangiectatica congenita is a rare vascular anomaly with possible associations of body asymmetry, cleft palate and/or glaucoma (to name a few)
  • Harlequin
    • One sided erythema, usually on the side the baby is lying on
      • The color change lasts for about 20 min and resolves with re-positioning and/or stimulation
      • The thought is that it has to do with immature development of vasculature and capillary beds
    • Can occur in up to 10% of term infants, more common in the premature population
    • Harlequin ichthyosis is a serious skin condition in which the skin barrier is destroyed and gives a scaled appearance

Localized, pigmented and depigmented vascular lesions

  • Congenital dermal melanocytosis (CDM)
    • Bluish, gray, brownish lesions most commonly on the shoulder, back, sacral area
    • More common in Asian, Black and Hispanic neonates
    • Should always be documented in the initial exam so as not to be confused with bruising 
    • Very rarely, CDM is associated with lysosomal storage disorders
  • Congenital melanocytic nevi
    • Described as your “classic” birthmark and can be monitored for growth over time
  • Cafe au lait spots
    • Flat, well circumscribed, brown colored (not as dark as the melanocytic nevi) common on the torso, buttocks and lower extremities
    • More than 6: can be present in Neurofibromatosis Type 1
  • Nevus depigmentosus
    • Localized areas of depigmentation

 Vascular birthmarks

  • Nevus simplex
    • Blanchable; pink/red/violet colored
    • Usually fade within the first few years of life
  • Nevus flammeus (port wine stain)
    • Dark purple, non-blanching, generally in the V1 distribution and can represent underlying neurocutaneous diagnosis of Sturge Weber
  • Infantile hemangiomas 
    • Vascular neoplasms which proliferate in infancy
    • Initially, the lesions are purplish and become more red over time; they can be dimpled and many smaller ones resolve on their own
    • More prevalent in caucasians and female
    • Treated with propranolol, steroids or laser surgery (depending on derm) if in areas on face/beard distribution, near eye (affecting vision), sacrum  and/or in the GU area
    • If more than one is seen on the skin, work up for underlying PHACE syndrome should be completed

Papular, pustular lesions

  • Milia
    • Retention of keratin or sebaceous material that causes tiny white papules, tend to be on the face
      • In the mouth, they are called Epstein pearls
  • Miliaria
    • Obstruction of the sweat glands, generally caused by heat and humidity
      • Sometimes look like water droplets
    • Miliaria rubra is “heat rash” and should improve with cooling measures (fungal infections tend to be beefier red)
  • Sebaceous hyperplasia
    • White smooth papules on the nose and upper lip that self resolve
  • Erythema toxicum 
    • Most common pustular eruption in neonates
    • Macules and papules on an erythematous base - seen within 72 hours of birth, transient in different locations and resolves within a week
    • Does not look fluid filled
  • Cephalic pustulosis (neonatal acne)
    • Usually occurs around 3 weeks of life and can be monitored and most commonly self resolves
  • Transient neonatal pustular melanosis
    • More common in African American babies
    • Starts as little pustules that become pigmented macules and then looks like some white drying skin around the lesion as it evolves; generally self resolves within 3-4 weeks
  • Seborrheic dermatitis 
    • Greasy and scale-like lesions generally on the scalp, but can be in the face, neck and diaper area
    • Can be due to Malassezia furfur and/or hormonal fluctuations
    • Does not need to be treated, but can use mineral or olive oil with a comb through the hair or across the scalp; can use topical antifungals if persistent 

 Blistering lesions

  • HSV
    • Generally affects babies on day 7-14 of life
    • Taking a good history is important, but also unroofing the blister and sending for PCR is helpful in diagnosis


Ed’s Note: for great images of many of the conditions we discussed in this segment, plus several more dermatologic newborn findings,  we recommend checking out this site from Stanford Medicine:


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