22 HOW TO TREAT : BABY RASHES
22 HOW TO TREAT : BABY RASHES
1 SEPTEMBER 2023 ausdoc . com . au
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The final subtype , miliaria profunda , presents as deeper papules .
Management of miliaria includes wearing loose-fitting , breathable clothing , cool compresses , keeping the infant in a cool , well-ventilated environment and avoiding excessive soaps or irritants . 39
Acne
Neonatal acne affects babies within the first six weeks of life . It affects around one in five healthy newborns and presents as superficial pustules and / or comedones on the head and trunk . 38 Neonatal acne usually does not scar and is self-resolving .
Neonatal cephalic pustulosis may be considered a variant of neonatal acne that is distinguished by the paucity of comedones . Unlike true neonatal acne , neonatal cephalic pustulosis is caused by Malassezia spp ., which may be confirmed with mycology of the pustules . Neonatal cephalic pustulosis often resolves without treatment but in some cases , topical antifungals , such as ketoconazole , may be used . 24
True infantile acne is rare and presents between six to 16 months as comedones , papules , pustules and occasional cystic acne and is more common in male infants . Infantile acne is usually self-limiting and resolves spontaneously by one year of life , but patients may be left with scarring . Treatment is similar to the management of acne vulgaris with topical agents such as benzoyl peroxide or topical retinoids . In severe cases , oral therapy may be required .
Transient neonatal pustular melanosis
Transient neonatal pustular melanosis ( TNPM ) is a benign and self-limiting condition that affects 0.2-4 % of infants in the first days of life . 40 Clinically , TNPM presents as a diffuse eruption of 1-3mm pustules , present at birth , distributed over the chin , neck , forehead , back and buttocks . 41 Lesions will rupture and crust , leaving hyperpigmentation which fades over weeks . 42 TNPM resolves spontaneously within a few days to weeks with no long-term sequelae . 43
Neonatal blistering
Pathological causes of neonatal blistering are categorised as infective , genetic , autoimmune , congenital and environmentally induced ( see table 1 ). Given the wide and potentially serious differential diagnoses for neonatal blistering , urgent dermatological referral is indicated . 44
VASCULAR LESIONS
Infantile haemangioma
INFANTILE haemangioma ( IH ) is the most common benign vascular tumour , affecting up to 10 % of infants . 46 Risk factors include prematurity , low birthweight , female sex , multiple gestation , progesterone therapy and family history . IHs are typically present in the first few days of life as discrete pink macules which proliferate rapidly over the first six months of life and involute from 12 months of age . 47 The clinical presentation depends on the depth of involvement , varying from red bosselated plaques to blue subcutaneous masses . Most are superficial lesions that spontaneously regress . However , some are classified as high risk as they are obstructive ,
Table 1 . Differential diagnoses for neonatal blistering Aetiology Benign / physiological
Diagnoses
ulcerating , functionally impairing or potentially disfiguring and need to be treated . 48 The IH referral score is a validated screening tool that informs primary care physicians when specialist referral is required . 49 Investigations and recommendations for referral are summarised in table 2 . Given the well-described natural
history , observation is a reasonable management option in most cases . In patients who require active treatment , options include one drop of topical timolol 0.5 % twice daily or systemic agents such as propranolol and atenolol which should be initiated under specialist care .
Capillary malformations
Capillary malformations ( CMs ), also known as port-wine stains , present congenitally as erythematous patches . If left untreated , they grow commensurate with the child and may evolve into darker , nodular plaques ( see figure 10 ). CM may be mistaken for naevus simplex , a common , benign vascular birthmark that is colloquially termed a ‘ salmon patch ’. 51 Naevus simplex is typically found in the midline , with common locations including the nape of the
Erythema toxicum neonatorum Neonatal cephalic pustulosis Neonatal pustular melanosis Miliaria Eosinophilic pustular folliculitis of infancy Neonatal acne
Infection Viral : HSV Varicella – zoster virus Enteroviruses CMV
Bacterial : Staphylococcus aureus — bullous impetigo , staphylococcal scalded skin syndrome Streptococcus pyogenes — bullous impetigo , blistering distal dactylitis Congenital syphilis
Fungal : Dermatophytes Candida
Parasitic : Sarcoptes scabiei var . hominis — scabies
Genodermatoses
Maternally transmitted autoimmune disease
Cellular infiltrates
Epidermolysis bullosa Specific porphyrias Ichythoses ( eg , epidermolytic ichthyosis , congenital ichthyosiform erythroderma ) Incontinentia pigmenti Acrodermatitis enteropathica
Neonatal lupus erythematosus Pemphigus ( see figure 9 ) Bullous pemphigoid
Mastocytosis Langerhans and non-Langerhans cell histiocytoses
Environmental Nutritional : Pellagra Acquired acrodermatitis enteropathica Necrolytic migratory erythema
Physical : Neonatal sucking blisters Trauma
Source : Tatian A et al 2021 45 neck (‘ stork bite ’), upper eyelids , glabella (‘ angel ’ s kiss ’) and philtrum . 52 In some cases , CM involving the upper face represent Sturge-Weber syndrome , a rare neurocutaneous syndrome that has ophthalmological and neurological sequelae . 53 Children with suspected Sturge-Weber syndrome require gadolinium-enhanced
Infantile haemangioma is the most common benign vascular tumour , affecting up to 10 % of infants .
MRI to assess neurological involvement , and ophthalmological evaluation is required . Early intervention with pulsed dye laser helps ameliorate the CM . 54
Bruises
Infants with a history of increased bruising or bleeding require distinction between pathologic and normal bleeding . Diagnostic considerations of bruising are outlined in table 3 . While bruises are common in older children and adults , they are rare in infants younger than six months because of their lack of mobility . Bruises in this age group should raise concerns for non-accidental injury . 56 Patients with clinically significant bleeding require an FBC with prothrombin time , activated partial thromboplastin time , fibrinogen , examination of peripheral blood
Figure 4 . Dermoscopy demonstrating the pigmented anterior head of Sarcoptes scabiei .
Figure 5 . Infantile seborrhoeic dermatitis .
Figure 6 . Tinea faciei .
Figure 7 . Annular plaques of neonatal lupus erythematosus .