Neonatal Dermatologic Challenges

Robert H. Johr; Lawrence A. Schachner

doi:10.1542/pir.18-3-86

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Robert H. Johr, MD^*
Lawrence A. Schachner, MD^†

^*Associate Professor of Dermatology, Assistant Professor of Pediatrics, Director, Pigmented Lesion Clinic, University of Miami School of Medicine, Miami, FL.
^†Editorial Board.

IMPORTANT POINTS

The differential diagnosis of vesiculopustular rashes in the neonatal period is extensive, with more than 30 diverse, yet clinically similar, conditions. It is essential to separate the diseases into four basic categories: mild noninfectious and infectious diseases and potentially serious, life-threatening infectious and noninfectious processes.
Potentially life-threatening infections can have a banal clinical appearance, whereas self-limited dermatoses can be widespread and clinically dramatic. Signs and symptoms of systemic involvement should be noted and acted upon.
Various combinations of primary lesions (vesicles, bullae, and pustules) and secondary changes (erosions, ulcerations, and crusting) are seen. Because pathognomonic morphology or distribution of lesions often is not evident, laboratory testing is required to make the correct diagnosis.
Due to the heterogenicity of clinical findings seen with vesiculopustular rashes in the neonate, a detailed maternal, obstetric, and family history as well as a complete history and physical examination of the neonate are essential.
The potential negative consequences of initiating inappropriate therapy includes delayed diagnosis due to the creation of atypical presentations, spread of infectious agents, increased morbidity from prolonged illness, and toxicity created by invasive diagnostic tests and therapies.

Introduction

Medicine is both an art and a science, and there is no more critical situation for the two to blend as in the evaluation of the newborn who has a vesiculopustular rash. Does the patient appear healthy or toxic? Life-threatening conditions can look innocuous, whereas self-limited rashes that do not need therapy can become generalized and appear dramatic! More than 30 conditions are included in the differential diagnosis, and there is no place for “shotgun” approaches with their inherent dangers.

Signs and symptoms can be deceiving, or at the very least misleading. Primary lesions (vesicles, bullae, or pustules) often are hidden in a sea of secondary changes (erosions, ulcerations, or crusting). Classic presentations, such as grouped …