Common Skin Rashes in the Newborn Period
A newborn’s skin may exhibit a variety of changes during the first four weeks of life. Most of these changes are benign and self-limited, but others require further work-up for infectious aetiologies or underlying systemic disorders. Nearly all these skin changes, are concerning to parents. Identify the morphology, distribution, and characteristics of common skin disorders. Infants with unusual presentations or signs of systemic illness should be evaluated for Candida, viral, and bacterial infections. Distinguish these benign neonatal rashes from conditions that require diagnostic and therapeutic interventions (such as skin infections and inherited conditions).
A concise discussion of the common newborn rashes is done here.
Erythema Toxicum Neonatorum
Cause: Inflammatory disorder of unknown aetiology. Vesicular fluid shows eosinophils.
Clinical Features: Appears within 24 to 48 hours of birth. Common (up to 50%) in term neonates. Uncommon in preterm neonates. Blotchy, erythematous macules and papules, often with central papule, vesicle, or pustule (Figure 1).
Treatment: None. Typically resolves within 4-5 days.
Cause: Epidermal inclusion cysts. They occur in up to 50 percent of newborns.
Clinical Features: Tiny white papules present on forehead, nose, and cheeks. Present at birth or will appear thereafter.
Treatment: Milia are a common source of parental concern, and simple reassurance about their benign, self-limited course is appropriate.
Cause: Duct obstruction leading to dilatation and rupture.
Clinical Features: Tiny erythematous macules or papules. They are seen in concentrated on areas of skin covered by clothing.
1) Prevention. Avoid excess environmental heat, overdressing with warm clothes, and applying thick emollients which can occlude the ducts.
2) Established. Low humidity (dry), cool airconditioned environments will help. Cool baths or sponge baths may be helpful.
Harlequin Colour Change:
Causes: Harlequin colour change occurs when the newborn lies on his or her side. Harlequin colour change is thought to be caused by immaturity of the hypothalamic centre that controls the dilation of peripheral blood vessels.
Clinical features: Erythema of the dependent side of the body with simultaneous blanching of the contralateral side. The colour change develops suddenly and persists from 30 seconds to 20 minutes. It resolves with increased muscle activity or crying. This phenomenon can affect up to ten percent of full-term infants, but it often goes unnoticed because the infant is bundled- up.
It occurs most commonly during the second to fifth day of life and may continue for up to three weeks.
Causes and clinical features: Seborrheic dermatitis is an extremely common rash characterized by erythema and greasy scales. Many parents know this rash as “cradle cap” because it occurs most commonly on the scalp. Other affected areas may include the face, ears, and neck. Erythema tends to predominate in the flexural folds and intertriginous areas, whereas scaling predominates on the scalp. Because seborrheic dermatitis often spreads to the diaper area, it is important to consider it in the evaluation of diaper dermatitis.
Treatment: It is self-limited and often resolves within a few weeks to months. Scales can be removed with soft brush/fine comb. In more severe cases, antifungal shampoos or low-potency topical steroid can shorten the duration of disease.
Cause: Obstruction and inflammation within pilosebaceous follicles may be androgen related.
Clinical Features: Present in 20% of newborns during the first few weeks. Primarily on the face. Mild (papules, pustules, closed comedones) acne is common. Papulonodular or scarring is rare.
Treatment: It is usually unnecessary. Resolves as androgen levels decline during first months of life. Refer only if persistent or unusually severe. Work up for androgen excess.
Transient Pustular Melanosis:
Cause: Unknown. Pustular fluid = polymorphonuclear leukocytes.
Clinical Features: 5% African American (rare in other races). Pustules and vesiculo pustules rupture easily (often before birth). Then small hyperpigmented macules with a rim of scale form.
Treatment: None. Pustules resolve within a few days. Hyperpigmented macules fade in 3 to 4 months.
Neonatal Herpes Simplex :
Cause: Herpes simplex virus (HSV), usually intrapartum acquisition.
Clinical Features: Mean age at presentation around 11 days
1) Skin, eye and mouth (40%) – If untreated 70% disseminate
2) Disseminated (25%) – Skin lesions in up to 60%
3) CNS (35%) – Skin lesions in up to 60%
Viral culture, PCR, or direct immuno-fluorescence. Sample skin lesions as well as other sites (conjunctivae, nasopharynx, oropharynx, cerebrospinal fluid)
Management: This has a significant morbidity and mortality. Full evaluation and treatment with high dose intravenous acyclovir.
Also known as “salmon patch”, “stork bite”, “angel kiss”
Cause: Area of superficially dilated capillaries
Clinical Features: Seen in up to 30% to 40% of newborns. Commonly occurs on the glabella, eyelids, or nape of the neck.
Treatment: None. On the face it usually resolves in 2 years. On the nape of the neck it may persist.
Flat birthmarks that can be deep brown, slate grey, or blue-black in colour. They sometimes look like bruises and are often found on the lower back and buttocks. Mongolian spots are present at birth and most of them fade (at least somewhat) by age 2 and usually completely by age 5.
They are very common in babies of African, Asian, Hispanic and biracial descent.
Causes: Group A or B Streptococcus, Listeria monocytogenes, Pseudomonas aeruginosa, Staphylococcus aureus, and other gram-negative organisms.
Clinical features: Other signs of sepsis are usually present such as an elevated band count, and positive blood culture; Gram stain of intralesional contents shows polymorphic neutrophils.
Treatment: Antibiotics and further work up for sepsis.
Cause: Diaper rash is a skin irritation caused by long-term dampness from sweat, urine and faeces in the diaper which irritates the skin from prolonged contact.
Treatment: Keep the skin dry. Change wet diapers as quickly as possible. Allow the baby’s skin to air-dry intermittently and if possible without the diaper if practical. Launder cloth diapers in mild soap and rinse well. Avoid using plastic pants. Avoid irritating wipes (especially those containing alcohol) when cleaning the infant.
Cause: Vasomotor instability
Clinical Features: Reticulated mottling of the skin, accentuated by cold. Can be accentuated in certain conditions (for example in Downs syndrome)
Treatment: Warming, if there are signs of systemic infections think about sepsis and refer patient. A tendency to cutis marmorata may persist for several weeks or months, or sometimes into early childhood.
- Liu C, Feng J, Qu R, et al. Epidemiologic study of the predisposing factors in erythema toxicum neonatorum. Dermatology. 2005;210(4):269-72.
- Carr JA, Hodgman JE, Freedman RI, Levan NE. Relationship between toxic erythema and infant maturity. Am J Dis Child. 1966;112(2):129–134.
- Schachner L, Press S. Vesicular, bullous and pustular disorders in infancy and childhood. Pediatr Clin North Am. 1983;30(4):609-29.
- Paller A, Mancini AJ, Hurwitz S. Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence. 3rd Edition. Philadelphia, Pa.: Elsevier Saunders, 2006:737.
- Selimoglu MA, Dilmen U, Karakelleoglu C, Bitlisli H, Tunnessen WW. Picture of the month. Harlequin color change. Arch Pediatr Adolesc Med. 1995;149(10):1171–1172.
- Janniger CK. Infantile seborrheic dermatitis: an approach to cradle cap.Cutis. 1993;51(4):233-35.
- Williams ML. Differential diagnosis of seborrheic dermatitis. Pediatr Rev.1986;7(7):204-211.
- Mazereeuw-Hautier J, Carel-Caneppele S, Bonafé JL. Cutis marmorata telangiectatica congenita: report of two persistent cases. Pediatr Dermatol. 2002;19(6):506–509.