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5 Common-to-Rare Infant Skin Conditions
Aimee M Barton, MD, FAAP | May 13, 2021
| Contributor Information
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Image courtesy of Medscape.
5 Common-to-Rare Infant Skin Conditions
Aimee M Barton, MD, FAAP | May 13, 2021 | Contributor Information
Many dermatologic conditions present specifically during childhood, from infancy through adolescence. The causes of these conditions range from infectious to inflammatory to congenital. Many common rashes and birthmarks that present in the pediatric population are benign, and although they may be important to identify, they do not require any specific therapy. Other conditions, however, need extensive evaluation and close follow-up to ensure the best possible outcomes. This slideshow addresses multiple pediatric dermatoses, including their diagnosis and treatment.
The above image shows erythema toxicum neonatorum in a full-term infant at 6 hours of life.
Image from Wikimedia Commons | Zeimusu.
5 Common-to-Rare Infant Skin Conditions
Aimee M Barton, MD, FAAP | May 13, 2021 | Contributor Information
Infantile Hemangiomas
Epidemiology and classification
Infantile hemangiomas are benign vascular neoplasms composed of proliferating, plump endothelial cells (shown). They are the most common tumors of infancy.[1-3] Infantile hemangiomas occur more often in females than in males and are more prevalent among White infants.[1] The key risk factor is low birth weight; however, prematurity, multiple gestation pregnancies, advanced maternal age, placenta previa, preeclampsia, and placental abnormalities are also risk factors.[3-5]
Infantile hemangiomas are classified as follows:
Superficial hemangiomas (strawberry hemangiomas) - Involve the uppermost layer of skin
Deep hemangiomas - Occur in the dermis and subcutaneous tissue
Mixed hemangiomas - Contain superficial and deep components
They can be further classified into localized or segmental hemangiomas.
Image courtesy of Medscape.
5 Common-to-Rare Infant Skin Conditions
Aimee M Barton, MD, FAAP | May 13, 2021 | Contributor Information
The above image demonstrates a painful, ulcerated infantile hemangioma near the axilla.
Presentation
Eighty percent of infantile hemangiomas are focal and solitary.[6] Many are not clinically evident at birth and instead present within the first days to months of life.[3,7,8] The course is characterized by two phases: proliferation and involution. In the proliferation phase, which usually occurs in the first year of life, blood vessels expand, causing growth of the hemangioma. Following this phase, the lesion regresses over 3-10 years, and the vasculature is replaced by fibrofatty tissue.[3,9]
Although they most commonly occur in the skin, infantile hemangiomas can also develop at extracutaneous sites, including the mucous membranes and internal organs.[3]
Image courtesy of Medscape.
5 Common-to-Rare Infant Skin Conditions
Aimee M Barton, MD, FAAP | May 13, 2021 | Contributor Information
The above image demonstrates a superficial and deep infantile hemangioma that resulted in astigmatism of the left eye, requiring spectacles to correct the refractive error and prevent amblyopia.
Complications
Infantile hemangiomas are usually benign and do not require intervention. Ulceration and bleeding are the most commonly observed complications.[10] Sometimes, however, the lesions may impinge on vital structures, cause high-output cardiac failure (if large), or create significant structural abnormalities or disfigurement. Hemangiomas can also pose significant risk if they are located in the periorbital area, lip, neck, or sacral region.[7]
Image courtesy of Medscape.
5 Common-to-Rare Infant Skin Conditions
Aimee M Barton, MD, FAAP | May 13, 2021 | Contributor Information
The image shown demonstrates a segmental infantile hemangioma in a female infant with PHACE syndrome.
PHACE syndrome
PHACE syndrome is defined by the presence of congenital malformations that include posterior fossa brain malformations, large segmental infantile hemangiomas, arterial anomalies, cardiac anomalies, and eye and endocrine abnormalities, as well as possible sternal clefts or supraumbilical raphae.[11]
Hemangiomas in PHACE syndrome typically present on the face or scalp. Patients with suspected PHACE syndrome require work-up with magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA) of the head and neck, echocardiography, and an ophthalmology exam.[11]
Image courtesy of Medscape.
5 Common-to-Rare Infant Skin Conditions
Aimee M Barton, MD, FAAP | May 13, 2021 | Contributor Information
The image shown demonstrates a segmental infantile hemangioma in a patient with PELVIS (perineal hemangioma, external genital malformations, lipomyelomeningocele, vesicorenal abnormalities, imperforate anus, skin tag) syndrome.
Treatment
Without any specific intervention, the majority of infantile hemangiomas involute, with the lesion shrinking from the center. Approximately 50-60% resolve incompletely, leaving permanent skin changes.[12]
Complicated hemangiomas, including large segmental hemangiomas, facial hemangiomas, airway or periorbital hemangiomas, or those with large ulcerations, should be treated with systemic propranolol. Topical beta blockers can be considered for uncomplicated, superficial hemangiomas that may be of minor cosmetic concern. Pulsed-dye laser treatment, surgical excision, and embolization may be considered for hemangiomas that have refractory ulceration or do not involute completely.
Images courtesy of Medscape.
5 Common-to-Rare Infant Skin Conditions
Aimee M Barton, MD, FAAP | May 13, 2021 | Contributor Information
Nevus Sebaceous
A nevus sebaceous is a circumscribed hamartoma composed primarily of sebaceous glands. The condition affects 0.3% of newborns, with sporadic but equal frequency in males and females of all races.[13]
The lesion is usually noted as a solitary, hairless patch on the scalp or as a velvety, tan or orange-yellow plaque (left image) in other areas. During adolescence, it may become verrucous and nodular with a round, oval, or linear (right image) shape.
The definitive management of a nevus sebaceous is full-thickness excision.[14] However, because the risk of malignancy arising in a nevus sebaceous is estimated to be less than 1%,[15] observation is typically chosen over excision.
Image courtesy of Dr. Anthony J. Mancini.
5 Common-to-Rare Infant Skin Conditions
Aimee M Barton, MD, FAAP | May 13, 2021 | Contributor Information
Transient Neonatal Pustular Melanosis
Transient neonatal pustular melanosis is a benign, idiopathic skin condition characterized by vesicles, superficial pustules, and pigmented macules (shown). The overall incidence is 2.2%, equally divided between sexes, with rates of 0.6% in White and 4.4% in Black infants.[16]
Present at birth, the lesions commonly appear on the chin, neck, forehead, chest, buttocks, and back and less often on the palms and soles. Lesions are normally 2-10 mm in diameter and usually resolve within 48 hours. However, brown macules may persist for several months.
No therapy is indicated, but the lesions must be differentiated from pustular and vesicular dermatoses that develop from infectious causes, particularly congenital herpes simplex.
Image courtesy of Dr. Jining I. Wang.
5 Common-to-Rare Infant Skin Conditions
Aimee M Barton, MD, FAAP | May 13, 2021 | Contributor Information
In the image above, a 5-day-old infant's abdomen bears erythematous papules surrounded by indistinct, blotchy erythema.
Erythema Toxicum Neonatorum
Erythema toxicum neonatorum (ETN) is a benign, self-limited, asymptomatic skin condition that affects 31-72% of newborns, with equal incidence between sexes and among races.[17] ETN typically presents within the first 4 days of life.
Characteristic lesions are erythematous macules and papules that are typically distributed over the trunk and proximal extremities. They progress to pustules on an erythematous base. The condition typically resolves within 5-7 days but may wax and wane prior to resolution.
The diagnosis can usually be made with history and physical examination alone, although a Wright stain of pustular contents characteristically demonstrates eosinophils.
Image courtesy of Medscape | Dr. Richard J. Whitley.
5 Common-to-Rare Infant Skin Conditions
Aimee M Barton, MD, FAAP | May 13, 2021 | Contributor Information
The above image demonstrates vesicular scalp lesions of herpes simplex virus (HSV) infection in a 7-day-old infant.
Neonatal Herpes Simplex Virus Infection
Neonatal herpes simplex is an infection caused by the vertical transmission of herpesvirus from mother to child. Factors that influence transmission include the mode of delivery (cesarean vs vaginal), outbreak status during delivery (active vs nonactive), type of infection (primary vs recurrent), maternal HSV antibody status, use of fetal scalp electrodes, and duration of membrane rupture. Infection can occur during asymptomatic shedding of the virus.
Neonatal HSV infection can be classified into three main categories: skin, eye, and mouth (SEM) disease; central nervous system (CNS) disease with or without SEM disease; and disseminated disease.
Image from the Centers for Disease Control and Prevention (CDC).
5 Common-to-Rare Infant Skin Conditions
Aimee M Barton, MD, FAAP | May 13, 2021 | Contributor Information
HSV lesions in an infant are shown above.
Disseminated and SEM disease
Disseminated infection represents 25% of neonatal HSV disease and usually presents in the first few days of life as severe hepatic, pulmonary, and neurologic dysfunction. Without prompt treatment, mortality can exceed 80%. Disseminated HSV infection is often mistaken for bacterial sepsis.[18-22]
SEM disease presents at 10-12 days of life with macules that rapidly progress into vesicles with an erythematous base. Outcomes are good with prompt antiviral therapy; when the condition is left untreated, however, it is estimated that 75% of infants will progress to disseminated disease.[23]
Image from the CDC.
5 Common-to-Rare Infant Skin Conditions
Aimee M Barton, MD, FAAP | May 13, 2021 | Contributor Information
The image shown demonstrates herpes simplex on an infant's foot.
CNS disease
One third of herpes neonatorum infections manifest in the CNS[24]; this presentation is usually seen within the first 2-3 weeks of life. Initial manifestations include lethargy, irritability, tremors, poor feeding, temperature instability, bulging of the anterior fontanel, and focal seizures. Cerebrospinal fluid (CSF) examinations reveal pleocytosis and elevated protein levels. Electroencephalographic evaluations are diffusely abnormal. Without treatment, most patients with CNS involvement die or suffer severe neurologic impairment.
Definitive diagnosis of neonatal herpes infection requires viral culture or detection of herpes simplex viral DNA by polymerase chain reaction assay. Treatment involves antiviral medications and often requires admission to the intensive care unit.
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Contributor Information
Author
Aimee M Barton, MD, FAAP
Director of Neonatology
Spotsylvania Regional Medical Center
Fredericksburg, VA
Disclosure: Aimee M Barton, MD, FAAP, has disclosed no relevant financial relationships.
Reviewers
Brett Sloan, MD, FAAD
Professor of Dermatology
University of Connecticut School of Medicine;
Residency Site Director
Connecticut Veterans Affairs Healthcare System;
Assistant Clinical Professor
Yale University School of Medicine;
Editor-in-Chief, Journal of the American Academy of Dermatology Case Reports
Disclosure: Brett Sloan, MD, FAAD, has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, adviser, consultant, or trustee for: Journal of the American Academy of Dermatology; UpToDate; Medical Review Institute of America.
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References
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Kilcline C, Frieden IJ. Infantile hemangiomas: how common are they? A systematic review of the medical literature. Pediatr Dermatol. 2008 Mar-Apr;25(2):168-73. PMID: 18429772
Haggstrom AN, Drolet BA, Baselga E, et al. Prospective study of infantile hemangiomas: demographic, prenatal, and perinatal characteristics. J Pediatr. 2007 Mar;150(3):291-4. PMID: 17307549
Drolet BA, Swanson EA, Frieden IJ. Infantile hemangiomas: an emerging health issue linked to an increased rate of low birth weight infants. J Pediatr. 2008 Nov;153(5):712-5, 715.e1. PMID: 18940356
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Metry DW, Hebert AA. Benign cutaneous vascular tumors of infancy: when to worry, what to do. Arch Dermatol. 2000 Jul;136(7):905-14. PMID: 10890993
Haggstrom AN, Drolet BA, Baselga E, et al. Prospective study of infantile hemangiomas: demographic, prenatal, and perinatal characteristics. J Pediatr. 2007 Mar;150(3):291-4. PMID: 17307549
Cribier B, Scrivener Y, Grosshans E. Tumors arising in nevus sebaceous: a study of 596 cases. J Am Acad Dermatol. 2000 Feb;42(2 Pt 1):263-8. PMID: 10642683
Carr JA, Hodgman JE, Freedman RI, Levan NE. Relationship between toxic erythema and infant maturity. Am J Dis Child. 1966 Aug;112(2):129-34. PMID: 5947490
Kimberlin DW. Herpes simplex virus infections in neonates and early childhood. Semin Pediatr Infect Dis. 2005 Oct;16(4):271-81. PMID: 16210107
Kimberlin DW. Herpes simplex virus infections of the newborn. Semin Perinatol. 2007 Feb;31(1):19-25. PMID: 17317423
Kimberlin DW, Whitley RJ. Neonatal herpes: what have we learned. Semin Pediatr Infect Dis. 2005 Jan;16(1):7-16. PMID: 15685144
Kimberlin D. Herpes simplex virus, meningitis and encephalitis in neonates. Herpes. 2004 Jun;11 suppl 2:65A-76A. PMID: 15319092
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