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By: Eufronia Apple G. Puzon, MD
Erythema Toxicum Neonatorum
Cutis Marmorata Hemangioma of Infancy
ERYTHEMA TOXICUM NEONATORUM
Idiopathic common condition seen up to 75% of term newborns. Rarely seen in premature infants. Usually begin at 24 to 48 hours of age PE: Blotchy erythematous macules 1 to 3 cm in diameter with a 1 to 4 mm central vesicle or pustule. Trunk is the common site Spare the palms and soles
Fitzpatrick Dermatology 7th Ed. p. 937
Erythematous macules, some with a tiny central papulopustule on the arm of a 1-day-old newborn.
Wright stained smear: Numerous eosinophils
Transient Neonatal Pustular Melanosis Miliaria - Bacterial Folliculitis Neonatal Herpes Scabies Benign and clears spontaneously by 2 to 3 weeks of age without residua.ERYTHEMA TOXICUM NEONATORUM Differential Diagnosis: . Andrews' Diseases of the Skin 10th Ed. p. 937 . 140 Fitzpatrick Dermatology 7th Ed. p.
23 . Common in hot humid climates. p.MILIARIA Retention of sweat as a result of occlusion of eccrine sweat ducts. Rupture of gland or duct at different levels Occlusion from the sweat glands Escape of sweat MILIARIA Andrews' Diseases of the Skin 10th Ed.
FOUR TYPES: Miliaria Crystallina Miliaria Rubra Miliaria Pustulosa Miliaria Profunda .
No treatment required. Duration short PE: . sub-corneal. non-inflammatory vesicles that easily rupture when rubbed with a finger. 730 . p. Self-limited.superficial.23 Fitzpatrick Dermatology 7th Ed.MILIARIA CRYSTALLINA Aka Miliaria Sudamina Asymptomatic. p. Andrews' Diseases of the Skin 10th Ed.
23 Fitzpatrick Dermatology 7th Ed. trunk.MILIARIA RUBRA Aka Prickly Heat Obstructed sweat migrates into the epidermis and upper dermis causing pruritic inflammatory papules around the sweat pores. Sites: antecubital and popliteal fossae. Andrews' Diseases of the Skin 10th Ed. abdomen (waistline) and inguinal regions. inframammary areas. p. p. 730 .
burning or tingling.23 Ffitzpatrick Dermatology 7th Ed.MILIARIA RUBRA PE: . 730 . erythematous papulovesicles accompanied by a sensation of prickling. Eruption subsides after the patient moves to a cool environment. p. p.discrete extremely pruritic. Andrews' Diseases of the Skin 10th Ed.
Disappears when extremities are warmed. Commonly seen on lower extremities.CUTIS MARMORATA Physiologic mottling of the skin.818 . Transient and common finding in newborns. p. Andrews' Diseases of the Skin 10th Ed. Aka “marbled skin” because of its mottled bluish discoloration.
com/2011/03/mottled-skin-or-cutis-marmorata-in.html .blogspot. http://doctorsgates.CUTIS MARMORATA Caused by instability or immaturity of the nerve supply to the superficial capillary blood vessels in the skin. This causes the blood vessels in some regions of the skin to dilate.
Regresses gradually over 2 to 6 years and is usually complete by the age of 10. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology 5th Ed. 180 . p. Enlarge rapidly during 1st year.HEMANGIOMA OF INFANCY Aka Strawberry Hemangioma Most common tumor of infancy. Females > Males 3:1 ratio Etiology: localized proliferative process of angioblastic mesenchyme (embryonic mesenchymal tissue from which blood cells and blood vessels arise). Course of Lesion: Initial proliferation phase lasts 3 to 9 months.
p. white-to-gray area appears on the surface of the central part of the lesion Usually solitary and locaized or extend over an entire region.Soft.HEMANGIOMA OF INFANCY PE: . does not blanch completely With onset of spontaneous. Trunk 25% Distribution: - - Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology 5th Ed. 180 . Head and neck 50%. bright red to deep purple On diascopy.
Deep Hemangioma . p.lower dermis and subcutaneous fat. 180 . .aka Cavernous Hemangioma .HEMANGIOMA OF INFANCY SPECIAL PRESENTATIONS 1. firm rubbery mass of bluish color with telangiectases in overlying skin. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology 5th Ed.localized.
multiple small (<2cm).HEMANGIOMA OF INFANCY 2. . cherry red papular lesions involving skin alone ( benign cutaneous hemangiomatosis) or skin and internal organs (diffuse neonatal hemangiomatosis). Multiple HIs .
HEMANGIOMA OF INFANCY 3.violaceous tumors with overlying telangiectasia with large veins in periphery or as red-violaceous plaques invading deeper tissues. .develop in utero Subdivided: Rapidly involuting congenital hemangiomas (RICH) Noninvoluting congenital hemangiomas (NICH) .NICH – fast flow hemangioma requiring surgery . Congenital Hemangiomas .
Diagnosis: Clinical findings and MRI Doppler and arteriography – fast flow Course and Prognosis: No residual skin change at the site in most lesions (80%). 181 . telangiectasia and scarring (20%).HEMANGIOMA OF INFANCY Dermatopathology: Proliferation of endothelial cells in various amounts in the dermis and/or subcutaneous tissue. Residual atrophy. depigmentation. p. Deeper lesions may not involute completely (mucous membranes) Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology 5th Ed.
HEMANGIOMA OF INFANCY Management: .INF-α Majority of HIs active nonintervention is the best approach because spontaneous resolution gives the best cosmetic results.Cryosurgery .Intralesional and systemic high dose glucocorticoids .Continuous wave or pulsed dye laser . .
URTICARIA PIGMENTOSA Generalized Eruption. pruritic. p. papules or nodules.616 . urticarial. - Oval or round and vary in diameter between 5 and 15mm and may coalesce Varies from yellowish-brown to yellowish-red Occ. lesions are a pale yellow color (Xanthelasmoidea) Andrews' Diseases of the Skin 10th Ed. Childhood Type Form of cutaneous mastocytosis Begins during the first weeks of life PE: Rose-colored. slightly pigmented macules.
616 .URTICARIA PIGMENTOSA PE: Vesicle and Bulla formation –prominent feature early in the disease Not evanescent Lesions persist and gradually become chamois or slatecolored Andrews' Diseases of the Skin 10th Ed. p.
urticaria with a surrounding erythematous flare usually develops * Commonly disappear within a few years. . generally before puberty.Firmly stroked or vigorously rubbed.URTICARIA PIGMENTOSA Darier’s Sign .
Associated with fetal immunologic competence (depends on immune response of fetus) • • Adequate treatment before 16th week – prevents fetal damage Untreated – fetal loss up to 40% Andrews' Diseases of the Skin 10th Ed.CONGENITAL SYPHILIS Acquired in utero Infection through the placenta usually does not occur before the 4th month.Lesions usually develop after 4th month of gestation. p.360 Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology 5th Ed. p. . Pathogenesis: . 924 .
CONGENITAL SYPHILIS CLINICAL MANIFESTATIONS: Early Congenital Syphilis – within first 2 years of life Late congenital Syphilis – after the age of 2 years .
dehydrated Face is pinched and drawn (old man or woman) Multisystem disease – characteristic Snuffles – form of rhinitis.361 .EARLY CONGENITAL SYPHILIS Presents within first 2 years of life Cutaneous manifestations – 3rd week of life Premature. p. first specific finding Andrews' Diseases of the Skin 10th Ed. fretful. often marasmic.
palms and soles. frequently scaling is pronounced. Predilection to face.EARLY CONGENITAL SYPHILIS Cutaneous Lesions: Usually morbilliform and rarely purely papular. - Papules may become large and infiltrated. legs. buttocks. There is secondary pustule formation with crusting. Bright or violaceous red later fading to coppery color. arms. .
EARLY CONGENITAL SYPHILIS Syphilitic Pemphigus Bullous eruption usually on the palms and soles Uncommon lesion Present at birth or appear in the first week of life Bullae become purulent and rupture – weeping erosions Desquamation is common often preceded by edema and erythema .
. hypertrophic papules found about the anus and in the other folds of the body.EARLY CONGENITAL SYPHILIS Condylomata Lata Large. moist. More common around the first year of life than in the newborn period.
EARLY CONGENITAL SYPHILIS Bone lesions occur in 70% to 80% Epiphysitis Common - Causes pain on motion. meningeal or meningovascular in origin (3rd to 6th month of life) Hepatomegaly. enlargement of lymph nodes. leading to the infant’s refusing to move (Parrot pseudoparalysis) Bone lesions occur at the epiphyseal ends of the long bones. . splenomegaly. CNS involvement – 86%.
painless swelling. and CNS are the most important. Interstitial Keratitis - Perisynovitis (Clutton joints) - Seizures – frequent symptom . bones. intense pericorneal inflammation and persists to diffuse clouding of the cornea w/o surface ulceration (20% to 50%) Affects the knees leads to symmetrical.LATE CONGENITAL SYPHILIS Inflammatory Late Congenital Syphilis lesions of the cornea.
LATE CONGENITAL SYPHILIS Malformations (Stigmata) Hutchinson’s teeth Malformation of the central upper incisors. Appears on the right side in right-handed persons and on the left side in left-handed persons. p. Mulberry molar Nasal Chondritis Higoumenaki’s Sign Andrews' Diseases of the Skin 10th Ed. Hyperplastic tooth Flattening of the nasal bones Unilateral thickening of the inner 3rd of one clavicle.362 .
CONGENITAL SYPHILIS Diagnosis: Infants of women who meet the following criteria should be evaluated for congenital syphilis: 1. Treatment of maternal syphilis with erythromycin. Appropriate treatment before pregnancy. Treatment less than 1 month before delivery. Maternal untreated syphilis. p. 3. or no documentation of adequate treatment. Inadequate maternal response to treatment. inadequate treatment. 4. but insufficient serologic follow-up to document adequacy of therapy.362 . 2. Andrews' Diseases of the Skin 10th Ed. 5.
.CONGENITAL SYPHILIS Management: Therapy should be undertaken in consultation with a pediatric infectious disease specialist.
Complete blood count (CBC) and differential and platelet count 3. chest radiograph. liver-function tests. 2. cranial ultrasound. Recommended Evaluation: 1.an abnormal physical examination that is consistent with congenital syphilis.g. ophthalmologic examination. cell count.a positive darkfield test of body fluid(s). and protein 2.CDC TREATMENT GUIDELINES 2010 Infants with proven or highly probable disease and 1. a serum quantitative nontreponemal serologic titer that is fourfold higher than the mother’s titer. or 3. and auditory brain stem response) . long-bone radiographs. Other tests as clinically indicated (e. CSF analysis for VDRL..
CDC TREATMENT GUIDELINES 2010 Recommended Regimens: Aqueous crystalline penicillin G 100.000 units/kg/day.000 units/kg/dose IV every 12 hours during the first 7 days of life and every 8 hours thereafter for a total of 10 days OR Procaine penicillin G 50.000–150.000 units/kg/dose IM in a single daily dose for 10 days . administered as 50.
mother was treated with erythromycin or another nonpenicillin regimen. 2. cell count. Long-bone radiographs . mother was not treated. and protein 2.CDC TREATMENT GUIDELINES 2010 Infants who have a normal physical examination and a serum quantitive nontreponemal serologic titer the same or less than fourfold the maternal titer and the 1. mother received treatment <4 weeks before delivery. and platelet count 3.or 3. or has no documentation of having received treatment. Recommended Evaluation 1. differential. inadequately treated. CBC. CSF analysis for VDRL.
CDC TREATMENT GUIDELINES 2010 Recommended Regimens: Aqueous crystalline penicillin G 100.000 units/kg/day.000–150.000 units/kg/dose IM in a single daily dose for 10 days OR Benzathine penicillin G 50. administered as 50.000 units/kg/dose IV every 12 hours during the first 7 days of life and every 8 hours thereafter for a total of 10 days OR Procaine penicillin G 50.000 units/kg/dose IM in a single dose .
. Recommended Evaluation No evaluation is required. and treatment was administered >4 weeks before delivery and 2. mother was treated during pregnancy.CDC TREATMENT GUIDELINES 2010 Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer the same or less than fourfold the maternal titer and the 1. mother has no evidence of reinfection or relapse. treatment was appropriate for the stage of infection.
CDC TREATMENT GUIDELINES 2010 Recommended Regimen: Benzathine penicillin G 50. . but rather providing close serologic follow-up in those whose mother’s nontreponemal titers decreased fourfold after appropriate therapy for early syphilis or remained stable or low for late syphilis.000 units/kg/dose IM in a single dose * Another approach involves not treating the infant.
CDC TREATMENT GUIDELINES 2010 Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer the same or less than fourfold the maternal titer and the 1.000 units/kg as a single IM injection might be considered. benzathine penicillin G 50. RPR <1:4). mother’s nontreponemal serologic titer remained low and stable before and during pregnancy and at delivery (VDRL <1:2. Recommended Evaluation No evaluation is required. Recommended Regimen: No treatment is required. . however. mother’s treatment was adequate before pregnancy and 2. particularly if follow-up is uncertain.