Neonatal and Pediatric Dermatology

Question 1

What is Vernix caseosa?

Answer 1

-moist, yellow-white coating on term infants
-Combination of sebaceous gland secretion, desquamated skin cells, and shed lanugo hairs
Important for maintaining hydration, pH balance, and protecting against infection

Question 2

What are the consequences of barrier immaturity in a pre term infant?

Answer 2

Increased transepidermal water loss (TEWL) fluid and electrolyte imbalance, dehydration 
Energy loss through heat of evaporation
Increased risk of percutaneous toxicity
Increased risk of mechanical injury
Decreased barrier to infection

Question 3

What are normal physiological findings in newborns?

Answer 3

• Cutis Marmorata -exaggerated vasomotor response to hypothermia, disappears with rewarming
• physiologic desquamation-most term neonates in first few days, pronounced in post term infants, 40-42 weeks, self resolves
• Harlequin color change-premies, sudden onset, when lying on side, bottom half turns red

Question 4

What are benign transient cutaneous eruptions on babies/peds?

Answer 4

• neonatal acne- red papules and pustules on face due to yeast Malassezia, onset around 3 weeks, self resolves
• infantile acne - 3-6 mos., comedones, lasts months to years
• milia - small keratin-filled cysts on nose, chin, cheeks, forehead, usually disappears in 1st month.
• Bohn’s nodules-milia in gum margins
• Epstein’s Pearls-milia in midline hard palate
• sebaceous hyperplasia-on nose, due to maternal androgen stimulation, often with milia
• Erythema toxic neonatorum-red macules→evolves to papules and pustules with surrounded blotchy erythema “flea bite appearance” Appears first few days of life, lasts 2 weeks. Eosinophils in gram stain
• Miliaria - obstruction of eccrine duct–>rupture of ducts and sweating into skin
• Transient neonatal pustular melanosis -Vesicopustules –> rupture with collarette of scale —> hyper pigmented macules. disappear in 1-2 days.

Question 5

What are the types of miliaria?

Answer 5

Miliaria Crystallina – obstruction at level of stratum corneum. 1st week of life
Miliaria Rubra – intraepidermal obstruction. After 1st or 2nd week of life
Miliaria Profunda – obstruction at dermal-epidermal junction. Rare in neonates.

Question 6

Describe neonatal HSV.

Answer 6

Presentation: erythematous macules  individual and grouped vesicles on an erythematous base
Diagnosis: Unroof vesicle, swab base for viral culture, direct fluorescent assay, or PCR
Mostly HSV-2 (70%)
Most with neonatal herpes are infected around time of delivery
85% during delivery
Ranges from mild, self-limited to severe with neurologic sequelae or death
1) Mucocutaneous infection (skin, eye, mouth)
2) Disseminated infection-lungs, liver, CNS, skin
3) CNS infection (with or without skin, but no other organ involvement)

Question 7

Diagnose vascular lesions and potentially associated syndromes

Answer 7

1. Nevus SImplex - Salmon Patch, aka stork bite, angel’s kiss. most common vascular lesion. on forehead and nape of neck, eyelids. Disappears in 1-2 years except neck.
2. Port wine stain - less common, mainly unilateral, present at birth, persistent
3. Sturge Weber Syndrome - Triad: port wine stain, seizures, glaucoma. Tram Tack calcifications
4. Klippel Trenaunay Syndrome - Triad: port wine, limb hypertrophy, venous varicosities
5. Segmental infantile hemangioma- beings 1-2 weeks after birth, assoc with PHACE

Question 8

What are the characteristics of infantile hemangioma?

Answer 8

• most common vascular tumor
• major assoc: prematurity, female, multiple gestation, white non-hispanic
• mainly head and neck
• evolution: precursor lesion “bruise like” patch–>proliferation phase, most growth by 3 months–>involution phase, apoptosis, may cause disfigurement

Question 9

What is the pathogenesis of infantile hemangioma?

Answer 9

-Clonal proliferation of endothelial cells from vasculogenesis, not angiogenesis
-Vasculogenesis: formation of primitive blood vessels from angioblasts
-Angiogenesis: growth of new vessels from pre-existing vessels
-Possibly placenta-derived cells: Placenta-associated vascular antigens highly expressed in IH
GLUT-1
-Hypoxia plays role in triggering vasculogenesis - Glut-1 and Insulin like growth factor 2 (IGF2)

Question 10

What are the indications for treatment of infantile hemangioma?

Answer 10

-mainly :anticipatory guidance
-lesions that may require treatment:
Ulceration (occurs in 15%)
Impairment of vital function – periocular, perioral, airway involvement (beard hemangioma), liver involvement (5+ cutaneous IH) resulting in high output congestive heart failture
Risk for permanent disfigurement (usually facial)

Question 11

What are the associations with IH?

Answer 11

-Facial segmental IH
IH usually >5 cm
Association: PHACE(S) Syndrome
-Lumbosacral segmental IH:
IH usually >2.5 cm
Association: LUMBAR syndrome (other acronyms describing same associations - SACRAL, PELVIS)

Question 12

What is eczema Herpeticum?

Answer 12

HSV superinfection in the setting of defective barrier
Presents as eruptive monomorphous punched out erosions
Swab base for viral culture, direct fluorescent assay, or PCR
Treat with acyclovir

Question 13

What are the causes of diaper rash? What are defining characteristics of each cause?

Answer 13

• Candidiasis-peripheral scaling and satellite papules/pustules, predisposed by diarrhea or antibiotic use
• irritant diaper dermatitis-folds spared, red along convex surfaces, due to friction, moisture, urine/feces
• psoriasis-bright red well defined patches
• seborrheic dermatitis-red, moist patches along creases, also scalp
• Perianal strep-bright red around perianal area