Infectious disorders in neonates are rare.46 Congenital cutaneous candidiasis arises from intrauterine exposure and presents as a inflammatory eruption with scattered pustules and rarely vesicles.21,46-48 Lesions develop within the first six days of life, spreading from the trunk to acral sites, and can include the palms and soles. The lesions may rarely lead to life-threatening systemic infection and exfoliative erythroderma.21,46-48
Common types of erythema include erythema toxic neonatorum [ETN], miliaria, neonatal cephalic pustulosis [NCP], and transient neonatal pustular melanosis [TNPM] (Figure 2B).21,22
ETN is uncommon in premature neonates but affects about 30–50% of full-term babies. This condition arises in the first few days after birth and presents with scattered transient pink or red papules and wheals scattered over the face and the rest of the body, sparing the palms and soles. ETN does not cause discomfort and resolves spontaneously over one to two days.21,22
Transient neonatal pustular melanosis is a disorder in which macules and papules are present at birth.21,22 The pustules show a mixture of neutrophils and some eosinophils and resolve with hyperpigmented macules that fade with time.21 As in ETN the babies are otherwise well.
Miliaria affects about 15% of newborn babies in warm climates due to occlusion of the sweat duct. If the occlusion is superficial, sweat collects just below the SC forming clear, thin-walled blisters (miliaria crystallina). Slightly deeper occlusion results in red papules and pustules (miliaria rubra or ‘prickly heat’).21,22 Miliaria most often affects the forehead, neck, and upper trunk and occluded skin areas of neonates in the first few weeks of life. The skin changes resolve within a few days on cooling and removing occlusive clothing.21,22
Neonatal cephalic pustulosis or Pityrosoprum folliculitis are none pruritic, erythematous papules, and superficial pustules presenting in crops commonly on the cheeks, nose, and forehead.21,22 The condition results from an inflammatory reaction to Malessezia species on the skin and within the hair follicles which can be seen after birth and may relate to increased activity of the sebaceous glands.21,22 It affects newborn infants in the first weeks of life and will resolve within weeks without treatment, but may resolve more quickly with topical antifungal agents.21,22
Erosion and Bullae
Severe conditions such as staphylococcus scalded skin syndrome, epidermolysis bullosa, eczema herpeticum, herpes simplex, and erosions are outside the scope of this algorithm.46-48
Newborns are more likely to develop bullae and erosions in response to heat, chemical irritants, and mechanical trauma and are at an increased risk for cutaneous infections.9,14,21-23,48 As the SC barrier is maturing, neonates and infants are especially vulnerable.14 Exposure to common irritants, including saliva, nasal secretions, urine, feces, fecal enzymes, dirt, and microbial pathogens for long periods can lead to discomfort, irritation, infection, and skin barrier disruption.14 Furthermore, the unsaturated fatty acids are easily extracted during cleansing, compromising SC barrier function.14,15,29
Diaper rash is the most common skin condition in infants presenting as erythema or, in more severe cases, skin erosion.21 The most common type of diaper rash is irritant dermatitis due to stool, urine, or mechanical irritation.21 The groin folds are usually protected from urine and stool and therefore not affected.21 If the rash is continuous despite appropriate care, rule out a candida infection.21,48 If a candida infection is present, also check for oral candidiasis.21,48 Details on diaper care are given in Box 4.
Umbilical cord care until its detachment remains controversial.47,49,50 The World Health Organization advocates for dry cord care; however, the use of chlorhexidine on the stump is recommended when hygienic conditions are poor, and the risk for omphalitis is higher
(Box 5).47,49,50
Common types of erythema include erythema toxic neonatorum [ETN], miliaria, neonatal cephalic pustulosis [NCP], and transient neonatal pustular melanosis [TNPM] (Figure 2B).21,22
ETN is uncommon in premature neonates but affects about 30–50% of full-term babies. This condition arises in the first few days after birth and presents with scattered transient pink or red papules and wheals scattered over the face and the rest of the body, sparing the palms and soles. ETN does not cause discomfort and resolves spontaneously over one to two days.21,22
Transient neonatal pustular melanosis is a disorder in which macules and papules are present at birth.21,22 The pustules show a mixture of neutrophils and some eosinophils and resolve with hyperpigmented macules that fade with time.21 As in ETN the babies are otherwise well.
Miliaria affects about 15% of newborn babies in warm climates due to occlusion of the sweat duct. If the occlusion is superficial, sweat collects just below the SC forming clear, thin-walled blisters (miliaria crystallina). Slightly deeper occlusion results in red papules and pustules (miliaria rubra or ‘prickly heat’).21,22 Miliaria most often affects the forehead, neck, and upper trunk and occluded skin areas of neonates in the first few weeks of life. The skin changes resolve within a few days on cooling and removing occlusive clothing.21,22
Neonatal cephalic pustulosis or Pityrosoprum folliculitis are none pruritic, erythematous papules, and superficial pustules presenting in crops commonly on the cheeks, nose, and forehead.21,22 The condition results from an inflammatory reaction to Malessezia species on the skin and within the hair follicles which can be seen after birth and may relate to increased activity of the sebaceous glands.21,22 It affects newborn infants in the first weeks of life and will resolve within weeks without treatment, but may resolve more quickly with topical antifungal agents.21,22
Erosion and Bullae
Severe conditions such as staphylococcus scalded skin syndrome, epidermolysis bullosa, eczema herpeticum, herpes simplex, and erosions are outside the scope of this algorithm.46-48
Newborns are more likely to develop bullae and erosions in response to heat, chemical irritants, and mechanical trauma and are at an increased risk for cutaneous infections.9,14,21-23,48 As the SC barrier is maturing, neonates and infants are especially vulnerable.14 Exposure to common irritants, including saliva, nasal secretions, urine, feces, fecal enzymes, dirt, and microbial pathogens for long periods can lead to discomfort, irritation, infection, and skin barrier disruption.14 Furthermore, the unsaturated fatty acids are easily extracted during cleansing, compromising SC barrier function.14,15,29
Diaper rash is the most common skin condition in infants presenting as erythema or, in more severe cases, skin erosion.21 The most common type of diaper rash is irritant dermatitis due to stool, urine, or mechanical irritation.21 The groin folds are usually protected from urine and stool and therefore not affected.21 If the rash is continuous despite appropriate care, rule out a candida infection.21,48 If a candida infection is present, also check for oral candidiasis.21,48 Details on diaper care are given in Box 4.
Umbilical cord care until its detachment remains controversial.47,49,50 The World Health Organization advocates for dry cord care; however, the use of chlorhexidine on the stump is recommended when hygienic conditions are poor, and the risk for omphalitis is higher
(Box 5).47,49,50
