The Skinny on Newborn Rash

10/16/2019

OBJECTIVES THE SKINNY • Recognize common neonatal skin problems • Identify neonatal skin problems that need further evaluation • Identify the difference between an IV infiltrate and phlebitis ON NEWBORN • Identify treatment of infiltrates and phlebitis RASH

KELSEY SOUTHARD, APRN, NNP-BC

LESION LINGO COMMON

• LESION - This is a vague term meaning "the thing that is wrong with the patient." • MACULE – Small (<1cm) circumscribed and flat. BENIGN – PATCH - Large macule • PAPULE – Circumscribed, raised solid. Up to 1cm in size. • PLAQUE – Circumscribed, raised, solid, plateau-like SKIN LESIONS • NODULE – Circumscribed, raised, solid. Has depth. Up to 2cm in size. – TUMOR – Greater than 2cm in size ERYTHEMA TOXICUM • VESICLE – Circumscribed, raised, fluid-filled. Up to 1cm in size. TRANSIENT NEONATAL PUSTULAR MELANOSIS MILIA – BULLA—raised >1cm, with clear fluid MILIARIA CRYSTALLINA MILIARIA RUBRA • PUSTULE—Circumscribed, raised, purulent fluid. Less than 1cm in size. NEVUS SIMPLEX— “STORK BITE”, “SALMON PATCH”, “ANGEL’S KISS” – ABSCESS—raised >1cm, with purulent fluid MONGOLIAN SPOT (DERMAL MELANOCYTOSIS) CUTIS MARMORATA HARLEQUIN SIGN

INFANTILE HEMANGIOMA

ERYTHEMA TOXICUM TRANSIENT NEONATAL PUSTULAR MELANOSIS

• Most well known benign lesion • Occurs most often in full term African- – Etiology is unkown American newborns • Occurs in approx. half of full-term • 3 phases/3 types of lesion newborns – Superficial vesicopustules—evident at • Usually not seen in preterm newborns birth, wiped away easily – Fine collarette of scale around • Yellowish papules or pustules with a resolving pustule surrounding irregular macular flare – Hyperpigmented brown macules at • Pustule full of eosinophils site of previous pustulation

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MILIARIA MILIA

• Papules that primarily occur on the • Epstein’s pearls (palate) and Bohn’s CRYSTALLINA RUBRA face and scalp nodules (gum line) are basically milia • Immediate newborn period • Common in overheated/febrile infants • Trapped keratinized stratum corneum in the mouth. • Superficial trapping of sweat • “Heat rash” or “Prickly heat” • Water droplets on skin • Erythematous papules • Head, neck, face, scalp, trunk

HEMANGIOMA NEVUS SIMPLEX

AKA—SALMON PATCH, ANGEL’S KISS, STORK BITE

• Benign proliferation of endothelial • Benign red birthmark that typically cells fades over time • Phase of rapid growth follow by • Confluent or spotty but uniform in spontaneous regression color • If there are multiple cutaneous • Can have lesion in more than one area hemangiomas the baby needs to be evaluated for visceral involvement. • May grow for child’s first year of life • First line treatment is propranolol if hemangioma will be problematic

DERMAL MELANOSIS COLOR CHANGES RESULTING AKA—MONGOLIAN SPOT FROM VASCULAR

• Macules or patches ABNORMALITIES • Collection of melanocytes located in the CUTIS MARMORATA HARLEQUIN COLOR CHANGE dermis • “Mottled” , reticulated and blanchable • Vasodilation of one side (dependent) • Slate blue, gray or black • Cold stress leads to constriction of of the body • Most commonly located on buttocks and capillaries and venules • Sharp cutoff at midline sacrum but can be anywhere • Should go away if rewarmed • No pathologic significance • Seen in up to 96% of African American babies, 86% of Asian babies

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SKIN LESIONS THAT REQUIRE FURTHER EVALUATION

• Aplasia Cutis congenital THE NOT SO • Epidermolysis Bullosa • HSV NICE LESIONS – Neonatal & Congenital • CMV • Rubella

APLASIA CUTIS CONGENITA EPIDERMOLYSIS BULLOSA

• Focal, congenital defect of the skin • The skin is unable to withstand • Well circumscribed, look “punched friction, resulting in skin blistering out” • Many subtypes, all inherited • Thin, glistening, membranelike surface • Blistering may be generalized but usually occurs in areas subjected to • Irregular, large scalp defects are rare friction: hands, feet, diaper area and but occur along the midline. back • Small, superficial lesions usually heal • Management: minimize trauma, in the first few months of life prevent infection, heal wounds, provide psychosocial support

HERPES SIMPLEX VIRUS HERPES SIMPLEX VIRUS

CONGENITAL NEONATAL • Vesicles that evolve into pustules, • Rare, high rate of fetal demise • SEM (skin, eyes, mouth) crusts, or erosions – Most common • Microcephaly, hydrocephaly, – Without treatment will progress • Grouped vesicles on an erythematous chorioretinitis • Disseminated base • Skin ulcerations – Worst prognosis—look like septic shock – Won’t always have lesions • CNS disease – With/without lesions – Seizures, irritability, poor feeding, bulging fontanelle

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HERPES SIMPLEX VIRUS “BLUEBERRY MUFFIN” SPOTS EXTRAMEDULLARY HEMATOPOIESIS

NEONATAL CYTOMEGALOVIRUS (CMV) RUBELLA • ¾ of all neonatal herpes are secondary • MUST know if it’s a PRIMARY vs. to HSV 2 recurrent infection • Can be acquired intrauterine, – Primary infection/SVD intrapartum or postnatal • Transmission rate is 50% • 85% acquired intrapartum as an ascending infection. – Recurrent infection/SVD – ROM 4-6 hrs • Transmission rate <2% – SVD thru infected cervix or vagina

MY IV LOOKS BAD… NOW WHAT DO I DO???

CRY…JUST A LITTLE

WHAT IS THE ANTIDOTE? Phlebitis Infiltrate Extravasation AND HOW DO I ADMINISTER IT? Definition Inflammation of vein Leakage of Leakage of vesicant nonvesicant fluid to fluid to surrounding surrounding tissues tissues Characteristics Red streak *Swelling *Swelling • Hyaluronidase *Pain *Pain – Appropriate for extravasation of IV fluid except vasoconstrictors *Does not cause *Mild to severe tissue necrosis. necrosis. – Ideally given within the 1st hour after insult but not after the 3rd hour *Blanching *Blanching *Skin is cool *Skin is cool – Inject 1 ml as 5 separate 0.2ml subcutaneous injections *Good *Poor perfusion/pulses perfusion/pulses • Around the periphery of the extravasation site • Use aseptic technique Treatment Remove IV Remove IV Remove IV • Change the needle after each injection Elevate Elevate Consider antidote

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REFERENCES

• Eichenfield, Lawrence F. Textbook of Neonatal Dermatology. Saunders, 2001. • Gomella, Tricia Lacy. Neonatology Management, Procedures, on-Call Problems, Diseases and Drugs. McGraw Hill Medical-, 2013. • Krowchuk, Daniel P., et al. “Clinical Practice Guideline for the Management of Infantile Hemangiomas.” Pediatrics, vol. 143, no. 1, 2018, doi:10.1542/peds.2018- 3475.

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