Think the Worst With Neonatal Vesicles, Pustules

SAN FRANCISCO — When pediatricians call in dermatologists to assess neonatal vesiculopustular eruptions, what they're really asking is, "Could it be herpes?" said Dr. Ilona J. Frieden.

Think of the neonate as an immunocompromised host, and consider the worst possible diagnosis, she advised at a meeting sponsored by Skin Disease Education Foundation.

Think of infection first, but don't stop there, because more than 25 other conditions can cause vesicles and pustules on the skin. "This is something that pediatricians call us about most often—children who have vesiculopustular eruptions," said Dr. Frieden, professor of dermatology and pediatrics at the University of California, San Francisco.

Herpes simplex virus infection in neonates is rare but devastating. The lesions can look like typical herpes lesions in older patients, or can have a more fragile-looking pustule because baby skin is thinner, "an almost impetigo-like look," she said. Commonly, neonatal herpes lesions are on the scalp, buried in hair and hard to see. Widespread erosions of the skin may be seen in infants born with intrauterine herpes infection.

The initial findings of neonatal herpes, however, tend to be nonspecific, such as temperature instability, lethargy, and a little regurgitation of breast milk or formula. These symptoms, plus metabolic acidosis and tachycardia or tachypnea, are signs and symptoms of neonatal sepsis. "Not so much high fevers—that would be quite unusual—but temperature instability," Dr. Frieden said.

More benign causes of pustular eruptions that can be confused with herpes include erythema toxicum or transient pustular melanosis. These occur only in term infants, not preterm. Transient pustular melanosis usually appears on the first day of life, while erythema toxicum tends to appear in the first 5 days, she said. Later lesions are more likely to be something else.

Erythema toxicum lesions tend to be migrating rather than fixed, Dr. Frieden noted. A noninflamed base is characteristic of transient pustular melanosis.

Pruritic papules and pustules in newborns also can be caused by eosinophilic pustular folliculitis, "which is a pretty uncommon condition," she added.

Langerhans cell histiocytosis can produce multiple crusted lesions, papules, and pustules. "The clue is these kinds of roundish pustular lesions," she said. This disease can become more indolent or aggressive later in life.

Other skin problems can also be cause for neonatal emergencies, Dr. Frieden added. Small purpuric lesions on a neonate—sometimes called a "blueberry muffin baby"–may be caused by dermal erythropoiesis (the presence of blood cells in the skin because they're not being produced in bone marrow). "These are very stingy blueberries, typically. You're not looking for big, plump blueberries. They are teeny blueberries, almost more like currants in the skin," she explained.

The lesions may be caused by congenital infection, hemolytic disease of the newborn, or neoplastic-infiltrative diseases such as congenital leukemia. Among infections, the most common cause of "blueberry muffin" babies is cytomegalovirus, but any infection can be the cause, including parvovirus, enteroviruses, rubella, and more. In this case, biopsies and a full evaluation are urgent, Dr. Frieden said.

Newborn skin that is extremely fragile or falling off also needs immediate care to dress the wound.

Apply a topical antibiotic sparingly and petrolatum thickly, add Vaseline gauze (not Xeroform, which doesn't stick to newborn skin), wrap it all in Kerlix for padding and top it off with a stockinette instead of tape to minimize trauma, she suggested.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO — When pediatricians call in dermatologists to assess neonatal vesiculopustular eruptions, what they're really asking is, "Could it be herpes?" said Dr. Ilona J. Frieden.

Think of the neonate as an immunocompromised host, and consider the worst possible diagnosis, she advised at a meeting sponsored by Skin Disease Education Foundation.

Think of infection first, but don't stop there, because more than 25 other conditions can cause vesicles and pustules on the skin. "This is something that pediatricians call us about most often—children who have vesiculopustular eruptions," said Dr. Frieden, professor of dermatology and pediatrics at the University of California, San Francisco.

Herpes simplex virus infection in neonates is rare but devastating. The lesions can look like typical herpes lesions in older patients, or can have a more fragile-looking pustule because baby skin is thinner, "an almost impetigo-like look," she said. Commonly, neonatal herpes lesions are on the scalp, buried in hair and hard to see. Widespread erosions of the skin may be seen in infants born with intrauterine herpes infection.

The initial findings of neonatal herpes, however, tend to be nonspecific, such as temperature instability, lethargy, and a little regurgitation of breast milk or formula. These symptoms, plus metabolic acidosis and tachycardia or tachypnea, are signs and symptoms of neonatal sepsis. "Not so much high fevers—that would be quite unusual—but temperature instability," Dr. Frieden said.

More benign causes of pustular eruptions that can be confused with herpes include erythema toxicum or transient pustular melanosis. These occur only in term infants, not preterm. Transient pustular melanosis usually appears on the first day of life, while erythema toxicum tends to appear in the first 5 days, she said. Later lesions are more likely to be something else.

Erythema toxicum lesions tend to be migrating rather than fixed, Dr. Frieden noted. A noninflamed base is characteristic of transient pustular melanosis.

Pruritic papules and pustules in newborns also can be caused by eosinophilic pustular folliculitis, "which is a pretty uncommon condition," she added.

Langerhans cell histiocytosis can produce multiple crusted lesions, papules, and pustules. "The clue is these kinds of roundish pustular lesions," she said. This disease can become more indolent or aggressive later in life.

Other skin problems can also be cause for neonatal emergencies, Dr. Frieden added. Small purpuric lesions on a neonate—sometimes called a "blueberry muffin baby"–may be caused by dermal erythropoiesis (the presence of blood cells in the skin because they're not being produced in bone marrow). "These are very stingy blueberries, typically. You're not looking for big, plump blueberries. They are teeny blueberries, almost more like currants in the skin," she explained.

The lesions may be caused by congenital infection, hemolytic disease of the newborn, or neoplastic-infiltrative diseases such as congenital leukemia. Among infections, the most common cause of "blueberry muffin" babies is cytomegalovirus, but any infection can be the cause, including parvovirus, enteroviruses, rubella, and more. In this case, biopsies and a full evaluation are urgent, Dr. Frieden said.

Newborn skin that is extremely fragile or falling off also needs immediate care to dress the wound.

Apply a topical antibiotic sparingly and petrolatum thickly, add Vaseline gauze (not Xeroform, which doesn't stick to newborn skin), wrap it all in Kerlix for padding and top it off with a stockinette instead of tape to minimize trauma, she suggested.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

SAN FRANCISCO — When pediatricians call in dermatologists to assess neonatal vesiculopustular eruptions, what they're really asking is, "Could it be herpes?" said Dr. Ilona J. Frieden.

Think of the neonate as an immunocompromised host, and consider the worst possible diagnosis, she advised at a meeting sponsored by Skin Disease Education Foundation.

Think of infection first, but don't stop there, because more than 25 other conditions can cause vesicles and pustules on the skin. "This is something that pediatricians call us about most often—children who have vesiculopustular eruptions," said Dr. Frieden, professor of dermatology and pediatrics at the University of California, San Francisco.

Herpes simplex virus infection in neonates is rare but devastating. The lesions can look like typical herpes lesions in older patients, or can have a more fragile-looking pustule because baby skin is thinner, "an almost impetigo-like look," she said. Commonly, neonatal herpes lesions are on the scalp, buried in hair and hard to see. Widespread erosions of the skin may be seen in infants born with intrauterine herpes infection.

The initial findings of neonatal herpes, however, tend to be nonspecific, such as temperature instability, lethargy, and a little regurgitation of breast milk or formula. These symptoms, plus metabolic acidosis and tachycardia or tachypnea, are signs and symptoms of neonatal sepsis. "Not so much high fevers—that would be quite unusual—but temperature instability," Dr. Frieden said.

More benign causes of pustular eruptions that can be confused with herpes include erythema toxicum or transient pustular melanosis. These occur only in term infants, not preterm. Transient pustular melanosis usually appears on the first day of life, while erythema toxicum tends to appear in the first 5 days, she said. Later lesions are more likely to be something else.

Erythema toxicum lesions tend to be migrating rather than fixed, Dr. Frieden noted. A noninflamed base is characteristic of transient pustular melanosis.

Pruritic papules and pustules in newborns also can be caused by eosinophilic pustular folliculitis, "which is a pretty uncommon condition," she added.

Langerhans cell histiocytosis can produce multiple crusted lesions, papules, and pustules. "The clue is these kinds of roundish pustular lesions," she said. This disease can become more indolent or aggressive later in life.

Other skin problems can also be cause for neonatal emergencies, Dr. Frieden added. Small purpuric lesions on a neonate—sometimes called a "blueberry muffin baby"–may be caused by dermal erythropoiesis (the presence of blood cells in the skin because they're not being produced in bone marrow). "These are very stingy blueberries, typically. You're not looking for big, plump blueberries. They are teeny blueberries, almost more like currants in the skin," she explained.

The lesions may be caused by congenital infection, hemolytic disease of the newborn, or neoplastic-infiltrative diseases such as congenital leukemia. Among infections, the most common cause of "blueberry muffin" babies is cytomegalovirus, but any infection can be the cause, including parvovirus, enteroviruses, rubella, and more. In this case, biopsies and a full evaluation are urgent, Dr. Frieden said.

Newborn skin that is extremely fragile or falling off also needs immediate care to dress the wound.

Apply a topical antibiotic sparingly and petrolatum thickly, add Vaseline gauze (not Xeroform, which doesn't stick to newborn skin), wrap it all in Kerlix for padding and top it off with a stockinette instead of tape to minimize trauma, she suggested.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.