June 2006

A 2-week-old male patient was referred for admission for evaluation and treatment of a facial rash.

The onset of the rash was a few days earlier. There was no history of fever, vomiting, diarrhea or irritability during his life so far, and, according to the mother, the rash did not appear to bother the baby. The baby was born full term, weighing 7 pounds 11 ounces and had a normal examination in couplet care, which is mother and child rooming in. His feedings were normal since birth. The mother’s history was complicated by having a history of genital herpes simplex virus (HSV) infections with occasional recurrences, the last (self-diagnosed) being a few days after the baby’s birth. However, both her cultures and examination by her obstetrician during labor were negative for herpes.

The patient lives with both parents and one 7-year-old sibling. Except for his mother’s self-diagnosed HSV, there were no sick exposures. The family lives in a rural Texas community with city water. There has been no animal or insect exposure so far.

Examination on admission revealed a normal-appearing 2-week-old baby, with normal vital signs, in no acute distress with numerous facial pustular lesions on small erythematous bases as shown in figures 1 and 2 on his right and left cheeks only. The rest of his examination, including the rest of his skin and all mucous membranes, was normal.

After admission, the baby had numerous tests, including a CBC, metabolic profile including liver enzymes, urine analysis, standard spinal fluid analysis with HSV cultures and PCR, and a swab of a representative cheek pustule for HSV culture and PCR. He also had treatment with high-dose intravenous acyclovir initiated.

What’s Your Diagnosis?

1. Erythema toxicum
2. Neonatal candidiasis
3. Cutaneous HSV infection
4. Neonatal acne

Answer

Obviously, the concern was for neonatal herpes simplex infection. However, the answer was D, neonatal acne. Up to 20% of neonates have some degree of neonatal acne. Most will have very mild manifestations, but some will be significant, and may mimic other conditions, such as cutaneous herpes (figure 3), candidiasis (figures 4a & 4b), erythema toxicum (figure 5) or neonatal cephalic pustulosis, a condition thought to be due to superficial infection with Malassezia species. Neonatal acne may look almost exactly like neonatal cephalic pustulosis, differing only by the presence of comedones, when present, in acne.

Most cases of neonatal acne present between 2 and 4 weeks of age and may persist for several months. However, it can present earlier, overlapping with the usual onset of neonatal herpes. The lesions are typically discrete papulopustular lesions, usually on the face, but may be seen on the back and diaper area as well. Treatment is reassurance, but in severe cases, one may consider using topical benzoyl peroxide.

Erythema toxicum is a common rash that about half of newborns get during the first few days of life. The lesions can consist of both small vesicles and/or pustules, on various sized erythematous bases, occurring on the face, neck, chest, back and proximal extremities. The lesions usually clear within a week. A smear of the contents of a lesion with Wright’s stain can be done, which will typically show numerous eosinophils to help confirm the diagnosis. No treatment is required.

Neonatal candidiasis is acquired as the baby is passing through the birth canal and manifests within the first week of life. The lesions may appear similar to numerous erythematous papulopustular lesions that contain pseudohyphae and budding yeast on KOH prep, and will readily grow on fungal media. Topical antifungal treatment may be all that’s needed, unless the infection is widespread or systemic, such as pulmonary. In that case, IV amphotericin B is usually recommended.

Neonatal HSV is, of course, the most important diagnosis to make or rule out.

Vesicle clusters on erythematous bases characterize cutaneous HSV. They usually first appear after the fifth day of life, but can be present at birth. If confined to the skin and/or mucous membrane, it is usually referred to as the “skin-eye-mouth” (SEM) form of neonatal HSV infection, as opposed to disseminated, or central nervous system, disease. While babies with SEM disease may look and act normal, they are more likely to have fever and other symptoms than one with simple neonatal acne. In cases of doubt, attempts should be made to diagnose the infection by culture and/or PCR of representative lesion(s), spinal fluid analysis, and, as in the case presented, treated empirically with high-dose acyclovir (60mg/kg/day, every 8 hours) pending culture and/or PCR results.

Commentary

With summer upon us, this would be a good time to remind your parents about the hazards of babies and children in the sun too long, which may be as little as 20 minutes.

I was asked recently about the use of sunscreen on an infant, because the label stated to consult with your physician for children younger than 1 year of age. My response was to not rely on sunscreen to protect these babies. I’m not saying not to use them, but it would be best to keep these young children and babies out of direct or reflected sunlight altogether. The potential for rapid burning is too great to take a chance. Other hazards of too much time in the sun are hyperthermia and dehydration, which can also occur in babies much faster than older children. Having to tell parents this is about like having to tell them that it’s not good to leave their children in a car alone in the summer. What seems obvious to most of us may not be so apparent to parents, especially the young, new parents.

With high school graduations behind us, there’s always a summertime increase in fatal automobile accidents involving teenaged drivers, oftentimes under the influence of alcohol. This would be a good time to readdress this issue with your patients and their parents. Many of us have lost relatives and close friends to these tragedies, which changes lives forever.

Another thing that changes lives forever is the loss of a soldier, who may be a husband or wife, a father or mother, brother or sister, son or daughter or someone’s best friend. As many of you have unfortunately found out, their lives are never the same again. As of this writing (early May), 2,426 American soldiers died in Iraq and 17,648 have been wounded. The numbers for Afghanistan are 295 dead and 718 wounded. I’m not trying to make a point, just reminding us all of the immeasurable price of war. I am always put off and offended by news reports that round these numbers off. So periodically, I may post them in this column as a reminder.

Remember, the 14th is Flag Day. Fly it high and keep in touch at jhbrien@aol.com.