Pediatric emergency medicine trisk 334

PATCHES AND PLAQUES
Annular Rash
Neonatal Lupus
Neonatal lupus is an autoimmune disorder caused by the passive transfer of
maternal autoantibodies, anti-Ro, anti-La, and, less commonly, antiribonucleoprotein (U1-RNP) ( Fig. 69.9 ). The skin and heart are commonly
affected, with the most serious complication being third-degree atrioventricular
heart block, which results in fetal and neonatal mortality rates of 15% to 30%.
Ten percent of patients experience thrombocytopenia, neutropenia, or anemia,
which are usually transient. Neonatal lupus can present as annular (ring-like), red,
scaly patches, most commonly on the head and neck. Rash around the periorbital
region should make suspicion very high ( Fig. 69.10 ). Neonatal lupus can also
manifest as scaly atrophic patches similar to discoid lupus. Mucosal erosions have
been noted in some infants. The diagnosis also has implications for the mother
and her future pregnancies. Women who have had a child with NLE have an
increased risk of having a child with neonatal lupus in subsequent pregnancies.
Up to 83% of mothers who have an infant diagnosed with NLE are themselves
asymptomatic at the time. However, approximately 50% of these mothers have or
will subsequently develop an autoimmune disorder, commonly Sjogren disease.
Any annular erythematous rash in a newborn should be assumed to be NLE until
definitively proven otherwise.


FIGURE 69.9 Infant with neonatal lupus.

Scaly Red Patches and Plaques
Dermatophyte Infections
Rarely, tinea has been reported in infants as young as a 2 to 3 weeks of life.
Topical therapy is usually sufficient to treat tinea capitis or corporis in this group,
and a dermatophyte screen can confirm the diagnosis. Please see Chapter 66
Rash: Bacterial and Fungal Infections/Rash: Maculopapular for more details.

FIGURE 69.10 Annular red plaque near the eye of an infant with neonatal lupus.

FIGURE 69.11 A: Infant with seborrheic dermatitis on scalp and face. B: Infant with
seborrheic dermatitis in the diaper area.


Atopic Dermatitis/Seborrheic Dermatitis
Neonates can present with scaly and greasy red patches as early as the first month
of life. Seborrheic dermatitis is the term given to the salmon-colored patches with
yellow, greasy scales occurring primarily in the so-called seborrheic areas (face,
postauricular area, scalp, axilla, groin, and presternal area) ( Fig. 69.11A,B ).
Seborrheic dermatitis is seen in infants or adolescents. Its onset occurs during the
first 3 months. It may also reappear in adolescence. Often in the first months of
life, atopic dermatitis and seborrheic dermatitis can overlap, leading to a head to
toe pattern of redness and scale with accentuation on the scalp and face. For the
seborrheic dermatitis component in the scalp, removing scales with a soft brush
after application of an oil or petrolatum can be useful. Shampoos can be helpful
for pure seborrheic dermatitis but will make atopic dermatitis worse because of
increasing dryness. Low-potency topical steroids are usually sufficient to treat
both seborrheic dermatitis and atopic dermatitis. This should accompany gentle
skin care, including use of moisturizing cleanser when bathing a few times a
week and using moisturizers twice a day. A clue to the presence of atopic
dermatitis is the waxing and waning of the rash ( Fig. 69.12 ). Car seat dermatitis
(reaction to materials that line car seats) and other contact and irritant reactions
(e.g., pacifiers) have been reported in neonates as well. These typically present
more suddenly and when the causative agent is removed the rash will resolve and
not recur. Full discussion of atopic dermatitis can be found in Chapter 65 Rash:
Atopic/Contact Dermatitis and Photosensitivity .
Diaper Dermatitis

Diaper dermatitis is a general term used to describe skin abnormalities beneath
the diaper. The problem is common in children 2 years of age or younger and
generally disappears after toilet training. The pathogenesis of the problem is
multifactorial ( Fig. 69.13 ), and likely includes concentration of bacteria or
fungi, action of organisms on urine, and moisture itself.
The chronic exposure of diaper-area skin to moisture is critical to the
development of diaper dermatitis. This leads to maceration and alteration of the
epidermal barrier with overgrowth of bacteria (including group A β-hemolytic
streptococci) and C. albicans. Traditional diaper creams and ointments create a
moisture barrier and are usually recommended for skin protection purposes.
These include petrolatum-based, silicone, and zinc oxide preparations.
There is no conclusive evidence that bacteria play a major role in diaper
dermatitis. However, bacterial overgrowth occurs with time on moist skin, and
bacteria have been implicated in liberating ammonia from urine and raising urine