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Acute Management of Blistering Infants

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INTRODUCTION

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The management of neonates with blistering requires a disciplined approach that includes a broad differential diagnosis of common and rare disorders. For the purposes of this chapter, blistering is broadly defined as primary fluid-filled lesions, such as vesicles, bullae, and pustules, as well as resultant secondary lesions, such as erosions (see Figure 121-1). Blistering lesions are not uncommon in the neonate, and although the majority of etiologies are relatively benign, the rare, life-threatening subset requires that thorough evaluations be considered for all affected neonates.

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FIGURE 121-1

A, A vesicle is a fluid-filled lesion 1 cm or less in size; B, the term bulla refers to a larger blister. Vesiculopustules (C) and pustules are filled with purulent fluid. Note the cloudy-to-white appearance of these lesions. D, Erosions result from loss of the epidermis and are often secondary to prior bullous lesions. This neonate with epidermolysis bullosa has a large congenital erosion.

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Over 40 different neonatal disorders can present with bullous or erosive skin changes.1 A useful diagnostic algorithm divides these conditions into infectious and noninfectious etiologies, with the latter further divided based on localized or generalized distribution, followed by predominant lesion morphology (see Figure 121-2).2,3 A thorough history, including the prenatal and neonatal course, and physical examination will direct the initial evaluation and treatment. The maternal history should include maternal and family history of skin and mucous membrane disease, prenatal care, maternal serologies, maternal illness, and delivery course (including delivery method and duration of rupture of membranes). If the maternal history is positive for skin or mucous membrane disease, maternal examination is indicated. Neonatal history should include gestation, symptoms of illness, prior procedures, medications, feeding history, neurologic status, and vital sign instability. Skin and mucous membrane evaluation should note lesion distribution, configuration, and morphology. Evaluation of other organ systems may be warranted as indicated (see Table 121-1).1,2

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FIGURE 121-2

A diagnostic flowchart for neonates with bullous and erosive lesions, based on the predominant lesion morphology: B, blisters; P, pustules, E, erosions.

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Table Graphic Jump Location
Table 121-1Considerations in the History and Physical Examination of the Neonate With Blisters

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