Infectious Causes |
Staphylococcus
aureus |
Impetigo | Few days to week | Pustules, bullae, occ. vesicles | Mainly diaper area, periumbilical | Boys > girls: occ. epidemics | Gram stains: neutrophils gram+ cocci in clusters;
bacterial culture |
Staphylococcal scalded skin syndrome | 3 to 7 days; occasionally older | Erythema; cutaneous tenderness; superficial blisters and
erosions | Generalized, begins on the face; blistering and erosions
in areas of mechanical stress | Irritability, fever | Skin biopsy, superficial epidermal split, bacterial cultures, blood,
urine, etc |
Group A streptococcus | Few days to week | Isolated pustules; honey-crusted lesions | No predisposed sites | Moist umbilical stump; occ. cellulitis; meningitis, pneumonia | Smear: gram+ cocci in chains; bacterial culture |
Group B streptococcus | Birth or first few days | Vesicles, bullae, erosions, honey-crusted lesions | No predisposed sites | Pneumonia; sepsis | Smear: gram+ cocci in chains; bacterial culture |
Listeria monocytogenes | Usually at birth | Hemorrhagic pustules and petechiae | Generalized, esp. trunk and extremities | Sepsis; respiratory distress; maternal fever | Smear: gram+ rods; bacterial culture |
Haemophilus influenzae | Birth or first few days | Vesicles and crusted lesions | No predisposed sites | Sepsis; occ. meningitis | Smear: small gram– rods; bacterial culture |
Congenital syphilis | Usually at birth | Blisters or erosions on dusky or hemorrhagic base | Palms, soles, knees, abdomen, groin, buttocks | Low birthweight; hepatosplenomegaly; metaphyseal dystrophy | Darkfield or FA of involved skin; serial serology |
Candidiasis |
Congenital | Birth or first week | Erythema and fine papules evolve into pustules | Any part of body; esp. palms and soles | Prematurity | KOH: pseudohyphae, budding yeasts |
Neonatal | Week to month | Scaly red patches with satellite papules, pustules | Diaper and intertriginous areas | Usually none; maternal intrauterine device, cervical suture;
previous antibiotic therapy | KOH: pseudohyphae, budding yeasts |
Herpes simplex |
Intrauterine | Birth | Vesicles, widespread bullae, erosions, scars, missing skin | Anywhere on body; skin involved in 90% | Low birth weight; microcephaly, chorioretinitis | Tzanck and FA slide tests; viral culture |
Neonatal | Usual: 5 to 14 days | Vesicles, crusts, erosions; may be grouped or not | Anywhere: esp. scalp monitor sites, torso, intraoral | Signs of sepsis, irritability, lethargy | Tzanck and FA slide tests: viral culture |
Varicella |
Intrauterine | Birth | Usually: scars, limb hypoplasia, erosions | Anywhere, esp. extremities | Maternal varicella first trimester | Tzanck and FA slide tests; viral culture |
Neonatal | 0 to 14 days | Vesicles on an erythematous base; may be very numerous | Generalized | Maternal varicella 4 days to 2 weeks after delivery | Tzanck and FA slide tests; viral culture |
Cytomegalovirus (CMV) | Birth (one case) | Vesicles | Forehead | Prematurity, jaundice, hepatosplenomegaly | Urine culture; anti-CMV IgM |
Scabies | After 3 weeks | Papules, nodules, vesicles, crusted lesions | Generalized, esp. palms, insteps of feet, axillae | Others in family with pruritus or rash | Scabies prep: mites, eggs, or feces |
Sporadic Conditions:
Common |
Erythema toxicum neonatorum | 24 to 48 hours to few weeks | Erythematous macules, papules, pustules | Buttocks, torso, proximal extremities; spares palms, soles | Usually term infants (birth weight > 2500 g) | Smear: eosinophils, no organisms |
Neonatal pustular melanosis | Birth | Pustules without erythema; hyperpigmented macules | Anywhere: esp. forehead, behind ears, neck, back | Term infants: more common in African-Americans | Smear: neutrophils, occ. eosinophils, no organisms |
Miliaria crystallina | Usually first week | Dew-drop like vesicles, very fragile; no erythema | Esp. forehead, upper trunk, volar forearms | Warm incubator, fever | Smear: few to no cells; no organisms |
Miliaria rubra | Day to week | Pustules on erythematous base; imposed pustules | Same as miliaria crystallina | Same as miliaria crystallina | Usually clinical: skin biopsy; intraepidermal pustule with neutrophils |
Pityrosporum (Malassezia furfur) pustulosis | 3 to 4 weeks | Papules and pustules | Face, esp. cheeks and forehead | Resembles neonatal acne but comedones are absent | KOH: short hyphae and yeast |
Sucking blisters | Birth | Flaccid bulla on nonerythematous base | Radial, forearm, wrist, hand, dorsal thumb, index finger | Infant sucks vigorously on affected areas | Clinical |
Acropustulosis of infancy | Birth or first day to week | Vesicles and pustules | Hands and feet, esp. palms, soles | Severe pruritus; lesions come in crops | Clinical: skin biopsy: intraepidermal pustule with eosinophils
and neutrophils |
Neonatal acne | 3 to 4 weeks | Comedones, papules, pustules | Face, esp. cheeks, forehead | Comedones, pathognomonic | Clinical |
Sporadic Conditions:
Rare |
Langerhans cell histiocytosis | Usually birth | Papules, pustules, purpura, erosions or scars | Generalized | Lymph nodes; liver, spleen, blood may be involved | Skin biopsy: atypical S-100 CDH histiocytes |
Diffuse cutaneous mastocytosis | Birth to few weeks | Bullae; thickened, yellowish skin; hives | Generalized | Wheezing, diarrhea, bleeding diathesis | Skin biopsy: mast-cell infiltrate |
Maternal autoimmune bullous disease | Birth | Tense or flaccid bullae, erosions | Generalized | Maternal blistering disease | Maternal immunofluorescence biopsy |
Toxic epidermal necrolysis | Birth to few weeks | Diffuse skin erythema, tenderness, erosions | Generalized | Graft-vs-host disease; Klebsiella sepsis,
etc | Skin biopsy: full-thickness necrosis |
Congenital erosive and vesicular dermatosis (CEVD) | Birth | Vesicles and erosions | Generalized, >75% if body | ? Infection or placental infarctions | ? Skin biopsy |
Eosinophilic pustular folliculitis | Birth or later | Multiple pustules, crusted areas | Scalp, hands, feet | Often peripheral eosinophilia | Skin biopsy: folliculitis with eosinophiles |
Genetic and Developmental
Causes |
Epidermolysis bullosa | Birth, rarely later | Bullae or erosions, milia, nail dystrophy; occ. cutis aplasia | Anywhere; esp. extremities, mucosa | Any epithelia (gastrointestinal, genitourinary, cornea, trachea) may
be affected | Skin biopsy: electron microscopy or immunofluorescence mapping |
Epidermolytic hyperkeratosis (bullous ichthyosis) | Birth | Bullae, erosions, hyperkeratoses | Generalized; blisters more on hands and feet | Family history (autosomal dominant) | Skin biopsy: abn. “keratohyalin” granules;
electron microscopy |
Incontinentia pigmenti | Birth or first week | Linear streaks of erythematous papules and vesicles; focal alopecia | Swirling, following Blaschko lines | Family history (X-dominant) Eye CNS abnormality | Skin biopsy: eosinophilic spongiosis and dyskeratosis |
Acrodermatitis enteropathica | Week to month | Sharply demarcated, psoriasiform plaques, sometimes vesicles and
bullae | Periorificial and acral | Diarrhea, irritability, alopecia, hyperalimentation, prematurity, trial
of zinc | Low serum zinc |
Hyperimmunoglobulin E syndrome | Day to week | Multiple vesicles, grouped and individual | Generalized | Recurrent S aureus infection; eosinophilia | IgE 10× for age |
Aplasia cutis congenita | Birth | One or more membrane-covered depressions or ulcerations | Usually scalp | Occ. associated with epidermal nevus | Clinical, skin biopsy |
Ectodermal dysplasias | Congenital or early infancy | Rarely: vesicles or bullae | Depends on specific form; acral in some | Abn. teeth, hair, nails, sweating, depends on specific form | Usually clinical |
Goltz syndrome | Congenital or early infancy | Rarely: vesicles or bullae; linear bands of atrophy | Linear pattern following Blaschko lines | X-dominant, females only, limb abnormalities | Clinical |
Erythropoietic porphyria | Early infancy | Vesicles or bullae | Photodistribution | Hemolytic anemia, pink urine | High porphyrins in blood, urine |
Protein C deficiency | Birth or first day | Hemorrhagic bullae and skin infarctions | May be focal or generalized | Disseminated intravascular coagulation | Absent protein C in blood |