be classified into the following categories: disseminated disease, central nervous system (CNS) disease, or skin, eye, and/or mouth (SEM) disease A high index of suspicion is necessary in neonates presenting with vesicles or pustules, especially with a negative bacterial culture About 40% of neonatal herpes is confined to the SEM Most infections acquired during the peripartum period present between and 11 days of life, though they can be seen earlier or later Those infants with SEM disease are most easily diagnosed since they usually present with obvious vesicular lesions HSV that develops in the skin usually begins as papules or vesicles that erode Erosions may be the only visible lesions They usually have a red base and are to mm in diameter and can occur as a single unit or in clusters ( Fig 69.7 ) They appear anywhere on the body but are most commonly seen on the presenting parts such as the head in vertex presentation and buttocks in breach Scalp probe sites can become sites of primary infection The poorest outcome is in infants who present with widespread disease involving lungs, liver, adrenal gland, skin, eyes, and mouth Infants presenting with disseminated herpes disease typically present with symptoms very similar to those associated with bacterial infection Although the diagnosis may be easily confused, disseminated herpes disease may often be distinguishable from bacterial infection by the presence of vesicular lesions, neonatal hepatitis of unknown etiology, and DIC Disseminated herpes infection may have CNS involvement and the infant may therefore exhibit symptoms consistent with encephalitis or meningitis The highest risk of developing neonatal HSV occurs when the mother has true primary infection at the time of delivery; the risk for developing neonatal herpes is about 30% The risk for transmission in infants born to mothers with known genital herpes is less than 1%, which may be related to transfer of maternal HSV IgG antibodies across the placenta FIGURE 69.2 Infant with papules and pustules of erythema toxicum on the face FIGURE 69.3 Multiple collarets of scale on the leg of a newborn with TNPM FIGURE 69.4 Skin peeling on the trunk of infant with staphylococcal scalded skin syndrome