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 to 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 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 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