FIGURE 96.4 Milia (Reprinted with permission from Jensen S Nursing Health Assessment Philadelphia, PA: Lippincott Williams & Wilkins; 2010.) FIGURE 96.5 Erythema toxicum (Reprinted with permission from Fletcher M Physical Diagnosis in Neonatology Philadelphia, PA: Lippincott-Raven Publishers; 1998.) FIGURE 96.6 Neonatal acne (Courtesy of Amy Ross, MD In: Chung EK, Atkinson-McEvoy LR, Boom JA, et al., eds Visual diagnosis and Treatment in Pediatrics 2nd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2010 With permission.) Significant Neonatal Rashes (See Chapter 69 Rash: Neonatal ) HSV Infection HSV is the most important condition to consider when evaluating a vesicular eruption because of its significant associated morbidity and mortality Current Evidence Most neonatal HSV infections are caused by HSV type While transplacental transmission can rarely occur, most neonatal HSV disease is acquired perinatally from infection of the maternal genitourinary tract Primary maternal infection at the time of delivery is associated with a 40% to 50% chance of transmission but most neonates with HSV are born to mothers who did not provide a history of HSV infection or other identifiable risk factors Clinical Considerations Goals of treatment: early diagnosis and prompt initiation of antiviral therapy to decrease morbidity and mortality Clinical Recognition The infant can appear well at birth but become ill at days to 7, at which time a vesicular eruption may be noted ( Fig 96.7 ) The most common lesions are small vesicles on an erythematous base which may become pustular in to days However, early manifestations can be subtle and nonspecific HSV should be suspected in infants with or without vesicles who present with sepsis, respiratory distress, focal neurologic signs, or signs of hepatitis or liver failure FIGURE 96.7 Herpes simplex infection (Reprinted with permission from Goodheart HP Goodheart’s Photoguide of Common Skin Disorders 2nd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2003.) Triage Consideration Neonates presenting with new vesicles should be seen promptly Clinical Assessment Neonatal HSV is categorized into three main categories: localized skin, eye, and mouth (SEM) disease; central nervous system (CNS) with or without SEM; and disseminated disease, which may involve CNS, SEM, and other organs Comprehensive laboratory evaluation should occur in infants with suspected HSV, even if only limited SEM involvement is suspected Obtain CBC, blood chemistry, liver function tests, urinalysis, blood and urine culture, lumbar puncture, HSV polymerase chain reaction (PCR) of the blood, cerebrospinal fluid (CSF) cell count, glucose, protein, HSV PCR, viral culture, surface culture from conjunctiva, mouth, nasopharynx, and rectum—placed in single viral transport media tube—and evaluation for bacterial or metabolic disease as indicated Management If a neonate is suspected of having HSV, perform a complete sepsis workup, start acyclovir, and admit the patient to the hospital Infants may require supportive care with intubation, mechanical ventilation, and cardiac support for disseminated disease In addition, infants with significant liver dysfunction may require transfusions in the setting of significant coagulopathy and bleeding Neonatal Varicella Current Evidence Neonatal varicella may develop when maternal varicella infection occurs during last to weeks of pregnancy or the first few days postpartum The severity of neonatal disease depends on timing of maternal infection If maternal disease onset is or more days before delivery, the infection in the newborn is usually mild because of transplacental passage of maternal varicella IgG antibodies If maternal disease is within days before delivery the neonate is at risk of developing severe infection, with mortality as high as 30% caused by pulmonary or visceral involvement Infants born to mothers who demonstrate chickenpox lesions within to days of delivery should receive varicella zoster immunoglobulin Clinical Recognition The classic rash is described as vesicles on an erythematous base, or “dew drops on a rose petal” ( Fig 96.8 ) Goals of Treatment Early recognition, support, and prompt initiation of antiviral therapy for moderate to severe cases of varicella FIGURE 96.8 Varicella infection (Reprinted with permission from Burkhart C, Morrell D, Goldsmith LA, et al VisualDx: Essential Pediatric Dermatology Philadelphia, PA: Lippincott Williams & Wilkins; 2009.) ... Ross, MD In: Chung EK, Atkinson-McEvoy LR, Boom JA, et al., eds Visual diagnosis and Treatment in Pediatrics 2nd ed Philadelphia, PA: Lippincott Williams & Wilkins; 2010 With permission.) Significant... (Reprinted with permission from Burkhart C, Morrell D, Goldsmith LA, et al VisualDx: Essential Pediatric Dermatology Philadelphia, PA: Lippincott Williams & Wilkins; 2009.)