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Authors: Jessica Chen, Medical Student, University of New South Wales, Sydney, NSW, Australia; Dr Anes Yang, Dermatology Research Fellow, Premier Specialists, St George Hospital, Sydney, NSW, Australia. DermNet NZ Editor in Chief: Adjunct A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell/Maria McGivern. June 2019.
This page describes vesiculobullous and pustular lesions in newborns and their differentiating characteristics.
Vesiculobullous and pustular lesions in neonates can be due to miscellaneous benign conditions, an infection, a genodermatosis, or a transient autoimmune bullous disorder.
Fluid-filled skin lesions
There are several benign disorders that may present within a few days of birth with blisters and pustules. These include:
Benign neonatal conditions
Neonatal blistering diseases may be due to viral, bacterial, fungal, or parasitic infection.
The onset of viral infections is within days to weeks after birth.
Viral infections that cause blisters
Staphylococcal infection in a neonate usually presents with localised superficial, flaccid, vesiculobullous or pustular lesions that rupture to reveal an erythematous base and then form seropurulent crusts. The infection may extend to cause fever and widespread SSSS .
Listeriosis is a cause of premature birth. It presents early with multiple pustules on the mucous membranes and skin and may progress to cause meningitis and septicaemia .
Congenital syphilis is associated with generalised haemorrhagic bullae and petechiae.
Staphylococcal infections in newborn babies
An infection caused by Candida albicans tends to occur a few weeks after birth or in an older baby, often presenting as oral thrush (white sticky plaques on a reddened mucosa) or napkin dermatitis. Candida infections are characterised by very superficial blisters and pustules associated with erythematous papules and plaques in intertriginous sites. Systemic mycosis with disseminated candida can also occur in neonates .
Oral Candida albicans infection
Scabies is caused by the parasitic mite Sarcoptes scabiei. In a young baby, it causes a widespread vesiculopustular eruption, that is prominent on the palms and soles. The source of the infestation is likely to be a family member or visitor with an itchy rash .
Scabies in an infant
The blistering genodermatoses are:
Inherited vesiculopustular and bullous genodermatoses are rare. They should be suspected in newborns with a family history of a genodermatosis or consanguinity .
Genodermatoses that can blister
Maternal history of an autoimmune blistering disease can lead to a newborn presenting with the same autoimmune bullous disorder. Maternally transmitted autoimmune bullous disorders usually resolve within a few months of birth . These include:
An initial investigation in a neonate with blisters includes scraping fluid and cells from an intact blister for viral/bacterial/fungal microscopy, culture, and testing for a polymerase chain reaction to specific organisms [1,2].
Genodermatoses can be confirmed by skin biopsy using standard light microscopy, transmission electron microscopy, and immunofluorescence microscopy. Molecular genetic testing should also be considered .
An autoimmune blistering disease is investigated by a cord blood sample with serum indirect immunofluorescence on salt-split skin, and autoantibody enzyme-linked immunosorbent assay to desmoglein 1 and 3 and bullous pemphigoid antigen BP180. If there is no history of blistering in the mother, a lesional skin biopsy should be performed for histopathology. A perilesional skin biopsy should be submitted for direct immunofluorescence [2,4].
The treatment of the blistering disease depends on the diagnosis.
Books about skin diseases
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