For diagnosis

 Clinical–comedones and inflammatory papules and/or comedones. It usually begins in the first year of life and is secondary to a physiologic increase in adrenal and gonadal androgens.

 If severe consider work-up for hyperandrogenism

For treatment

 Treat to avoid formation of pitted scarring from acne

Gentle cleansing

E

Mild retinoid (adapalene 1 % gel or tretinoin 0.025 % cream)

C

Benzoyl peroxide 2.5 % cream

D

Oral erythromycin, azithromycin, or trimethoprim-sulfamethoxazole

D

Oral isotretinoin

D

For diagnosis

 Clinical–greasy yellow scale and erythematous patches on the face, scalp, ears, and intertriginous areas. Appears between 2 and 10 weeks of age and may be associated with colonization of Malassezia furfur

 Consider culture for bacteria and candida for any weeping intertriginous area

 KOH preparation and fungal culture to exclude superficial dermatophyte infection

For treatment

 None, self-limiting within a few weeks to months

Emollients. For thick scale, application of mineral or baby oil followed by gentle scalp massage with a soft toothbrush

A

Frequent shampooing with gentle shampoo or anti-seborrheic shampoo

E

Bifonazole 1 % shampoo

B

Ketoconazole 2 % shampoo

A

Ketoconazole 2 % cream

B

Hydrocortisone 1 % cream

B

For diagnosis

 Clinical–well demarcated scaly perioral and acral plaques, which may be accompanied by alopecia and diarrhea. It is secondary to an autosomal recessive mutation in intestinal zinc-specific transporter gene SLC39A4. Acquired forms of zinc deficiency will have the same clinical presentation and may be secondary to inadequate intake, excessive losses, malabsorption, and increased demands. Mothers may have low zinc secretion into milk caused by a mutation in the SLC30A2 gene, which encodes the transporter responsible for secreting zinc into breast milk

 Blood plasma or serum zinc levels, fasting; serum zinc levels <50 μg/dl

 Low alkaline phosphatase levels

 Urine zinc excretion

 Physical exam and routine laboratory evaluation, lipid profile, copper levels

 Genetic testing

For treatment

 Blood plasma or serum zinc levels q 3–6 months

Oral zinc supplementation

A

Inherited deficiency – 3 mg/kg/day for life (50 g elemental zinc per 220 mg zinc sulfate)

Acquired deficiency – 0.5 to 1.0 mg/kg/day until corrected

For diagnosis

 Clinical–pruritic recurrent pustules on palms and soles

 Rule out scabies

 Skin biopsy–intraepidermal pustules with neutrophils, occasional eosinophils

For treatment

 None

Potent topical corticosteroids

D

Oral antihistamines

E

Oral dapsone

E

For diagnosis

 Clinical–discrete ovoid defect covered with a membrane that may be bullous or flat at birth that eventually heals with a scar. Aplasia cutis congenita may present sporadically or may be inherited as part of a syndrome

 Thorough history and physical for other developmental anomalies

 If hair collar sign (ring of longer, darker hair around the defect) and midline, need evaluation for underlying neural tube defect; ultrasound or MRI if concerned

For treatment

 Follow-up proper formation of scar

For diagnosis

 Clinical–hyperpigmentation of the skin, serum, and urine during treatment for neonatal jaundice with phototherapy. It occurs in infants with cholestasis and elevated levels of unconjugated and conjugated bilirubin

 Evaluate for underlying cause of jaundice

 Evaluate for underlying hepatocellular disease

For treatment

 Monitor for jaundice, cholestasis, hepatocellular disease

Improves with discontinuation of phototherapy

E

For diagnosis

 Clinical–vesicles on an erythematous base; three recognized syndromes: skin, eyes, and mouth infection (SEM); disseminated infection; central nervous system infection

 Viral Culture (swab from mouth, nasopharynx, conjunctiva, anus, and any vesicles), Viral DFA or immune peroxidase slide test, PCR (skin vesicle, CSF, blood), Tzanck Preparation, ALT elevation, skin biopsy

 Must rule out CNS disease

 CT brain, MRI brain, EEG

For treatment with acyclovir

 Serial absolute neutrophil count (ANC) twice weekly

 Adjust dose of Acyclovir for renal failure or sustained ANC <500 mm³

 For infants with CNS disease- consider daily suppressive therapy with oral acyclovir for 6 months after parenteral regimen

Oral Acyclovir–20 mg/kg IV q8 × 14 (SEM)-21 days (disseminated or CNS)

B

For diagnosis

 Clinical; congenital–pustules on palms and soles birth to first few days of life, may have respiratory distress; neonatal–diaper (beefy erythema and satellite pustules or vesicles), oral thrush (white plaques on oral mucosa), and also commonly associated with intertrigo (erythema and maceration in skin folds). This warrants a high index of suspicion in premature and immunocompromised infants

 Smear of pustule with KOH, Giemsa, Gram, or calcofluor stain (budding yeast or pseudohyphae), fungal culture

 PCR, restriction fragment endonuclease digestion of chromosomal DNA, electrophoretic karyotyping, Southern blot hybridization analysis with DNA probes, B-glucan assay, gas chromatography mass spectrometry for D-arabinitol, buffy coat smear microscopy

 CBC (leukocytosis), Glucose (elevated)

 Congenital–evaluate placenta and umbilical cord for lesions; if suspect disseminated systemic disease (premature and low birth-weight), must culture blood, urine, cerebrospinal fluid

For treatment

 Monitor for sepsis

 Follow monitoring guidelines for any PO or parenteral antifungals

Thrush–nystatin solution (100,000 u/ml) applied to oral mucosa 4×/day; fluconazole (2–3 mg/kg/day)

A

For localized disease–topical anti-yeast preparations, Imidazoles, nystatin, allylamines

A

Invasive–oral fluconazole, itraconazole, amphotericin

A, B (amphotericin)

Prophylaxis in infants <1 kg-Fluconazole IV

A

Thrush–Itraconazole (2 mg/kg/day)

D

Localized–1 % gentian violet, or 2 % eosin

E

For diagnosis

 Clinical–discrete vesicles and pustules, or superficial erosions and crust

 Bacterial culture and gram stain of fluid from vesicle, pustule, or beneath crust. Nasal swabs to evaluate for S. Aureus carriage

 Consider work-up for deeper or systemic infection if any constitutional signs of illness (fever, temperature instability, irritability, lethargy, etc.)

For treatment

 Monitor for signs of deeper or systemic infection

 Monitor sensitivities of culture

 Consult with colleagues and local resources regarding resistance patterns in your hospital and community

Oral antibiotics–choose agent based on sensitivity and local resistance patterns

A

Topical antibiotic ointment (mupirocin, fusidic acid, or retapamulin ointments)

A

Decolonization of neonates and close contacts

A (adults– trial results pending in neonates)

For diagnosis

 Clinical–pruritic contagious infestation of the Sarcoptes scabiei mite that commonly involves the palms, soles, and axillae but also may involve the scalp of infants. Burrows, vesicles, erythematous papules, and nodules may be present

 Mineral oil examination–apply a drop of mineral oil and scrape with No. 15 blade then smear contents onto glass slide, cover with mineral oil and evaluate for mite, eggs, or feces

 Dermoscopy

For treatment

 May have pruritus for 1 month following treatment

Permethrin 5 % cream–approved for over 2 months of age but commonly used under 2 months of age, traditionally applied to all skin from neck down and rinsed after 8 h, but scalp must also be treated in infants; should be repeated after 1 week

A

Sulfur 6 % ointment–safe in infants and pregnant women; apply as above for 3 consecutive nights and rinse 24 h after last application

D

Treat all close contacts

E

Launder all linens following treatment