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Difficulty: MediumPediatric Infectious Diseases

A full-term male newborn is evaluated in the hospital nursery on his third day of life. The parents express concern about a sudden skin eruption that appeared on his chest and arms earlier this morning. The infant was born via uncomplicated spontaneous vaginal delivery to a 28-year-old primigravida mother who had regular prenatal care and tested negative for Group B Streptococcus. He is breastfeeding vigorously and producing adequate wet diapers. Vital signs include a temperature of 37.0°C (98.6°F), heart rate of 138/min, and respiratory rate of 40/min. Physical examination reveals a well-appearing, alert neonate. Skin examination shows scattered 1- to 2-mm yellow pustules, each surrounded by a large, irregularly shaped erythematous macule. The lesions are present on the trunk, back, and proximal extremities, but the palms and soles are completely spared. No other abnormalities are noted. Which of the following is the most appropriate next step in management?

  1. A
    Empiric intravenous ampicillin and gentamicin
  2. B
    Empiric intravenous acyclovir
  3. C
    Application of topical mupirocin
  4. Routine newborn care and parental reassuranceAnswer
  5. E
    Blood and cerebrospinal fluid cultures

Answer

Routine newborn care and parental reassurance
The correct answer is routine newborn care and parental reassurance because the infant's presentation is characteristic of erythema toxicum neonatorum (ETN). ETN is a benign, asymptomatic, self-limited rash that typically appears on days 2 to 5 of life. It classically presents as small erythematous macules that develop central papules or pustules, often described as resembling 'flea bites'. The lesions involve the trunk and proximal extremities but characteristically spare the palms and soles. Because the infant is well-appearing, afebrile, and feeding vigorously, no diagnostic testing or pharmacologic treatment is indicated. The pustules are sterile and contain numerous eosinophils. Resolution occurs spontaneously over 1 to 2 weeks.

Step-by-Step Solution

1
Evaluate the neonate's overall clinical status and vital signs.
The infant is well-appearing, vigorous, afebrile, and feeding normally.
This rules out emergent systemic conditions like neonatal sepsis or disseminated viral infections.
2
Analyze the morphological characteristics and distribution of the rash.
The rash consists of yellow pustules on a broad erythematous base located on the trunk and proximal extremities, sparing palms and soles.
Identifying the specific pattern of the rash is essential for distinguishing between benign and pathological neonatal dermatoses.
3
Synthesize the findings to establish the most likely diagnosis and appropriate management.
The clinical picture is diagnostic of erythema toxicum neonatorum, which requires only observation.
Recognizing benign rashes prevents unnecessary diagnostic testing and inappropriate antibiotic or antiviral therapy.

Key Concept

Diagnosis and management of erythema toxicum neonatorum
Estimated Time:1m 0s
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Topics

Pediatric Infectious Diseases

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