Considerations when examining NICU babies with blistering diseases

January 29, 2016

The neonatal intensive care unit (NICU) can be a scary place for some dermatologists, pediatric dermatologist, Sheila Fallon Friedlander, M.D., told colleagues at the MauiDerm 2016 meeting this week. She provided two key messages aimed at enabling clinicians and the babies to get the help they need. Learn and find out that they are

The neonatal intensive care unit (NICU) can be a scary place for some dermatologists, pediatric dermatologist, Sheila Fallon Friedlander, M.D., told colleagues at the MauiDerm 2016 meeting this week. She provided two key messages aimed at enabling clinicians and the babies to get the help they need:

·  First, Dr. Friedlander told her colleagues to consider the neonatal nurses as their allies.

·  Second, she emphasized the need to be able to recognize serious conditions so that they can act quickly with intervention.

Using Star Wars analogies, she said that dermatologists may consider the NICU as if it is the Death Star in terms of it being a very threatening place to enter, where they may not have the first clue as to what the tiny patient has. Once inside, they may feel as if they have entered an alien world populated by strange people and strange contraptions.

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“There is a lot of technology in the unit, and the babies laying in their incubators attached to an assortment of equipment can be difficult to see and intimidating to touch,” she said. Dr. Friedlander is professor of clinical dermatology and pediatrics, Rady Children's Hospital and UCSD School of Medicine, San Diego, Calif.

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Partner with NICU staff

Rather than thinking of the nurses as Darth Vader or a storm trooper standing guard over the infants, dermatologists should enlist the help of the NICU staff.

“Talk to the nurse in charge of the baby you have come to see, get the background on the child, and have the nurse undrape the baby to expose the skin so you can conduct your examination,” Dr. Friedlander advised.

Rule out infection

When a blistering rash and/or erosions are the cause of concern in a baby, the first priority is to rule out infection, which can be fatal if missed.

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“When you see these lesions, you must rule out herpes simplex virus and other viral infections as well as bacterial and fungal etiologies,” she said. “Obtain specimens for laboratory diagnosis and start empiric treatment to cover the baby for herpes and staphylococcal infection.”

Consider differentials

In addition to infection, epidermolysis bullosa (EB) and other mechanoblistering disorders should be on the differential diagnosis list. If there is suspicion of EB, a skin biopsy utilizing immunofluorescence microscopy will be key for making the diagnosis, and dermatologists can contact the Dystrophic Epidermolysis Bullosa Research Foundation of America for guidance on how to obtain the biopsy as well as on care for the baby.

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Regarding other blistering conditions, Dr. Friedlander mentioned that bullous mastocytosis can present with extensive blistering. Automimmune disorders, such as pemphigus vulgaris or bullous pemphigoid, are rarely seen in the offspring of affected mothers or in infants as a de novo disease. The possibility of a benign condition, such as sucking blisters or aplasia cutis, should also be considered.   

She concluded, “The most important thing is to ‘Culture and Cover’. EB will not lead to a rapid demise for the infant, but missing herpes simplex virus infection might.”