1. What essential question does one still need to ask to help make the diagnosis?
2. What is the tentative diagnosis?
3. Can you list at least three differential diagnoses?
4. What features of this condition differentiate it from other conditions?
5. What is the suitable treatment of this condition?
When A Newborn Presents With A Skin Condition On Both Feet
In full-term infants, isolated cutaneous findings include vesicles, pustules or, most commonly, a widespread erythematous macular rash that resembles a mild drug eruption. Candida albicans is demonstrated with potassium hydroxide (KOH) preparations of skin scrapings or via a Gram stain of pustular or vesicular contents, and is diagnostic. In contrast, congenital candidiasis in premature infants exhibits a more fulminant course and severe cutaneous findings are frequently coupled with invasive pulmonary disease and the precipitous onset of respiratory distress, which may be life-threatening. These more severe cases usually involve premature, low birth-weight infants and one would typically see this condition between the second and sixth weeks of life.
Additionally, if a new mother has a vaginal yeast infection, even if she is being treated with an antifungal, it is very important that she wash her hands frequently with hot, soapy water. This is especially important after visits to the bathroom, after diaper changes and before breastfeeding or pumping since she can spread the infection to her infant. She needs to be on the lookout for any symptoms of nipple thrush, such as suddenly sore nipples, once breastfeeding is well established. It is important to check the baby’s mouth regularly for white plaques that cannot be easily removed. The feet and toes should be scrutinized daily during the first few months of life.
What Is The Differential Diagnosis?
The differential diagnosis includes intertrigo, miliaria rubra, contact dermatitis, drug eruption, exfoliative dermatitis, tinea pedis, staphylococcal and herpes infections.
Intertrigo is inflammation of skin folds caused by skin on skin friction. Intertrigo may present a similar appearance as diaper rash or candidal infections in infants. The friction in the natural skin folds at the groin, buttocks, under the arms and between the toes can lead to a variety of complications such as secondary bacterial or fungal infections. Managing intertrigo usually involves minimizing moisture and friction with absorptive powders or barrier creams.
Miliaria rubra, or prickly heat, is a common disorder of the eccrine sweat glands that often occurs in conditions of increased heat and humidity. This condition is very common in newborns and infants. It is thought to be caused by a blockage of the sweat ducts. One commonly sees this in the diaper area but it may also occur on the hands and feet, and in any skin fold areas. Secondary infections with yeast, fungi or virus may complicate the condition.
Contact dermatitis and drug reactions are not quite as common but may occur if the baby is exposed to certain chemicals or drugs in the first few days of life.
A Guide To Prevention And Treatment
Prevention of cutaneous Candida infections in infants requires that all pregnant females be examined for vaginal yeast infections during and immediately after pregnancy, and be treated appropriately. After giving birth, mothers need to be very aware of vaginal yeast infections and methods to reduce the risk of infecting their babies by direct contact and during breast feeding.
In regard to cutaneous Candida in a newborn infant, one can treat this condition with topical nystatin or antifungal agents. Treatment should begin immediately at the first signs of skin involvement and needs to continue for one to two weeks once the symptoms have cleared. Infants with candidiasis limited to the skin have a very favorable outcome. However, systemic involvement may occur and needs to be aggressively treated.
Dr. Dockery is a Fellow of the American College of Foot and Ankle Surgeons, and a Fellow of the American Society of Podiatric Dermatology. He is the Chairman of the Board and Director of Scientific Affairs for the Northwest Podiatric Foundation for Education and Research in Seattle.