When A Newborn Presents With A Skin Condition On Both Feet

     A 30-year-old Caucasian female brings her 3-week-old son into the clinic with a skin condition on both feet. The mother reports that the pregnancy was uncomplicated. She says the baby was born full-term with a normal birth weight of 7.2 pounds and no problems noted.      The mother also says she was healthy before and during the pregnancy, and that she is not taking any prescription medications or other drugs. She has been taking regular perinatal vitamins and minerals, including vitamin C and E, as directed by her personal obstetrician. The mother denies smoking, drinking alcohol or caffeinated liquids.      At birth, the child received a clean bill of health. No deformities, irregularities or other problems were noted on the birth examination forms.      However, soon after arriving back at home, the mother noticed several small red flat spots and “bumps” on the infant’s hands, stomach and legs, which all resolved after a few days of regular bathing and using Penaten® Baby Lotion (Johnson and Johnson). At no time was there any obvious rash formation on the face or mouth. She says there was no diaper rash or similar problem involving the genitals, groin or buttocks area.      Shortly thereafter, the mother noticed redness between the baby’s toes, which eventually progressed to very small, fluid filled blisters forming within the area of redness. The mother states that several new small blisters then appeared on the bottom of both feet, followed by some cracking of the skin below the toes and on the balls of the feet. She began cleaning his skin and feet more often and applied Penaten. She said the lotion appeared to clear up the blisters but the condition did not respond completely. Two days prior to the latest visit, she also noticed extensive peeling of the skin around the toes and ball of both feet.

What Did The Exam Reveal?

     The physical exam at the first clinic visit revealed pink to erythematous intertriginous moist patches, surrounded by a thin, overhanging fringe of somewhat macerated epidermis. There is a large excoriation on the distal ball of the left foot coming from the first interdigital space. Tiny, superficial white pustules are adjacent to the patches. There is evidence of healed blisters and vesicles on the plantar aspect with increased erythema along the ball of the feet and the plantar surface of all the toes.      There are areas of maceration at the interdigital spaces, fine fissures and cracks of the skin at the plantar creases of most of the toes, and generalized areas of thin desquamation at the distal toes. The hands showed a similar pattern of skin changes but to a much less extensive degree. There are no other skin abnormalities.

What You Should Know About Cutaneous Candidiasis

     When a baby develops cutaneous candidiasis this early on, he or she likely picked it up during the birth process. Candida albicans, the most common cause of vaginitis, is more common in women during pregnancy. Reportedly 20 percent of healthy, non-pregnant women have vaginal Candida, and significantly more test positive during pregnancy. Since not all women show symptoms of a vaginal yeast infection, many no doubt are carrying Candida through their births. If the baby picked up Candida during his birth, he may get a cutaneous infection very quickly thereafter. In these cases, the oral cavity and diaper area are usually spared. Involved areas typically include the trunk, palms, soles and may include the cutaneous nail folds.      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.
 

References:

Suggested Reading
1. Amir L, Hoover K, Mulford C. Candidiasis and breastfeeding. LLLI Lactation Consultant Series, Unit 18. Garden City Park, New York: Avery Publishing, 1995.
2. Chapman RL. Candida infections in the neonate. Curr Opin Pediatr. 15;97-102, 2003.
3. Johnson, DE, Thompson TR, and Ferrieri, P. Congenital candidiasis. Am. J. Dis. Child. 135:273-275, 1981.
4. Levine NA, Wilson BB: Miliaria. eMedicine, Feb 2005, Available online: www.emedicine.com/DERM/topic266.htm
5. Odds, F.C. 1988. Candida and candidosis. 2nd Ed. Bailliere Tindall, London
6. Rudolph N, Tariq AA, Reale MR, et. al. Congenital cutaneous candidiasis. Arch Dermatol. 113:1101-1103, 1977.
7. Selden S. Intertrigo. eMedicine, Sept 2005. Available online: www.emedicine.com/DERM/topic198.htm