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Picture of the Month—Diagnosis
Arch Pediatr Adolesc Med. 2007;161(6):608.
Denouement and Discussion: Congenital Sucking Blisters
An otherwise healthy full-term female neonate was born with linear, bullous skin lesions involving both wrists. Some bullae were filled with clear fluid and others had apparently ruptured shortly before birth. No other skin abnormalities were detected.
Pregnancy had been uneventful and delivery was uncomplicated. The mother denied any history of syphilis, hereditary bullous disorders, or lupus erythematosus. Maternal examination revealed no evidence of herpes simplex lesions, and at prenatal screening at 36 weeks' gestation, no evidence of genital streptococcal carriage was noted.
The obstetrician in charge, a consulting dermatologist, and an infectious diseases specialist (R.A.) were unable to make an on-the-spot diagnosis. A wide range of potential infectious and noninfectious conditions were considered, including neonatal herpes simplex, varicella virus infection, bullous impetigo, and various congenital bullous diseases.
Before further tests were performed, the child started to suck vigorously at the involved areas, allowing a presumptive diagnosis of sucking blisters. Once feeding was established, sucking of the wrists stopped and no additional lesions appeared thereafter. The remaining erosions healed uneventfully without further treatment after several days.
BACKGROUND
Sucking blisters may be present at birth as single or multiple noninflammmatory vesicles or bullae, mostly being oval, thick-walled, and containing sterile fluid. Sometimes they only appear as demarcated erosions.1 The size varies between 0.5 and 2 cm. The lesions are located mainly at the dorsal or radial aspect of the wrists, hands, or fingers. Both unilateral or symmetrical bilateral distribution has been observed and has occasionally been accompanied by blisters or callus formation at the lips (sucking pads). Typically, the neonate is noted to suck excessively on the involved areas.
In a review from 1963, Murphy and Langley2 estimated that the frequency of congenital sucking blisters was approximately 1 in 250 births based on their personal observation. These authors and others1 believe the incidence to be even lower.
DIFFERENTIAL DIAGNOSIS
The diagnosis of congenital sucking blisters is a diagnosis of exclusion. The absence of lesions in other body regions, the timing of onset, and the rapid resolving of the blisters in combination with the otherwise well appearance of the neonate are highly suggestive of the cause of the phenomenon. The most helpful clue, though, for making the correct diagnosis, is the observation of the neonate’s intensive sucking of the involved areas. However, pathological disorders demonstrating similar lesions include both infectious and noninfectious diseases, which usually, but not always, demonstrate additional clinical signs or are accompanied by a suggestive maternal history (eg, congenital bullous disorders).
Congenital or neonatal herpes simplex virus infection, fetal or neonatal varicella, bullous impetigo, and congenital syphilis or candidiasis might be confused with sucking blisters. Rarely, neonatal lupus erythematosus, hereditary bullous diseases, and epidermolysis bullosa should be considered and appropriate tests may need to be performed. Given the morbidity and mortality associated with these neonatal infections, if any doubt exists about the diagnosis, patients should be screened with appropriate bacterial cultures, viral studies, and laboratory tests.
CONCLUSIONS
Most neonatal or dermatological textbooks include neonatal sucking blisters only in brief descriptions3-4; thus, the appearance of these skin lesions often remains unfamiliar to clinicians in pediatrics, obstetrics, and dermatology. To our knowledge, very few case reports have addressed this issue in the last 40 years.2, 5 Despite their harmlessness, intrauterine sucking blisters may cause intense anxiety and unnecessary diagnostic procedures. The physician familiar with the phenomenon can potentially make the diagnosis by observation in many cases, but testing to rule out more serious infection should be performed whenever appropriate.
AUTHOR INFORMATION
Correspondence: Rüdiger Adam, MD, Pediatric Infectious Diseases Unit, Department of General Pediatrics, University Children's Hospital, Moorenstrasse 5, 40225 Düsseldorf, Germany (adam{at}med.uni-duesseldorf.de).
Accepted for Publication: August 1, 2006.
Author Contributions: Study concept and design: Adam and Schroten. Acquisition of data: Adam. Analysis and interpretation of data: Adam. Drafting of the manuscript: Adam and Schroten. Critical revision of the manuscript for important intellectual content: Adam and Schroten.
Financial Disclosure: None reported.
REFERENCES
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1. Johr RH, Schachner LA. Neonatal dermatologic challenges. Pediatr Rev. 1997;18:86-94.
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2. Murphy WF, Langley AL. Common bullous lesions—presumably self-inflicted—occurring in utero in the newborn infant. Pediatrics. 1963;32:1099-1101.
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3. Walker NPJ. Neonatal dermatology. In: Rennie JM, Roberton NRC, eds. Textbook of Neonatology. 3rd ed. Edinburgh, Scotland: Churchill Livingstone; 1999: 889-902.4. Darmstadt GL, Sidbury R. Diseases of the neonate. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 17th ed. Philadelphia, Pa: WB Saunders Co; 2004:2162-2164.5. Libow LF, Reinmann JG. Symmetrical erosions in a neonate: a case of neonatal sucking blisters. Cutis. 1998;62:16-17.
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SECTION EDITOR: ALBERT C. YAN, MD; ASSISTANT SECTION EDITOR: SAMIR S. SHAH, MD
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Picture of the Month—Quiz Case
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