0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Special Feature |

Picture of the Month—Diagnosis FREE

[+] Author Affiliations

Section Editor: Albert C Yan, MD
Assistant Section Editor: Samir S. Shah, MD

More Author Information
Arch Pediatr Adolesc Med. 2007;161(6):608. doi:10.1001/archpedi.161.6.608.
Text Size: A A A
Published online

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.

Correspondence: Rüdiger Adam, MD, Pediatric Infectious Diseases Unit, Department of General Pediatrics, University Children's Hospital, Moorenstrasse 5, 40225 Düsseldorf, Germany (adam@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.

Johr  RHSchachner  LA Neonatal dermatologic challenges. Pediatr Rev 1997;1886- 94
PubMed Link to Article
Murphy  WFLangley  AL Common bullous lesions—presumably self-inflicted—occurring in utero in the newborn infant. Pediatrics 1963;321099- 1101
PubMed
Walker  NPJ Neonatal dermatology. Rennie  JMedRoberton  NRCedTextbook of Neonatology. 3rd ed Edinburgh, Scotland Churchill Livingstone1999;889- 902
Darmstadt  GLSidbury  R Diseases of the neonate. Behrman  REedKliegman  RMedJenson  HBedNelson Textbook of Pediatrics. 17th ed Philadelphia, Pa WB Saunders Co2004;2162- 2164
Libow  LFReinmann  JG Symmetrical erosions in a neonate: a case of neonatal sucking blisters. Cutis 1998;6216- 17
PubMed

Figures

Tables

References

Johr  RHSchachner  LA Neonatal dermatologic challenges. Pediatr Rev 1997;1886- 94
PubMed Link to Article
Murphy  WFLangley  AL Common bullous lesions—presumably self-inflicted—occurring in utero in the newborn infant. Pediatrics 1963;321099- 1101
PubMed
Walker  NPJ Neonatal dermatology. Rennie  JMedRoberton  NRCedTextbook of Neonatology. 3rd ed Edinburgh, Scotland Churchill Livingstone1999;889- 902
Darmstadt  GLSidbury  R Diseases of the neonate. Behrman  REedKliegman  RMedJenson  HBedNelson Textbook of Pediatrics. 17th ed Philadelphia, Pa WB Saunders Co2004;2162- 2164
Libow  LFReinmann  JG Symmetrical erosions in a neonate: a case of neonatal sucking blisters. Cutis 1998;6216- 17
PubMed

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles