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in toxic epidermal necrolysis: a retrospective analysis of 64 patients managed
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CHAPTER 69 ■ RASH: NEONATAL
ADITI S. MURTHY

INTRODUCTION
Rashes are common in the neonatal period and can cause significant parental
distress. The ability to distinguish worrisome rashes from those that are benign is
of critical importance. To provide a schema for understanding rashes in the
neonate, it can be helpful to divide the rashes into categories: pustules, vesicles,
patches/plaques, hamartomas, and dyspigmentation. Within these categories,
there are signs and symptoms that push the clinician to be more or less concerned.

PUSTULAR ERUPTIONS

Pustular rashes in neonates are common and can be caused by inflammation (such
as in erythema toxicum and transient neonatal melanosis) or infections (yeast,
bacteria like Staphylococcus aureus, and, rarely, herpes simplex virus [please see
vesicular neonatal rashes below for full discussion of herpes simplex]). The goal
of recognition is to spare healthy infants with benign pustular eruptions extensive
workups and not to miss those with more serious pustular eruptions.

Neonatal Acne
Neonatal acne is a fairly common papular and pustular eruption of the forehead
and face ( Fig. 69.1 ). The etiology is possibly due to overgrowth of commensal
yeasts. Treatment is not always necessary as this can be self-limited. Neonatal
acne distinguished from true “acne” in the sense that unlike infantile or
adolescent acne there are no comedones or scarring lesions.

Erythema Toxicum Neonatorum
Erythema toxicum neonatorum (ETN) is usually evident within the first 48 hours
of life. The rash typically has mixed features with erythema, wheals, papules, and
pustules ( Fig. 69.2 ). This transient rash resolves spontaneously without sequelae
over the course of 1 to 2 weeks. Histologically, ETN shows an abundance of
eosinophils. Etiology is unclear. One prospective study of 1,000 neonates
suggested that risk factors include higher birth weight, greater gestational age,
vaginal delivery, maternal age <30 years, and fewer than two previous
pregnancies. Culture and Gram stain looking for eosinophils can help distinguish
from bacterial infection.


Transient Neonatal Pustular Melanosis
Transient Neonatal Pustular Melanosis or TNPM is usually present at delivery.
TNPM is characterized by small pustules (0.3 to 0.5 cm) on a nonerythematous
base. These pustules rupture easily, and pigmented macules develop with

surrounding collarettes of scales that may persist for weeks to months. The
pustules are mostly located over the forehead, neck, and lower back, but
occasionally, palms and soles may be involved ( Fig. 69.3 ). No systemic
manifestations have been reported.

Staphylococcal Pustulosis
If a neonate presents after 48 hours of life with new pustules, it is important to
consider infection with staphylococcus or candida. Staphylococcal pustulosis is
relatively common and can occur in the setting of infection of the umbilicus or
circumcision site. Community-acquired S. aureus is common, and a history of
staph infection in close contacts may aid in diagnosis. Simple bacterial swabs are
the primary diagnostic tool. Pustules on the lower abdomen and in the diaper area
are common. A small number of pustules, in an otherwise healthy neonate, can
often be treated with oral and/or topical antibiotics. Providers should look for
peeling in the folds of the skin and very red or hot skin because this can be a sign
of staphylococcal scalded skin ( Fig. 69.4 ).

Neonatal Candida
Congenital candidiasis usually presents within 12 hours of birth as redness on the
affected area and then later with pustules with desquamation. Candida albicans
and Candida psiloparis are the most common causes of neonatal candida
infections. In full-term healthy infants, congenital candida can often be treated
topically and is usually not a worrisome infection. In preterm infants, or other
medically complex infants, candida can be invasive and can cause late-onset
neonatal sepsis. Therefore, in the appropriate setting, blood cultures, urine
cultures, evaluation of the CSF, ophthalmologic examination, echocardiogram,
renal ultrasound, and systemic antifungal therapy are needed.

Candidal Diaper Dermatitis
See Chapter 66 Rash: Bacterial and Fungal Infections/Rash: Maculopapular .

Candidal diaper dermatitis is the most characteristic of the diaper rashes (see
below for a more detailed discussion of diaper dermatitis). The skin in the diaper
area has clusters of erythematous papules and pustules that coalesce into an
intensely red confluent rash with sharp borders ( Fig. 69.5 ). Beyond these


borders frequently are “satellite” papules and pustules. At times, the infant has
concomitant oral thrush.

Infantile Acropustulosis
Infantile acropustulosis is a recurrent, self-limited, vesiculopustular disorder
affecting young children ( Fig. 69.6 ). It presents with itchy, deep-seated pustules
or vesicles on the palms and soles. Most cases occur after scabies infestation and
this condition can wax and wane for years. Scraping for scabies mites should be
performed and treatment initiated for scabies if mites are found. Therapy is
midpotency topical steroids.

FIGURE 69.1 Neonatal acne red pustules and papules are most prominent over the cheeks and
nose of some normal newborns. (Reprinted with permission from Goodheart H. A Photoguide
of Common Skin Disorders . Baltimore: Williams & Wilkins; 1999.)

VESICULAR ERUPTIONS
Neonatal Herpes Simplex Virus Infections
Neonatal herpes simplex virus infection causes significant morbidity and
mortality if not recognized and treated promptly (see Chapter 73 SepticAppearing Infant ). Neonatal HSV is most commonly acquired in the peripartum
period (85%) but can also be acquired in the postnatal period (10%) or in utero
(5%). For peripartum or postnatally acquired infections, the extent of disease can