Diagnosis of Common, Benign

Neonatal Dermatoses
DANIEL WALLACH, MD

eonatal dermatology is a growing field of medical knowledge. Excellent, comprehensive reviews of this field have been published recently.1,2 This article deals with a number of benign,
cutaneous conditions that are frequently observed in
the newborn. These conditions are of no medical consequence; they have also been called nondiseases of the
newborn. It is, however, important to identify them
correctly to avoid parental concern as well as unnecessary diagnostic or therapeutic aggressive procedures.

Normal Neonatal Skin

Inasmuch as benign neonatal dermatoses may be considered variations from the normal, it is important to
describe in detail the appearance of the normal skin at
birth. The appearance of neonatal skin depends on the
maturity of the newborn. In full-term newborns (gestational age 37-40 weeks), the skin is pink or pink-light
brown in children of African ancestry. It is opaque, soft,
and velvety. In prematurs, the skin is thinner, lacking
the external keratinized layer, and may be gelatinous,
glistening, or translucent. In postterm newborns, desquamation is prominent.
The skin at birth is covered with a white, greasy
coating called vernix caseosa; it is abundant mainly in
infants born at full term. The vernix caseosa is mainly
made of lipids deriving from the epidermis and sebaceous secretions; it may cover the whole body or only
the back and skinfold areas. Vernix caseosa is thought
to represent a barrier between the fetal epidermis and
the amniotic fluid. The vernix caseosa dries out after a
few hours but is usually wiped out as routine neonatal
care; in case of fetal distress, the vernix is stained yellow
or brown by contact with the meconium.

Routine Skin Care of the Full-Term Newborn

Bathing in 37C water and gentle cleansing with clean
hands, using a nonmedicated, mild syndet bar or liquid
cleanser, is advisable.3,4 Massage of the skin with a
bland emollient is beneficial in prematures5; in full-term
From the Department of Dermatology, Hopital Tarnier-Cochin, Paris,
France.
Address correspondence to Daniel Wallach, MD, Department of Dermatology, Hopital Tarnier-Cochin, 89 rue dAssas, 75006 Paris, France.
E-mail address: dwallach@noos.fr
2003 by Elsevier Inc. All rights reserved.
360 Park Avenue South, New York, NY 10010

newborns, there is no medical reason to neither recommend nor forbid it. There are as yet no accepted guidelines for umbilical cord care. As a consequence, many
uncontrolled techniques are currently in use; cleansing
with an aqueous chlorhexidine solution appears to be
the best current recommendation.6
Regular use of disposable, absorbant diapers has
made diaper dermatitis much rarer than it was when
cloth diapers were used. Diapers must be changed as
often as necessary (about 10 times daily in a newborn),
as contact with the urine and feces is the main cause of
diaper dermatitis. In addition to gentle cleansing, application of a protective emollient or paste is useful as a
barrier to protect the skin in the diaper area. In case of
erythema, topical antifungals are often recommended
to prevent infection.

Physiologic Desquamation
Full-term newborns often exhibit a fine, diffuse scaling,
starting from the second day of life and lasting a few
days (Fig 1); this scaling may be reduced by the application of emollient creams. When intense, physiologic
desquamation may appear ichthyosiform, but the rare
neonatal ichthyoses are very different, exhibiting continuous scaling with an underlying erythematous skin.
In the peeling skin syndrome, large sheets of skin are
removed, and the condition is long-lasting.

Milia
Milia are tiny, epidermal inclusion cysts due to retention of keratin at the extremity of hair follicles; they
occur almost exclusively on the face, although at times
some may be seen on the genital areas. Milia may be
very numerous (Fig 2) but desquamate spontaneously,
and no intervention is indicated. Widespread or lasting
milia are part of rare developmental syndromes such as
orofacialdigital syndrome type I or Marie Unna hypotrichosis. Epsteins pearls are tiny, palatal cysts, similar
to milia.

Miliaria
Miliaria is the consequence of sweat retention in immature, impermeable eccrine ducts. Sweating in newborns
occurs only in term infants and must lead to the correction of excessive environmental temperature or re0738-081X/03/$see front matter
doi:10.1016/S0738-081X(03)00049-X

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2003;21:264 268

DIAGNOSIS OF COMMON BENIGN NEONATAL DERMATOSES

Figure 1. Physiologic desquamation in a newborn, gestational

age 40 weeks.

moval of clothing. Miliaria crystallina appears as tiny,

translucid vesicles; inflammation induces peripheral erythema, known as miliaria rubra (Fig 3); in case of
superinfection, miliaria becomes pustular.

Cutaneous Consequences of
hormonal transition
During the last weeks of gestation, the fetus receives
important hormonal influences from the mother and
the placenta. At birth, this influence ceases abruptly,
and this cessation transiently stimulates the neonatal
endocrine system. All this endocrine transition has
visible consequences on the skin.

265

Figure 3. Miliaria rubra.

sient hyperplasia seems to be unrelated to neonatal

acne.

Neonatal Acne
Neonatal acne is a consequence of transient neonatal
androgen excess; very rarely, it can be due to congenital
adrenal hyperplasia or to a gonadal or adrenal tumor.
Neonatal acne predominates on the cheeks. Although
papules, pustules, and small nodules may be more
visible, the specific lesion is the comedo (Fig 5). Except
in a few instances, neonatal acne resolves in few weeks;
topical antimicrobial therapy is usually prescribed.

Sebaceous Gland Hyperplasia

As a consequence of the influence of maternal androgens, the sebaceous glands on the nose and central face
are often enlarged, and the openings of the follicles
appear as pinpoint, yellowish papules (Fig 4). This tran-

Figure 2. Numerous milia.

Figure 4. Hyperplasia of the sebaceous glands of the nose.

Clinics in Dermatology

266 WALLACH

Figure 5. Acne neonatorum.

Pseudopuberty of the Newborn

This transient consequence of stimulation by sexual
hormones is seen in both sexes. In girls, one may see
hyperpigmentation of the linea alba and of the external
genitalia; edema of the labia majora; vaginal discharge,
usually whitish, rarely hemorrhagic (pseudomenses);
and hypertrophy of the mammary glands, with the
possibility of a milky secretion for a few days. Mastitis
and abscess can occur, especially in cases of inadequate
manipulation. In boys, genitalia may similarly appear
to be of abnormally large size during the neonatal
period.

Figure 6. Physiologic cutis marmorata.

2003;21:264 268

Figure 7. Erythema toxicum.

Consequences of Vascular Immaturity

The change from the intra-amniotic to the aerial environment implies dramatic modifications in vasomotor
tone; some instability of the cutaneous vascularization
in the neonatal period may be visible.

Normal Skin Color

Many pathologic conditions may alter skin color: circulatory or respiratory distress, anemia, polycythemia,
jaundice, and so forth. In the absence of any of these
conditions, normal skin color at birth is associated with

Figure 8. A florid pustulosis due to Malassezia on the face of a

healthy newborn. Topical antifungal therapy led to complete cure
in 3 days.

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central erythema and peripheral cyanosis. Ethnic pigmentation is usually delayed.

Cutis Marmorata
Cutis marmorata (mottled skin) is a normal reaction to
cold in newborns, and it disappears with warming (Fig
6). Physiologic neonatal cutis marmorata must be differentiated from cutis marmorata telangiectatica congenita.7 In this rare vascular anomaly, mottling of the
skin is more marked, permanent, and associated with
areas of atrophy, ulceration, and other lesions. Systemic
malformations and mental retardation are rarely associated.

DIAGNOSIS OF COMMON BENIGN NEONATAL DERMATOSES

267

other neonatal pustuloses (Fig 8). The almost unique

location is the face (cheeks, forehead), but occasional
lesions may be seen on the neck, nape, or chest. The
main differential diagnosis is neonatal acne, but in this
condition, comedones are always present and lesions
are more durable. It is likely that many cases diagnosed
as neonatal acne were in fact Malassezia-induced pustulosis, also called neonatal cephalic pustulosis. Direct
microscopic examination shows Malassezia furfur, and
topical antifungals clear the eruption in a few days. The
spontaneous course is not known but is thought to be
self-limited.

Hair and Nail Conditions

Harlequin Color Change

Lanugo

The difference in skin coloration between the upper and

lower half of body may be seen during episodes lasting
a few minutes; it is the most spectacular manifestation
of neonatal vascular immaturity. Its observation is limited to the first days of life.

Lanugo is a vellus, unpigmented body hair. It is mainly

abundant in prematures (28-30 weeks gestational age);
the importance of lanugo is not predictive of later body
hair, which depends mainly on familial and ethnic patterns.

Erythema Toxicum

Scalp Hair Growth

Erythema toxicum is the most common of all neonatal

dermatoses. Its pathogenesis is unknown, and the word
toxicum does not indicate any toxicity. Erythema
toxicum occurs in about half of term neonates, and only
atypical forms attract dermatologic attention. It is not
present at birth, begins after the first day of life, and
usually lasts about 1 week. The lesions predominate on
the trunk and proximal parts of the limbs; they are
typically large (1-3 cm), erythematous macules and
papules; the center of the lesion is more elevated than
the periphery and at times, may be marked by a small
vesicle or even a pustule (Fig 7). Some lesions are
purely vesicular or pustular, lacking the erythematous
component. In these cases, one may need confirmation
of the diagnosis by showing the eosinophilic content of
the liquid lesions on Tzancks smear. There is also a
blood hypereosinophilia, the signification of which is
unknown.
Transient neonatal pustular melanosis, which is
more frequent in black newborns, is considered a variant of erythema toxicum,8 with hyperpigmented sequelar macules lasting for some weeks.

Most newborns have abundant terminal scalp hair; the

normal cycle of individual growth and fall is not yet
established, and synchronized telogen effluvium may
occur during the first months of life, followed by normal regrowth. A transient, occipital alopecia is frequent; it is probably favored by repeated rubbing on the
bed.

Neonatal Cephalic
(Malassezia-Induced) Pustulosis
A benign facial neonatal pustulosis induced by Malassezia species has recently been described9 and is probably
not rare.10 Malassezia-induced neonatal pustulosis usually starts between the ages of 7 and 30 days. It appears
as numerous, small, erythematous pustules on erythematous bases and in fact is clinically different from

Nails
The length of nails at birth is one of the indicators of the
duration of gestation, and postterm babies have long
nails. Newborn nails are usually small and soft, mainly
on the toes, and the surrounding skin may cover the
nails edges (pseudoingrown toenails). Except in cases
of scratching, nails must not be cut and in no instance
cut too short.

Nodular Fat Necrosis

Idiopathic panniculitis, known as nodular fat necrosis
of the newborn, is seen after difficult labor and delivery,
especially when the baby has suffered from hypoxia
and hypothermia; it also occurs in the absence of any
identifiable cause. Lesions are usually located on the
upper part of the posterior trunk. The buttocks, arms,
and legs may also be involved. Lesions are palpable as
subcutaneous, indurated masses; the overlying skin is
usually red. The main differential diagnosis is neonatal
sclerema, a diffuse induration of the skin occurring in
severely ill neonates. In contrast, babies with nodular
fat necrosis remain in good health. Nodular fat necrosis
heals in a few weeks; hypercalcemia has been reported

268 WALLACH

and must be prevented and monitored. Infection is very

rare.

References
1. Wagner AM, Hansen RC. Neonatal skin and skin disorders. In: Schachner LA, Hansen RC, editors. Pediatric
dermatology, 2nd edition. New York: Churchill Livingstone, 1995:236 46.
2. Eichenfield LF, Frieden IJ, Esterly NB. Textbook of neonatal dermatology. Philadelphia: Saunders, 2001.
3. Siegfried EC. Neonatal skin and skin care. Dermatol Clin
1998;16:43746.
4. Liou LW, Janniger CK. Skin care of the normal newborn.
Cutis 1997;59:1714.
5. Hoath SB, Narendran V. Adhesives and emollients in the
preterm infant. Semin Neonatol 2000;5:289 96.

Clinics in Dermatology

2003;21:264 268

6. Verber IG, Pagan FS. What cord care, if any? Arch Dis
Child 1993;68:594 6.
7. Picascia DD, Esterly NB. Cutis marmorata telangiectatica
congenita: report of 22 cases. J Am Acad Dermatol 1989;
20:1098 104.
8. Ferrandiz C, Coroleu W, Ribera M, et al. Sterile transient neonatal pustulosis is a precocious form of erythema toxicum neonatorum. Dermatology 1992;185:18
22.
9. Aractingi S, Cadranel S, Reygagne P, Wallach D. Pustulose ne o-natale induite par Malassezia furfur. Ann Dermatol Ve ne re ol 1991;118:856 8.
10. Bernier V, Weill FX, Hirigoyen V, et al. Skin colonization
by Malassezia species in neonates: a prospective study and
relationship with neonatal cephalic pustulosis. Arch Dermatol 2002;138:2158.