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Dermatology
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How to manage and treat
facial rashes in newborns
Managing facial rashes in infants often requires no more than accurate
diagnosis and maternal reassurance that the condition is self-limiting
In the first couple of months after birth, many mothers have concerns about their baby’s skin. Facial rashes
frequently cause confusion for doctors because of similarities in their presentation. The diagnostic dilemma is further
compounded by the lack of training physicians receive in
newborn dermatology, the lack of relevant publications and
the lack of consensus on the management of newborn facial
rashes. Facial rashes can undermine the mother’s confidence in their doctor if not properly dealt with initially.
Doctors need to be confident in their skill at accurate
diagnosis and assured that the advice they give mothers
is supported by evidence-based guidelines, which take
into consideration the uniqueness of newborn skin conditions and the sensitivity of newborn skin to chemicals and
irritants.
A survey on the management of newborn facial rashes,
which included several clinical scenarios, conducted
through the Rotunda Hospital, 1 highlighted several key
points:
• Paediatricians do not feel they received adequate training
in the management of newborn facial rashes. However,
they are confident in their own abilities, presumably
having ‘picked it up’ as they went along
• Despite this confidence, even with the most basic rashes,
the most common or most likely rash is frequently not
being diagnosed
• Paediatricians are reasonably good at treating newborn
facial rashes, but there is a worrying trend towards treating benign rashes with steroid creams.
The majority of facial skin conditions presenting in the
newborn period are self-limiting and require nothing more
than accurate diagnosis and maternal reassurance that the
condition is harmless and will resolve without treatment,
though often the disease course can by shortened by appropriate management.
When presented with a newborn facial rash, the key is,
when possible, to make the diagnosis and decide whether
or not treatment is required. There is a wide differential
diagnosis to be considered, from common newborn facial
rashes to some very rare metabolic, nutritional and immunodeficiency syndromes, which may present similarly.
Diagnosis is aided by the characteristic appearance of many
common rashes, age at onset and natural history. However
recognition of the rarer causes of facial rashes is important,
as some may be life-threatening.
The skin in the newborn comprises 13% of the total body
weight, compared to 3% in an adult. The skin primarily acts
as a barrier preventing water loss and protecting the body
from adverse external factors. It regulates body temperature
and has immunological function, mediated by Langerhans
cells. Through the action of UV radiation in sunlight the
skin produces vitamin D and also excretes waste material
in sweat.
Newborn skin differs from adult skin in many respects.
Newborn skin is more delicate, and therefore more susceptible to irritation and allergic reaction. As it matures
over the first six months of life, it undergoes many physiological changes; however, pathological changes can occur
due to toxic exposure resulting in dermatitis and other skin
eruptions.
The stratum corneum is the most superficial layer of the
epidermis, and consists of dead, keratinized, flat interdigitating cells which act as the skin’s major barrier. For the
first few days after birth the stratum corneum is still in the
process of adapting to extra-uterine life.
Alterations take place in its hydration and pH, which
makes newborn skin more permeable than adult skin to
substances such as drugs and chemicals. The larger surface
area to body ratio also increases absorption and potential
toxicity of topically applied substances such as drugs and
chemicals.2
As the stratum corneum hydration is significantly lower in
the newborn than in adults, newborns are more prone to dry
skin, which is a common problem.
Milia
• A etiology: Milia
are tiny, epidermal
inclusion cysts
caused by retention of keratin in
the hair follicle
• Frequency: Up to
Figure 1. Milia
50% of newborns
may be affected
• Age at onset: It occurs in the first few days of life
• Clinical features: They appear as pearly white to yellow
dome-shaped lesions measuring 1-2mm in diameter
• Distribution: Classically they occur on the chin, nose,
forehead and cheeks, although they may occur on the
upper trunk, limbs, penis, or mucus membranes3
• T reatment: They resolve without treatment, but may
persist for two to three months. All that is required is
diagnosis and maternal reassurance that the condition is
benign and self-limiting.
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Dermatology
Miliaria or ‘heat rash’
• Aetiology: Miliaria
is due to sweat retention caused by partial
closure of eccrine
structures. Four types
of miliaria have been
described; Miliaria
Figure 2. Miliaria or ‘heat rash’
Crystallinia, Miliaria
Rubra, Miliaria Pustulosa and Miliaria Profunda. The level of obstruction within
the eccrine ducts distinguishes the types
• Frequency: Miliaria occurs in up to 40% of infants, with
miliaria crystalline and miliaria rubra being the most
common4
• Age at onset: Miliaria presents in the first month of life
• Clinical features: Miliaria crystalline consists of 1-2mm
clear, thin walled vesicles, often described as ‘dewdrops’,
which rupture easily, without surrounding erythema. Miliaria rubra or ‘prickly heat’ presents as tiny scaly 1-3mm
erythematous papules or vesicles, which cause pruritus
• Distribution: Miliaria crystallina commonly affects the
head, neck and trunk, and has a predilection for intertriginous areas. Miliaria rubra usually affects the forehead,
upper trunk, flexural areas and areas covered by clothing5
• Treatment and natural history: Miliaria resolves without
treatment within a few hours to days. It is often misdiagnosed as atopic dermatitis and emollient use can then
make the condition worse. Prevention is by ensuring that
babies are not overheated, so that excessive sweating
does not occur, and by ensuring that emollients are not
applied excessively.
Neonatal acne
• Aetiology: Traditionally, the development
of neonatal acne has
been attributed to
the trans-placental
passage of maternal androgenic
Figure 3. Neonatal acne
hormones. Research
is now indicating an
association with the malassezia species (fungus)6
• Frequency: Neonatal acne is reported to occur in up to
20% of newborns7
• Age at onset: Neonatal acne usually occurs within a few
weeks of birth
• Distribution: It occurs predominantly on the cheeks, but
can also on chin, nose and forehead
• Clinical features: It presents as open and closed comedones, (similar to teenage acne) inflammatory papules,
and pustules
• Treatment and natural history: Most cases resolve spontaneously without scarring, within weeks to months; however it
may take up to six months to resolve. Treatment generally is
not indicated. We recommend washing the face daily with
silcox base diluted with water, then washing the silcox base
off well with water. In severe cases, some paediatric dermatologists are now recommending 2% ketoconazole cream
twice daily for one week, as an alternative to 1% hydrocortisone. However, there are no controlled trials to support the
efficacy of treatment. If acne is unresolving, severe, and
other signs of hyperandrogenism are present, physicians
should investigate for possible adrenal cortical hyperplasia,
virilising tumours, or underlying endocrinopathies.7
Erythema toxicum
• A e t i o l o g y : T h e
cause is unknown,
although many
theories have been
postulated. These
include; a reaction to stimulation;
either mechanical
Figure 4. Erythema toxicum
or thermal and possible obstruction of the pilosebaceous orifice
• Frequency: Erythema toxicum is the commonest pustular skin rash in neonates, with an estimated incidence of
between 40-70%.8 It is rare in preterm infants
• Age at onset: The rash presents in the first two days of life
• Clinical features: The rash presents as papules, pustules
and blotchy erythema, which is often described as having
a ‘flea bitten’ appearance9
• Distribution: Classically, it spares the palms and soles and
is usually seen on the face, trunk and proximal extremities. The distinctive feature of erythema toxicum is the
waxing and waning appearance of the rash
• Diagnosis: The diagnosis can be confirmed by demonstrating a high eosinophil count in the lesions, but this is
usually unnecessary
• Treatment and natural history: No treatment is required,
only maternal reassurance. The rash usually fades within
a week, but may rarely recur for several weeks.
Infantile seborrhoeic
dermatitis
• Aetiology: The exact
aetiology of seborrhoeic dermatitis
(ISD) is unknown.
It is thought to
be multifactorial;
Figure 5. Infantile seborrhoeic dermatitis
with immune, hormonal, infectious
(Malassezia furfur) and nutritional factors being theorised
• Frequency: ISD commonly occurs in newborns; however
the exact incidence is unknown
• Age at onset: It usually occurs in the first month of life
• Clinical features: Infantile seborrhoeic dermatitis is characterised by erythematous greasy yellow scales
• Distribution: When it affects the scalp, it is referred to
as ‘‘Cradle cap’’; however, it may extend diffusely on the
forehead, face, ears, flexural folds, or the nappy area, but
never affect the hands or feet10
• Differential diagnosis: Seborrhoeic dermatitis is commonly
misdiagnosed as atopic dermatitis or contact dermatitis.
Yates et al found the most useful features in distinguishing atopic dermatitis from ISD were the presence of
lesions on the forearms and shins in atopic dermatitis
and in the axilla in ISD11
• Treatment and natural history: Infantile seborrhoeic dermatitis clears spontaneously in weeks to months. For
cosmetic reasons, ISD affecting the scalp can be treated
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by using a soft brush to remove the scales after shampooing. We recommend using olive oil twice weekly to soften
the scales prior to washing with a mild baby shampoo.
If ISD persists despite the above treatment, anti-seborrhoeic shampoos can be used. These can be either
antifungal (ketoconazole), keratolytic (salicylic acid) or
antiproliferative (tar). Ketoconazole 2% shampoos have
the best preliminary safety data and are therefore recommended. For the treatment of severe ISD affecting areas
other than the scalp, we recommend washing with silcox
base diluted with water, and then washing off the silcox
base with just water. Traditionally, steroids have been
prescribed for more severe cases; however, there are still
concerns regarding their potential for systemic absorption and side-effects associated with prolonged use. Many
authors are now supporting the use of ketoconazole as an
alternative to steroid creams. A meta-analysis published
by Cohen et al showed that ketoconazole was at least as
effective as steroids for the treatment of seborrhoeic dermatitis and possibly better at preventing recurrence.12
Infantile atopic
dermatitis
• Aetiology: Atopic
dermatitis is a chronic
inflammatory skin
disease, the exact
aetiology of which is
unknown, although
Figure 6. Infantile atopic dermatitis
environmental and
genetic factors may
predispose to the condition13
• Frequency: Atopic dermatitis affects 5-20% of children
worldwide
• Age at onset: The rash commonly begins at 2-3 months of
age, with 58% commencing before one year of age
• Clinical features: Dry skin, pruritus, erythematous, scaly,
crusted or excoriated areas of skin
• Distribution: Commonly it occurs on the extensor surfaces
and cheeks, forehead or scalp. The rash usually spares
the nappy area14
• Treatment and natural history: Atopic dermatitis responds
well to emollient treatment, which moisturizes the skin
and prevents dryness. Emollients are most effective when
applied immediately after bathing. Trigger factors such as
soaps and detergents should be identified and avoided.
During a flare, a mid-potency steroid ointment can be
applied twice daily (for three to seven days) after bathing
(in addition to usual emollient use). The least potent formulation is hydrocortisone 1% cream. Atopic dermatitis
will clear in 90% of patients by six years of age.15
Neonatal pustular
melanosis
• Frequency: Neonatal pustular
melanosis affects 5%
of black infants and
0.1 to 0.3% of white
infants
Figure 7. Neonatal pustular melanosis
• Age at onset:
Present at birth
• Clinical features: It presents as non-erythematous ves-
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Dermatology
icopustular lesions, which rupture easily, forming a
pigmented macule surrounded by a characteristic collarette of white scales16
• Distribution: The disorder commonly affects the chin,
neck, upper chest and abdomen.
• Differential diagnosis: The main differentials to consider
in the diagnosis are erythema toxicum, impetigo and
herpes simplex. If there is any doubt about the diagnosis
a gram stain should always be taken
• Treatment and natural history: No treatment is required
other than maternal reassurance. The macule classically
fades in three to four weeks.
Newborn skin care
The NICE postnatal care guidelines published in 2006
failed to identify any research studies which addressed general care of the skin of the newborn infant apart from nappy
rash.17 With such an increasing number of newborn skin
care products available on the Irish market, it is important
that paediatricians and GPs have an awareness of the products available; the potential problems they may cause; and
which of them they should recommend.
Newborn products are among the top one hundred products purchased in Ireland. There are literally hundreds of
baby skin care products being purchased daily. However,
not all the available skin care products may be safe, beneficial or even indicated in the care of newborn skin.
The majority of facial skin conditions occurring in the first
two months of life are self-limiting, and rarely require the
use of any products or drugs unless severe, and if treatment
is recommended or prescribed this should be evidencebased. Most newborn skin does not require any treatment.
However, certain skin conditions, including dry skin, may
require the use of emollients, barrier creams or rarely, prescription medication.
Conclusion
Facial rashes are a common occurrence in the first two
months of life. The majority of conditions are self-limiting,
benign and require nothing more than accurate diagnosis
and maternal reassurance.
There is an abundance of newborn skin care products
available; however when it comes to the care of newborn
skin ‘less is definitely more’, and any products used should
be mild and pH neutral, such as E45 cream and aqueous cream. There is no evidence that expensive proprietary
emollients are better than cheap generic emollients.
As physicians we need to be confident in our skills at
accurate diagnosis and management of newborn facial
rashes, and have an understanding of the degree of maternal anxiety which any blemish on a baby’s skin may cause.
While most rashes are benign, with accurate diagnosis and
appropriate management, the course of the disease can
often be shortened, parental anxiety alleviated, and most
importantly exposure to incorrect and unnecessary treatment can be prevented.
Authors: Michelle McEvoy is a paediatric SpR in Our Lady
of Lourdes Hospital, Drogheda; Brian Walsh is a neonatal
research fellow at the Dept of Paediatrics and Child Health,
UCC; and Tom Clarke is a consultant neonatologist at the
Rotunda Hospital, Dublin
References on request
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