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Erythema Toxicum Neonatorum Clinical Presentation

  • Author: Neil F Gibbs, MD; Chief Editor: William D James, MD  more...
 
Updated: Apr 12, 2016
 

History

When evaluating for erythema toxicum neonatorum (ETN), focus the history on age at onset of the eruption, absence of systemic signs (eg, fever, irritability, lethargy, mucocutaneous involvement), or maternal history of herpes simplex/varicella viral infection, bacterial pyoderma, or candidiasis.[15]

Infants with erythema toxicum neonatorum are otherwise healthy and lack systemic symptoms. The eruption is self-limited with most cases resolving within 5-14 days without residual sequelae. Recurrences are uncommon but have been reported up to the sixth week of life. They tend to be mild in severity.

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Physical

Focus the physical examination on location, size, and distribution of macules, wheals, papules, and pustules on the skin. Note the absence of mucosal, palmar, or plantar involvement (ie, non – hair-bearing skin). Signs of systemic toxicity, including hypothermia or hyperthermia, lethargy, and irritability, are not associated with erythema toxicum neonatorum.

Erythema toxicum neonatorum most commonly presents with a blotchy, evanescent, macular erythema, often on the face or trunk.

The macules are irregular, blanchable, and vary in size.

In more severe cases, pale yellow or white wheals or papules on an erythematous base may follow. In approximately 10% of patients, 2-4 mm pustules develop.

Numbers and distribution of lesions vary from a few and widely scattered to numerous and extensive.

Sites of predilection include the most commonly include the trunk, buttocks, and proximal limbs, but lesions may occur anywhere, including the genitalia.[16] Involvement of the mucous membranes and palms and soles rarely occurs.

See the images below.

A 5-day-old newborn with erythematous papules with A 5-day-old newborn with erythematous papules with surrounding indistinct blotchy erythema visible on the abdomen. Image courtesy of Jining I. Wang, MD.
Yellow pustules, some with evidence of rupture, in Yellow pustules, some with evidence of rupture, in a full-term infant at 6 hours of life.
Erythematous blotchy patches localized to the trun Erythematous blotchy patches localized to the trunk in a neonate.
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Causes

The cause of erythema toxicum neonatorum is unknown. Multiple theories have been proposed to explain this common disorder.

Neonates have an increased number of hair follicles compared with adults, and the occurrence of erythema toxicum neonatorum in non–hair-bearing areas such as palms and soles is rare. Inflammatory cells tend to concentrate around hair follicles, and coccilike microbes have been demonstrated in the follicular epithelium and inside the inflammatory cells. This suggests that erythema toxicum neonatorum may be a response to microbes that have penetrated the hair follicle. This process may possibly be integral in developing the new immune system.[17]

The high frequency of eosinophilia suggests an allergic basis, leading some authors to suggest that erythema toxicum neonatorum may be an immediate hypersensitivity reaction to a substance passed from the mother transplacentally; however, convincing support is lacking for this theory.[18]

No responsible exotoxin, allergen, component of sebum, or infectious agent has been linked credibly to erythema toxicum neonatorum.

Medications administered to newborns and the mode of feeding have no effect on incidence.

Other proposed theories include a transient adjustment reaction of the skin to mechanical or thermal stimulation or an acute graft-versus-host reaction induced by the maternal-fetal transfer of lymphocytes before or during delivery.[19] Analysis of skin samples of 2 male patients with erythema toxicum neonatorum did not support a graft-versus-host reaction because no maternal cells were found in the samples using fluorescence in situ hybridization identification of cells with 2 XX chromosomes.[20]

Risk factors include higher birth weight, greater gestational age, and vaginal delivery. A positive correlation has been recognized between the length of labor and both the incidence of erythema toxicum neonatorum and the duration of the cutaneous manifestations.[9, 21]

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Contributor Information and Disclosures
Author

Neil F Gibbs, MD Voluntary Associate Professor, Departments of Pediatrics and Medicine (Dermatology), University of California, San Diego School of Medicine; Residency Program Director, Pediatric Dermatologist, Department of Dermatology, Naval Medical Center, San Diego; Clinical Professor of Dermatology and Clinical Professor of Pediatrics (Secondary), Uniformed Services University of the Health Sciences, Bethesda, Maryland

Neil F Gibbs, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Society for Pediatric Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Meghan E Seago, MD Staff Dermatologist, US Naval Hospital Guam

Meghan E Seago, MD is a member of the following medical societies: American Academy of Dermatology, Massachusetts Medical Society, Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Van Perry, MD Assistant Professor, Department of Medicine, Division of Dermatology, University of Texas School of Medicine at San Antonio

Van Perry, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Eleanor E Sahn, MD Director, Division of Pediatric Dermatology, Associate Professor, Departments of Dermatology and Pediatrics, Medical University of South Carolina

Eleanor E Sahn, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Southern Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Trisha C Beute, MD Staff Physician, Department of Dermatology, Naval Medical Center, Portsmouth

Trisha C Beute, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Robert Huff, MD Dermatology, Inc

Robert Huff, MD is a member of the following medical societies: American Academy of Dermatology and Phi Beta Kappa

Disclosure: Nothing to disclose.

Eleanor E Sahn, MD Director, Division of Pediatric Dermatology, Associate Professor, Departments of Dermatology and Pediatrics, Medical University of South Carolina

Eleanor E Sahn, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and Southern Medical Association

Disclosure: Nothing to disclose.

References
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  2. Marchini G, Hultenby K, Nelson A, et al. Increased expression of HMGB-1 in the skin lesions of erythema toxicum. Pediatr Dermatol. 2007 Sep-Oct. 24(5):474-82. [Medline].

  3. Marchini G, Lindow S, Brismar H, et al. The newborn infant is protected by an innate antimicrobial barrier: peptide antibiotics are present in the skin and vernix caseosa. Br J Dermatol. 2002 Dec. 147(6):1127-34. [Medline].

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  16. Maffei FA, Michaels MG, Wald ER. An unusual presentation of erythema toxicum scrotal pustules present at birth. Arch Pediatr Adolesc Med. 1996 Jun. 150(6):649-50. [Medline].

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  19. Bassukas ID. Is erythema toxicum neonatorum a mild self-limited acute cutaneous graft-versus-host-reaction from maternal-to-fetal lymphocyte transfer?. Med Hypotheses. 1992 Aug. 38(4):334-8. [Medline].

  20. Droitcourt C, Khosrotehran K, Halaby E, Aractingi S. Maternal cells are not responsible [corrected] for erythema toxicum neonatorum [corrected]. Pediatr Dermatol. 2008 May-Jun. 25(3):411-3. [Medline].

  21. Monteagudo B, Labandeira J, Cabanillas M, Acevedo A, Toribio J. Prospective study of erythema toxicum neonatorum: epidemiology and predisposing factors. Pediatr Dermatol. 2012 Mar-Apr. 29(2):166-8. [Medline].

  22. Ferrandiz C, Coroleu W, Ribera M, Lorenzo JC, Natal A. Sterile transient neonatal pustulosis is a precocious form of erythema toxicum neonatorum. Dermatology. 1992. 185(1):18-22. [Medline].

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A 5-day-old newborn with erythematous papules with surrounding indistinct blotchy erythema visible on the abdomen. Image courtesy of Jining I. Wang, MD.
Yellow pustules, some with evidence of rupture, in a full-term infant at 6 hours of life.
Erythematous blotchy patches localized to the trunk in a neonate.
A Wright-Giemsa stain performed on the contents of a ruptured pustule reveal numerous eosinophils.
 
 
 
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