Erythema Toxicum Neonatorum 

  • Author: Neil F Gibbs, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jan 24, 2012
 

Background

Erythema toxicum neonatorum (ETN) is a benign self-limited eruption occurring primarily in healthy newborns in the early neonatal period. Erythema toxicum neonatorum is characterized by macular erythema, papules, vesicles, and pustules, and it resolves without permanent sequelae.[1] Also see the eMedicine Pediatrics article, Erythema Toxicum.

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Pathophysiology

Increased levels of immunological and inflammatory mediators (eg, interleukins 1 and 8, eotaxin, the adhesion molecule E-selectin, the water-channel proteins aquaphorin 1 and aquaphorin 3, the chemotactic factor psoriasin, high-mobility group box chromosomal protein 1, nitric oxide and its isoforms, the antimicrobial peptide LL-37) suggest that erythema toxicum neonatorum may be an immune system reaction.[2, 3, 4] The location of erythema toxicum neonatorum to primarily hair-bearing areas suggests that the hair follicle may be involved. Additionally, the number of mast cells is increased around hair follicles in involved skin.[5]

The eosinophilic infiltrate of erythema toxicum neonatorum suggests an allergic- or hypersensitivity-related etiology, but no allergens have been identified. Newborn skin appears to respond to any injury with an eosinophilic infiltrate. Because erythema toxicum neonatorum is rarely seen in premature infants, it is believed that mature newborn skin is required to produce this reaction pattern.[6]

Contactants and mechanical irritation have been considered and rejected as etiologies.

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Epidemiology

Frequency

International

Erythema toxicum neonatorum occurs in one third to one half of full-term infants and in 5% of premature infants.

Mortality/Morbidity

Erythema toxicum neonatorum is a self-limited eruption that resolves spontaneously. Although one study found that infants with erythema toxicum neonatorum had an increased risk of atopy,[7] subsequent studies have failed to support this finding.

Race

No racial or ethnic predisposition is known.

Sex

The prevalence is higher in males (55%) than in females (30%),[8] except among females born of first pregnancies, who have a higher rate than males of first pregnancies.

Age

  • Erythema toxicum neonatorum presents within the first 4 days of life in full-term infants, with the peak onset occurring within the first 48 hours following birth. Rare cases have been reported at birth.[9, 10]
  • Incidence rises with increasing gestational age and birth weight.
  • Delayed onset rarely may occur in full-term and preterm infants up to age 14 days.[11, 12]
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Contributor Information and Disclosures
Author

Neil F Gibbs, MD  Voluntary Associate Professor, Departments of Pediatrics and Medicine, University of California, San Diego School of Medicine; Program Director, Pediatric Dermatologist, Department of Dermatology, Naval Medical Center, San Diego

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

Disclosure: Nothing to disclose.

Coauthor(s)

Robert Huff, MD, Dermatology, Inc 

Robert Huff, MD, Dermatology, Inc 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.

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.

Specialty Editor Board

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.

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

Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and 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 and American Society for Laser Medicine and Surgery

Disclosure: Nothing to disclose.

Joel M Gelfand, MD, MSCE  Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania

Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology

Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds Investigator; Genentech Grant/research funds investigator; Centocor Consulting fee Consulting; Abbott Grant/research funds investigator; Abbott Consulting fee Consulting; Novartis investigator; Pfizer Grant/research funds investigator; Celgene Consulting fee DMC Chair; NIAMS and NHLBI Grant/research funds investigator

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous Chief Editor, William D. James, MD, to the development and writing of this article.

References

  1. Schwartz RA, Janniger CK. Erythema toxicum neonatorum. Cutis. Aug 1996;58(2):153-5. [Medline].

  2. Marchini G, Hultenby K, Nelson A, et al. Increased expression of HMGB-1 in the skin lesions of erythema toxicum. Pediatr Dermatol. Sep-Oct 2007;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. Dec 2002;147(6):1127-34. [Medline].

  4. Marchini G, Stabi B, Kankes K, Lonne-Rahm S, Ostergaard M, Nielsen S. AQP1 and AQP3, psoriasin, and nitric oxide synthases 1-3 are inflammatory mediators in erythema toxicum neonatorum. Pediatr Dermatol. Sep-Oct 2003;20(5):377-84. [Medline].

  5. Nelson A, Ulfgren AK, Edner J, Stabi B, Brismar H, Hultenby K. Urticaria Neonatorum: accumulation of tryptase-expressing mast cells in the skin lesions of newborns with Erythema Toxicum. Pediatr Allergy Immunol. Dec 2007;18(8):652-8. [Medline].

  6. Carr JA, Hodgman JE, Freedman RI, Levan NE. Relationship between toxic erythema and infant maturity. Am J Dis Child. Aug 1966;112(2):129-34. [Medline].

  7. Singh M, Arora NK, Sroa HS. Urticaria neonatorum--an earliest marker of atopy. Indian J Med Res. Feb 1980;71:273-7. [Medline].

  8. Liu C, Feng J, Qu R, et al. Epidemiologic study of the predisposing factors in erythema toxicum neonatorum. Dermatology. 2005;210(4):269-72. [Medline].

  9. Levy HL, Cothran F. Erythema toxicum neonatorum present at birth. Am J Dis Child. Apr 1962;103:617-9. [Medline].

  10. Marino LJ. Toxic erythema present at birth. Arch Dermatol. Oct 1965;92(4):402-3. [Medline].

  11. Akoglu G, Ersoy Evans S, Akca T, Sahin S. An unusual presentation of erythema toxicum neonatorum: delayed onset in a preterm infant. Pediatr Dermatol. May-Jun 2006;23(3):301-2. [Medline].

  12. Chang MW, Jiang SB, Orlow SJ. Atypical erythema toxicum neonatorum of delayed onset in a term infant. Pediatr Dermatol. Mar-Apr 1999;16(2):137-41. [Medline].

  13. Monteagudo B, Labandeira J, Cabanillas M, Acevedo A, Toribio J. Prospective Study of Erythema Toxicum Neonatorum: Epidemiology and Predisposing Factors. Pediatr Dermatol. Nov 8 2011;[Medline].

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

  15. Marchini G, Nelson A, Edner J, Lonne-Rahm S, Stavreus-Evers A, Hultenby K. Erythema toxicum neonatorum is an innate immune response to commensal microbes penetrated into the skin of the newborn infant. Pediatr Res. Sep 2005;58(3):613-6. [Medline].

  16. Keitel HG, Yadav V. Etiology of toxic erythema. Erythema toxicum neonatorum. Am J Dis Child. Sep 1963;106:306-9. [Medline].

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

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

  19. 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].

  20. Van Praag MC, Van Rooij RW, Folkers E, Spritzer R, Menke HE, Oranje AP. Diagnosis and treatment of pustular disorders in the neonate. Pediatr Dermatol. Mar-Apr 1997;14(2):131-43. [Medline].

  21. Freeman RG, Spiller R, Knox JM. Histopathology of erythema toxicum neonatorum. Arch Dermatol. Oct 1960;82:586-9. [Medline].

  22. Luders D. Histologic observations in erythema toxicum neonatorum. Pediatrics. Aug 1960;26:219-24. [Medline].

  23. Marchini G, Ulfgren AK, Lore K, Stabi B, Berggren V, Lonne-Rahm S. Erythema toxicum neonatorum: an immunohistochemical analysis. Pediatr Dermatol. May-Jun 2001;18(3):177-87. [Medline].

 
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