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Transient Neonatal Pustular Melanosis

Britt A Durham, MD, Co-Director of Risk Management, Assistant Professor, Department of Emergency Medicine, King-Drew Trauma Center and University of California at Los Angeles
Anne Laumann, MB, BCh, MRCP, FAAD, Associate Professor, Department of Dermatology, Feinberg School of Medicine, Northwestern University

Updated: Sep 6, 2007

Introduction

Background

Neonatal skin lesions are common and are frequent concerns for parents; therefore, recognition of the clinical diagnosis is important in order to reassure the family. Transient neonatal pustular melanosis is a benign skin condition with distinctive features characterized by vesicles, superficial pustules, and pigmented macules. The lesions are commonly present at birth and are most likely to appear on the chin, neck, forehead, chest, and back. Although less common, lesions may be seen on the palms and soles. The vesicles and pustules usually resolve within 48 hours, while the brown macules may persist for several months.

Frequency

United States

The rate of transient neonatal pustular melanosis is estimated to be 0.1-0.35% in white infants and 4-5% in black infants. The overall rate has been reported to be as high as 2.2%.

Mortality/Morbidity

Transient neonatal pustular melanosis is a benign, asymptomatic, and self-limiting skin eruption with no associated mortality or morbidity. Although melanotic macules usually resolve over several months, hyperpigmentation may be a rare long-term sequela.

Race

Transient neonatal pustular melanosis occurs in as many as 5% of African American newborns and in less than 0.4% of white infants.

Sex

This condition occurs equally in both sexes.

Age

Transient neonatal pustular melanosis is present at birth. Later phases of the rash may be visible for several months.

Clinical

History

  • Often, only pigmented macules are present at birth, in which case the pustular phase may have occurred in utero. Skin findings can be correlated with gestational age at birth. Postterm infants are more likely to have pigmented macules.
  • No systemic symptoms are associated with the skin lesions.

Physical

Transient neonatal pustular melanosis is characterized by vesicles, superficial pustules, and pigmented macules.

  • Because of the fragile nature of the superficial pustules, most of them are broken in the initial drying or cleansing of newborns.
    • Intact lesions may remain in more protected areas such as beneath the chin, in the axillae, or in the groin.
    • The vesicles and pustules may desquamate with the neonate's first bath, leaving a white collarette of scale and brownish macules.
    • Therefore, depending on the time of the examination in the neonatal period, the vesicles, pustules, and pigmented macules may be found predominantly on the chin, neck, or forehead; behind the ears; or on the trunk, palms, and soles.
  • The lesions are 2-10 mm in diameter. Vesicular eruptions are usually 2-4 mm and are often filled with milky fluid.
  • No systemic signs are associated with the skin eruptions.
  • Papules are not seen in transient neonatal pustular melanosis, but they may be seen in neonates with erythema toxicum neonatorium, acne neonatorum, or miliaria. The vesiculopustular lesions may be similar to lesions seen in acropustulosis. However, patients with acropustulosis have lesions that cluster on the palms and soles.

Causes

  • The etiology is unknown.
  • No familial predisposition has been identified.

Differential Diagnoses

Acropustulosis of Infancy
Mongolian Spot
Erythema Toxicum Neonatorum
Syphilis
Herpes Simplex
Milia
Miliaria

Other Problems to Be Considered

Acne neonatorum
Congenital candidiasis
Impetigo neonatorum
Erythema toxicum
Staphylococcal infection
Ofuji syndrome
Neonatal varicella
Mongolian spots: These are bluish-black macular patches on the back and lumbosacral area; they are more common in dark-skinned babies than in light-skinned babies.

Workup

Laboratory Studies

  • The diagnosis is usually made at clinical examination.
  • A Tzanck smear may be performed. With a cellular stain (eg, Wright-Giemsa stain), a Tzanck smear reveals a predominance of neutrophils without evidence of bacteria, yeast, or viropathic changes.
  • Gram stain preparations for bacteria are negative.
  • Blood and skin culture results are negative.

Histologic Findings

Vesicles and pustules show intracorneal and subcorneal collections of neutrophils with some eosinophils and, occasionally, fragmented hairs. The dermis has an infiltrate of neutrophils and scattered eosinophils. The brown macules show epidermal basal cell melanosis.

Treatment

Medical Care

No specific therapy is indicated.

Medication

No medication is necessary.

Follow-up

Deterrence/Prevention

Contagious isolation is unnecessary.

Prognosis

The prognosis for this benign condition is good. The vesicles and pustules usually resolve within 48 hours, while the brown macules may persist for several months.

Patient Education

Reassure the parents that this is a benign, self-limiting condition.

Miscellaneous

Medicolegal Pitfalls

Failure to recognize and distinguish this condition from other neonatal pustular and vesicular dermatoses with more serious systemic implications is a pitfall. Congenital herpes is the differential diagnosis that represents the greatest threat of a poor outcome. Because pustules can be a manifestation of sepsis, it is important to consider infectious etiologies in neonates.

References

  1. Cohen L, Skopicki D, Harrist T, Clark Jr W. Noninfectious vesiculobullous and vesiculopustular diseases. In: Elder D, Elenitsasis R, Jaworsky C, Johnson Jr B, eds. Lever's Histopathology. 8th ed. Philadelphia, Pa: Lippincott-Raven; 1997:237.

  2. Dinulos JG, Graham EA. Influence of culture and pigment on skin conditions in children. Pediatr Rev. Aug 1998;19(8):268-75. [Medline].

  3. Ferrándiz 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].

  4. Mengesha YM, Bennett ML. Pustular skin disorders: diagnosis and treatment. Am J Clin Dermatol. 2002;3(6):389-400. [Medline].

  5. Ramamurthy RS, Reveri M, Esterly NB, Fretzin DF, Pildes RS. Transient neonatal pustular melanosis. J Pediatr. May 1976;88(5):831-5. [Medline].

  6. St John EB. Neonatal Pustular Melanosis. eMedicine from WebMD [serial online]. March 28, 2006;Available at http://www.emedicine.com/ped/topic698.htm.

  7. Ta A, Sandler B. Common transient neonatal dermatoses. In: Harper J, Oranje A, Prose N, eds. Textbook of Pediatric Dermatology. London, England: Blackwell Science; 2000:59-61.

  8. Treadwell PA. Dermatoses in newborns. Am Fam Physician. Aug 1997;56(2):443-50. [Medline].

  9. van Emmen E, Roord ST, Brouwer AF, Kuiters GR, Bekhof J. [Pustular and vesicular skin eruptions in newborns]. Ned Tijdschr Geneeskd. Feb 3 2007;151(5):277-83. [Medline].

Keywords

vesicles, superficial pustules, pigmented macules, neonatal skin conditions, neonatal dermatoses

Contributor Information and Disclosures

Author

Britt A Durham, MD, Co-Director of Risk Management, Assistant Professor, Department of Emergency Medicine, King-Drew Trauma Center and University of California at Los Angeles
Britt A Durham, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Anne Laumann, MB, BCh, MRCP, FAAD, Associate Professor, Department of Dermatology, Feinberg School of Medicine, Northwestern University
Anne Laumann, MB, BCh, MRCP, FAAD is a member of the following medical societies: American Academy of Dermatology, Chicago Dermatological Society, Chicago Medical Society, Illinois Dermatological Society, Illinois State Medical Society, Illinois State Medical Society, Medical Dermatology Society, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Medical Editor

James Fulton Jr, MD, PhD, Medical Director, Fulton Skin Institute
James Fulton Jr, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Cosmetic Surgery, American Academy of Dermatology, Phi Beta Kappa, and Sigma Xi
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
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.

Managing Editor

Van Perry, MD, Assistant Professor, Department of Medicine, Division of Dermatology, University of Texas Health Science Center
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.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System
William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology
Disclosure: elsevier Royalty Other

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