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Pediatric Erythema Toxicum

  • Author: Elizabeth Arrington, MD; Chief Editor: Dirk M Elston, MD  more...
Updated: Nov 04, 2014


Erythema toxicum neonatorum (ETN) is a benign, self-limited, asymptomatic skin condition that only occurs during the neonatal period.[1, 2] The eruption is characterized by small, erythematous papules, vesicles, and, occasionally, pustules. The lesions are usually surrounded by a distinctive diffuse, blotchy, erythematous halo. Individual lesions are transitory, often disappearing within hours and then appearing elsewhere on the body. See the image 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.

See 13 Common-to-Rare Infant Skin Conditions, a Critical Images slideshow, to help identify rashes, birthmarks, and other skin conditions encountered in infants.



The underlying pathophysiology is uncertain. Although the initial description of toxic erythema of the newborn is attributed to the 15th century physician Bartholomaeus Metlinger, this neonatal cutaneous eruption was recognized before the time of ancient Mesopotamia.[3] Ancient Mesopotamian physicians believed this eruption to be "nature's method of cleansing the child of impure blood of the mother." In A Treatise on the Theory and Practice of Midwifery, the 18th century English physician William Smellie attributed the condition to "the costiveness of the child when the meconium hath not been sufficiently purged off."

The characteristic presence of eosinophils within the lesions has led some investigators to attribute this condition to an allergy. Work by Eitzman and Smith suggested that eosinophilia is part of the normal spectrum of the nonspecific inflammatory response in the neonate.[4] This hypothesis is supported by cases in which premature neonates have infrequent eruptions that resolve within a few weeks after birth when the neonatal immune response matures.

The etiology of erythema toxicum neonatorum remains uncertain; however, more recent hypotheses explaining the appearance of this eruption include the following:

  • Relative, increased, ground-substance viscosity in neonatal skin, with associated trauma leading to eosinophilic inflammation
  • Self-limited, acute, cutaneous, graft-versus-host reaction caused by maternal lymphocytes in the relatively immunosuppressed fetal circulation [5]
  • An innate immunologic response to commensal microbes within hair follicle epithelium
  • An inflammatory response mediated by various inflammatory mediators, including aquaporins, psoriasin, nitric oxide synthases



United States

The condition affects 30-70% of newborns.[6] Carr and associates studied 270 newborns and found an incidence of 48%.[7] Keitel and Yadav studied 207 consecutive newborns and found an incidence of 62%.[8]


Incidence is 25.3% in Spain, 33.7% in Taiwan, and 20.6% in India.


This is a benign, asymptomatic, self-limited skin condition with no known sequelae.


No significant differences based on race are apparent. A study by Saracli and associates documented a low incidence among black neonates; however, this may be caused by the relative difficulty of diagnosing neonates with darker skin.[9] Other sets of observations have noted no racial difference in incidence.


In previous studies, no significant difference in incidence is noted between the sexes. However, a study from China indicated a statistically significant predilection in boys.[10]


This condition is limited to the neonatal period. In a study of 270 cases, the typical newborn with erythema toxicum neonatorum was of average birth weight and born at term.[7] Of the newborns affected, 88% weighed 2500 g or more. In addition, 98% were born at least 35 weeks' gestation, with 85% born at least 39 weeks' gestation.

Contributor Information and Disclosures

Elizabeth Arrington, MD Resident Physician, Department of Dermatology, University of South Florida College of Medicine

Elizabeth Arrington, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.


Neil Alan Fenske, MD Chairman, Department of Dermatology and Cutaneous Surgery, Professor, Department of Dermatology and Cutaneous Surgery, Department of Pathology and Cell Biology, Department of Oncologic Sciences, Medical Director, Health Cosmetic and Laser Center, University of South Florida College of Medicine

Disclosure: Received none from Abbvie for speaking and teaching; Received none from Valeant for speaking and teaching.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

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

Disclosure: Nothing to disclose.

Additional Contributors

Kevin P Connelly, DO Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University School of Medicine; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center

Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, American Osteopathic Association

Disclosure: Nothing to disclose.

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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.
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