Medscape is available in 5 Language Editions – Choose your Edition here.


Neonatal Pustular Melanosis Clinical Presentation

  • Author: Robert A Silverman, MD; Chief Editor: Dirk M Elston, MD  more...
Updated: Nov 04, 2014


The primary lesions in neonatal pustular melanosis progress through 3 stages of development. Initially, they appear as rather uniform round 2-mm to 4-mm nonerythematous pustules. They are not clear vesicles; rather, they contain milky, purulent exudate. The pustules rupture easily. They are frequently missed because they are superficial and are usually wiped off easily in the delivery suite when the newborn is cleansed of vernix. Pustules on the thicker areas of skin such as the knees or palms may persist for several days.[3, 4]

Next, a delicate collarette of thin white scale is left around the perimeter of each denuded pustule. Near-term infants, especially those delivered by cesarean delivery, may exhibit just the unbroken pustules, and term infants may have only macules remaining, usually with the telltale collarette of flaking epidermis.

Lastly, within hours of exposure to the terrestrial environment, the central pigmented brown macule becomes apparent. The macules are round, have smooth and distinct borders, and are frequently confused for freckles. They may be profuse or sparse and typically are found under the chin and on the neck, upper chest, back, and buttocks. Occasionally, the palms, soles, and scalp are affected.

When considering suspected neonatal pustular melanosis, the following should also be considered:

  • Erythema toxicum neonatorum: These lesions are small papules on an erythematous base, contain predominantly eosinophils, and do not heal with postinflammatory hyperpigmentation.
  • Congenital cutaneous candidiasis: The pustules are usually very inflamed and contain organisms on laboratory smear or biopsy.
  • Impetigo: Pustules are inflamed and contain organisms on laboratory smear and culture.
  • Congenital Langherhans cell histiocytosis: Widely distributed papules and pustules form adherent crusts, not frecklelike macules.
  • Congenital varicella: Pustules are larger, numerous, generalized, and widely dispersed in the setting of an ill neonate with unstable vital signs.
  • Miliaria: This characterized by clear vesicles (crystallina) or pustules (pustulosa) that erupt in a setting of hyperthermia.
  • Herpes simplex: Lesions begin as vesicles, become turbid, and develop into pustules. The vesicles are grouped or clustered and contain multinucleated giant cells.
  • Milia: This is characterized by firm, white, superficial, pin-head–sized papulelike cysts filled with keratin debris.
  • Acropustulosis: The pustules predominate on the palms and soles and are not present at birth.


The etiology is unknown. Some reports have described cases that evolved into erythema toxicum neonatorum;[5] however, in the author’s opinion, the disorders may coexist and are clinically distinct entities.

Contributor Information and Disclosures

Robert A Silverman, MD Clinical Associate Professor, Department of Pediatrics, Georgetown University Medical Center

Robert A Silverman, MD is a member of the following medical societies: American Academy of Dermatology, Society for Pediatric Dermatology

Disclosure: Nothing to disclose.

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.


The authors and editors at Medscape Reference gratefully acknowledge the contributions of previous author Elaine B St John, MD, to the original writing and development of this article.

  1. Eichenfield LF, Frieden IJ, Esterly NB, eds. Neonatal Dermatology. 2nd ed. Philadelphia, Pa: Saunders Elsevier; 2008. 142.

  2. O'Connor NR, McLaughlin MR, Ham P. Newborn skin: Part I. Common rashes. Am Fam Physician. 2008 Jan 1. 77(1):47-52. [Medline].

  3. Chia PS, Leung C, Hsu YL, Lo CY. An infant with transient neonatal pustular melanosis presenting as pustules. Pediatr Neonatol. 2010 Dec. 51(6):356-8. [Medline].

  4. Goyal T, Varshney A, Bakshi SK. Incidence of Vesicobullous and Erosive Disorders of Neonates: Where and How Much to Worry?. Indian J Pediatr. 2011 Oct 25. [Medline].

  5. Morgan AJ, Steen CJ, Schwartz RA, Janniger CK. Erythema toxicum neonatorum revisited. Cutis. 2009 Jan. 83(1):13-6. [Medline].

  6. Farnaroff AA, Martin RJ, eds. The skin. Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant. 5th ed. St. Louis, Mo: Mosby-Year Book; 1992. 1333-4.

  7. 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].

  8. Merlob P, Metzker A, Reisner SH. Transient neonatal pustular melanosis. Am J Dis Child. 1982 Jun. 136(6):521-2. [Medline].

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

Ruptured pustules and vesicles with remaining characteristic collarette of scale and brown hyperpigmented macules. Courtesy of Anthony J. Mancini, MD.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.