AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab 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

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

No specific therapy is indicated.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

No medication is necessary.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal 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

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• 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. 8^th ed. Philadelphia, Pa: Lippincott-Raven; 1997:237.
• Dinulos JG, Graham EA. Influence of culture and pigment on skin conditions in children. Pediatr Rev. Aug 1998;19(8):268-75. [Medline].
• 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].
• Mengesha YM, Bennett ML. Pustular skin disorders: diagnosis and treatment. Am J Clin Dermatol. 2002;3(6):389-400. [Medline].
• Ramamurthy RS, Reveri M, Esterly NB, Fretzin DF, Pildes RS. Transient neonatal pustular melanosis. J Pediatr. May 1976;88(5):831-5. [Medline].
• St John EB. Neonatal Pustular Melanosis. eMedicine from WebMD [serial online]. March 28, 2006;Available at http://www.emedicine.com/ped/topic698.htm.
• 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.
• Treadwell PA. Dermatoses in newborns. Am Fam Physician. Aug 1997;56(2):443-50. [Medline].
• 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].

Article Last Updated: Sep 6, 2007