124 Continuing Medical Education

s
Benign skin disease with pustules in the newborn*
Flávia Pereira Reginatto1 Damie De Villa2
Tania Ferreira Cestari1

DOI: http://dx.doi.org/10.1590/abd1806-4841.20164285

Abstract: The neonatal period comprises the first four weeks of life. It is a period of adaptation where the skin
often presents several changes: transient lesions, resulting from a physiological response, others as a consequence
of transient diseases and some as markers of severe disorders. The presence of pustules in the skin of the new-
born is always a reason for the family and for the assisting doctor to be worried, since the newborn is especially
vulnerable to bacterial, viral or fungal infection. However, the majority of neonatal skin pustules is not infectious,
comprising the benign neonatal pustulosis. Benign neonatal pustuloses are a group of clinical disease character-
ized by pustular eruptions in which a contagious agent is not responsible for its etiology. The most common ones
are erythema toxicum neonatorum, the transient neonatal pustular melanosis and the benign cephalic pustulosis.
These dermatoses are usually benign, asymptomatic and self-limited. It is important that the dermatologist and
the neonatologist can identify benign and transient lesions, those caused by genodermatoses, and especially dif-
ferentiate between neonates with systemic involvement from those with benign skin lesions, avoiding unneces-
sary diagnostic tests and worries.
Keywords: infant, newborn; Infant, newborn, diseases; Skin diseases; Neonatology; Skin abnormalities; Skin
manifestations

INTRODUCTION Benign neonatal pustulosis (BNP) are a set of

The neonatal period extends from birth to the clinical conditions characterized by transient pustular
first four weeks of life. 1 It is a time of adaptation where rash on the newborn skin. These are thus designated
the newborn usually has various dermatological find- because they are asymptomatic and self-limiting. They
ings: temporary lesions, some as a result of a physi- include sterile pustulosis, such as erythema toxicum
ological response or transient diseases, and others as neonatorum (ETN) and transient neonatal pustular
markers of serious diseases.2-4 The presence of pus- melanosis (TNPM), in which no infectious agent can
tules or vesico-pustular lesion in newborns is always be implied in its etiology; and benign cephalic pustu-
motive of concern to the family and to the attending losis (BCP) which, according to some authors, may be
physician, since at this age children are especially vul- related to the presence of Malassezia. 5 Other benign
nerable to bacterial, viral or fungal infections.5 Some- dermatological findings that may present pustules
times these lesions represent a diagnostic challenge during the neonatal period are: miliaria pustulosa;
because they may be due to a number of diseases with miliaria rubra (MR), which under occlusion areas may
variable prognostics, so it is important to differentiate present vesicles with pustular appearance; infantile
between benign and transient pustular eruptions from acropustulosis and eosinophilic folliculitis.
serious cases requiring hospitalization.6

Received on 04.12.2014.
Approved by the Advisory Board and accepted for publication on 03.03.2015.
* Study performed at Programa de Pós-Graduação em Saúde da Criança e Adolescente da Universidade Federal do Rio Grande do Sul – Hospital de Clínicas
de Porto Alegre (UFRGS-HCPA), Complexo Hospitalar Santa Casa de Misericórdia de Porto Alegre e Hospital Fêmina - Grupo Hospitalar Conceição – Porto
Alegre (RS), Brazil.
Financial Support: Incentive Fund for Research and Development of HCPA - FIPE.
Conflicts of Interest: None.
1
Universidade Federal do Rio Grande do Sul (UFRGS) – Porto Alegre (RS), Brazil.
2
Santa Casa de Misericórdia de Porto Alegre – Porto Alegre (RS), Brazil.

©2016 by Anais Brasileiros de Dermatologia

An Bras Dermatol. 2016;91(2):124-34.

Benign skin disease with pustules in the newborn 125

NEWBORN SKIN
Newborn (NB) skin is often characterized as scraping and staining by Gram method can identify
delicate and fragile.7 Functional differences between the presence of Gram positive bacteria such as Staphy-
the newborn and adult skin may be attributed to dif- lococcus and Streptococcus, and less frequently, Gram
ferences in skin microstructure.8 Besides being 40-60% negative; moreover, it helps to identify the cellular
thinner than adult skin, newborn skin has a higher composition of the inflammatory infiltrate when pres-
transepidermal water loss and delay in sudoral re- ent. 12 Direct examination of scales clarified with potas-
sponse, believed to be due to the immaturity of the sium hydroxide allows identifying fungal elements,
sympathetic system.2 In neonatal period the skin plays
an important role as a regulator of temperature and as
a barrier against skin infections. The cutis of the new- Table 1: Neonatal dermatoses that occur
born is also more likely to develop certain dermatoses with pustules
such as irritant contact dermatitis, when compared Neonatal dermatoses that occur with pustules
with adult skin. 3,7 Infectious causes
The barrier function of human skin begins to a) Bacterial:
develop in utero with the stratification of the epider- – Bullous impetigo (Staphylococcus aureus)
mis during the first trimester of pregnancy, and it is – Folliculitis (Staphylococcus aureus, Streptococcus,
believed to be complete by 34 weeks of gestation. 3,9 negative Gram bacteria)
The formation of vernix caseosa in the third quarter – Ecthyma (Staphylococcus aureus)
contributes to the final stage of maturation of the epi- – Ecthyma gangrenosum (Pseudomona aeruginosa)
dermal barrier. 3 Despite the epidermal barrier function – Congenital syphilis (Treponema pallidum)
by baseline permeability being established at birth, in- b) Viral
creased risk of infections, dermatitis and percutaneous – Neonatal herpes simplex (herpes simplex virus)
absorption of toxic agents can indicate an incomplete – Congenital herpes (intrauterine infection by herpes
maturation in early neonatal period. 10 simplex virus)
– Neonatal varicella (varicella zoster virus)
NEONATAL SKIN PUSTULES – Cytomegalic inclusion disease (Cytomegalovirus)
Dermatoses that can present pustules during – Congenital Epstein-Barr virus syndrome (Ep-
the neonatal period can be divided into two major stein-Barr virus)
groups: infectious and non-infectious or sterile. 2 It is c) Fungal
important that the neonatologist and the dermatolo- – Congenital candidiasis (Candida albicans, C. glabrata)
gist know how to identify benign and transient lesions – Neonatal candidiasis (Candida albicans, C.parapsilosis)
and, mainly, to differentiate newborns with systemic – Pityrosporum folliculitis (Malassezia sp.)
involvement from those in which the dermatosis is re- d) Parasites
stricted to skin. 6,11 – Scabies (Sarcoptes scabiei)
Table 1 lists the major skin diseases in the
neonatal period that presents pustules and its usual Non-infectious causes
pathogens. a) Miliaria pustulosa or profunda
In most cases, BNP are transient, and caused by b) Transient benign neonatal pustules
environmental factors, or occur as a physiological skin - Erythema toxicum neonatorum (ETN)
response.6 Diagnosis of BNP is clinical, but in atypical - Transient neonatal pustular melanosis (TNPM)
cases it may be necessary to use methods of investiga- c) Infantile acropustulosis
tion with complementary tests, preferably non-inva- d) Benign cephalic pustulosis (BCP) including neonatal
sive, and that are useful in differentiating benign and acne
transient pustules from serious cases requiring hospi- f) Pigmentary incontinence
talization. g) Neonatal Langerhans cell histiocytosis
Facing the newborn with pustules, maternal h) Transient myeloproliferative disease in patients with
diseases should be discarded, such as vulvovaginal Down syndrome
candidiasis, genital herpes, syphilis and scabies. Der- i) Eosinophilic pustular folliculitis in childhood
matological examination of the newborn should eval- j) Eosinophilic papular-pustular rash of Hyper IgE syn-
uate the distribution and morphology of lesions, the drome
time when the skin lesions appeared and how they k) Eeosinophilic pustulosis
evolved. It is important to discard the signs of system- l) Neonatal Behcet’s disease
ic disease in newborns as fever or hepatosplenomeg- m) Neonatal pustular psoriasis
aly. Realization of the direct examination of the lesion

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126 Reginatto FP, De Villa D, Cestari TF

which is useful for the detection of dermatophytosis Erythema toxicum neonatorum:

and other infections caused by Malassezia or Candi- Erythema toxicum neonatorum (ETN) is con-
da spp. The cytodiagnosis of Tzank informs about the sidered an inflammatory reaction of the skin and is
presence of multinucleated cells and inclusion bodies also called allergic neonatal erythema or neonatal er-
suggestive of herpes infection. Direct examination of ythema. 13 It is characterized by erythematous papules
lesion scraping can identify mites such as Sarcoptes and sterile pustules surrounded by an erythematous
scabiei. These procedures are generally sufficient to halo measuring approximately 1 to 2 cm affecting the
identify an infectious process; in the case of persistent trunk, the extremities and face of the NB (Figures 1
doubt, syphilis serology, culture of pustules’ contents and 2). Lesions usually appear on the second day of
or skin biopsy should be performed. 5 life and regress in 5 to 14 days, but atypical setting
may have a later onset. 14-16
BENIGN SKIN PUSTULOSES IN NEONA- ETN occurs in about 16% of NB. 17 In a multi-
TAL PERIOD center study with 2878 newborns, performed in a capi-
The main lesions described as typical of the tal in the Southern region of Brazil, ETN was observed
neonatal period include erythema toxicum neona- in 21% of the NB. 18
torum (ETN), transient neonatal pustular melanosis ETN is most commonly observed in male new-
(TNPM) and benign cephalic pustulosis (BCP). These borns. 13,18 It also tends to be more prevalent in full-
are a benign, self-limited, asymptomatic skin diseases term compared with preterm newborns; in NB who
that occur in the first days of life. In rare cases, miliaria are born during the spring months; in NB with good
rubra can present pustules, mainly in the areas of fric- health - characterized by the Apgar score in the first
tion, or even progress to miliaria pustulosa in the skin minute of life greater than 8, and in the children born
of the newborn. of mothers with no gestational risk factors. 18,19

A
B

C D

Figure 1: Erythema toxic neonatorum. A: ETN lesions on the trunk and limbs of a full-term newborn. B: Detail of the lesion: pustule surrounded
by an erythematous halo of appoximatelly 2 cm on the thigh side. C: Pustules affecting the back of the upper limbs D: Involvement of the face

An Bras Dermatol. 2016;91(2):124-34.

Benign skin disease with pustules in the newborn 127

ETN was reported by some authors as being Although the etiology of ETN is still consid-
more frequent in newborns delivered by cesarean, ered unknown, some studies have shown activation
while other authors affirm that it is more common in of the immune response in the lesions, suggesting
vaginal delivery, and a study conducted in the South- that this setting may correspond to an inflammatory
ern region of Brazil observed no difference between reaction of the skin to microbial colonization occured
types of delivery. 13,18,20,21 It was also described as being at birth.17,26,27 It was also shown the activation of the
more prevalent in children of multiparous mothers by immune system through the identification of inflam-
some authors and with no difference between the type matory mediators aquaporin-1 (AQP1), aquaporin-3
of delivery by others. 18,21 (AQP3), psoriasin and nitric oxide synthase (NOS) by
There are cases of ETN predominantly pustular, immunohistochemistry in ETN lesions. 28
but they are uncommon. In such cases there is a tendency Among the children with allergy manifestation
to use some synonyms, such as transient neonatal pustu- during the first two years, 84.2% had ETN or low skin
losis, pustular ETN and atypical ETN (Figure 2). 22,23 pH at birth, and atopic dermatitis was diagnosed in
The cytological examination of pustule reveals 85.7% of the NB who presented the pustulosis. 29 The
the presence of numerous eosinophils. Histopatho- description of ETN in siblings raises the possibility
logical changes include subcorneal pustule; dense that common environmental and genetic factors may
inflammatory infiltrate mainly near the hair follicles, also influence its development. 23
comprising numerous dendritic cells, eosinophils,
neutrophils and macrophages. High expression of Transient neonatal pustular melanosis:
E-selectin molecule was demonstrated, as well as Transient neonatal pustular melanosis (TNPM)
pro-inflammatory cytokines IL-1α and IL-1β, IL-8 is characterized by flaccid and superficial pustules,
chemokine and eotaxin. 24,25 which disrupt easily forming a collarette of scales, and

A B C

Figure 2:
Erythema tox-
icum neonato-
rum (ETN).
A and B: Lesion
characteristic of
ETN: pustule
surrounded by
an erythema-
tous halo.
C and D: ETN
D pustulosis

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128 Reginatto FP, De Villa D, Cestari TF

thus progressing to residual hyperpigmented macules of ETN.5,14 In addition, it is often difficult to establish a
of residual character (Figures 3 and 4). 30 All areas of the clear distinction between the two diseases, which has
body can be affected, including palms, soles and genita- raised the idea that the same unknown trigger factor
lia. Lesions are usually present at birth. (Figure 3) would cause initially different settings when it affects
TNPM is more prevalent in African-American the skin of the fetus (TNPM) or of the NB (ETN). Be-
NB, occurring in about 5% of black NB and in only 0.2% cause of the difficulty in differentiating the clinical and
of whites. 31 A study conducted in maternity hospitals in histopathological limit of both diseases, Ferrandiz et al
Porto Alegre showed a prevalence of 3.4%. 18 proposed the term sterile transient neonatal pustulosis
TNPM affects both sexes with the same frequen- to unify ETN and TNPM. 5
cy.6,18 Cytological examination of the pustules show
polymorphonuclear neutrophils. So far the etiological Benign cephalic pustulosis:
mechanisms of TNPM are not clear. It is likely that Benign cephalic pustulosis (BCP) was described
TNPM corresponds to a variance of ETN, as there are in 1991 by Aractingi. It is a relatively common benign
described cases in which the same NB presents clinical disease with prevalence estimated between 10% and
and histological findings of ETN and TNPM, and oth- 66% in the neonatal period, and it presents a benign
er cases in which clinical findings are characteristic of and self-limited course. 5,12,32 This dermatosis is char-
TNPM, but the histology shows findings characteristic acterized by multiple inflammatory papules and pus-
tules on the face and scalp that usually begin between
5 days and 3 weeks of age (Figure 5 and 6). 2 The di-
rect examination of smear of pustule, clarified with
potassium hydroxide, can show mycotic elements and
culture can show Malassezia synpodialis, and less fre-
quently M. furfur or M. globosa. 12 A study conducted
in Turkey with 104 newborns showed that colonization
by Malassezia increases significantly with days of life
of the NB with BCP (5% in the first week, 30% between
the second and fourth week of life). However, this cor-
relation between neonatal cephalic pustulosis and col-
onization by Malassezia is not well established.33

Miliaria:
Miliaria is a common condition in newborns
and is more observed during the summer months, fe-
brile periods or in NB with excess clothing.2 The most
Figure 3: Transient neonatal pustular melanosis. Hyperchromic common is miliaria crystalline (MC), which is charac-
macules present at birth terized by small vesicles over healthy skin, especially

Scaling

Pustules
hyperchromic
macules

Figure 5:
Benign ce-
phalic pus-
tulosis. Er-
ythematous
papules and
pustules on
the face of a
Figure 4: Transient neonatal pustular melanosis (TNPM). Presence newborn with
of pustules, hyperchromic macules and scaling in newborn with 24 three weeks
hours of life of life

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Benign skin disease with pustules in the newborn 129

face, neck and trunk (Figures 7 and 8). Miliaria rubra in the epidermis. MR is characterized by numerous
(MR) is caused by obstruction of eccrine sweat gland erythematous papules or grouped pruritic papular
duct, slightly deeper than MC, with sweat retention vesicles, and when they are in areas under occlusion
they can have a pustular aspect (Figure 8). 11 Rarely
MR can progress to deep miliaria or miliaria pustulo-
sa (MP), caused by a deeper obstruction of the eccrine
gland duct and characterized by the presence of pus-
tules (Figure 8). 32 MR lesions usually begin after the
second week of life and predominate in the trunk and
in intertriginous areas where occlusion by clothing is
Figure 6: accentuated. In hot environments lesions on the scalp,
Benign ce- face and neck may appear.5 It is the only pustular erup-
phalic pustu-
tion of NB where most cells observed in cytology are
losis (BCP).
Erythematous lymphocytes.5 A recent analytical study of pustular
papules and eruptions in newborns showed that Staphylococcus
pustules on aureus was isolated in 29.4% of cases of MP. 6 Diagno-
the face
sis of miliaria is clinical. Lesions may resolve without
intervention, but there is a proven benefit in lowering
the environment temperature, thus reducing the NB
transpiration.32

UNUSUAL CAUSES OF NEONATAL PUS-

TULOSIS
The differential diagnosis of neonatal benign
Figure 7: pustulosis (NBP) is performed with the infantile acro-
Miliaria crys- pustulosis (IA), eosinophilic pustular folliculitis (EPF)
tallina. Mi-
crovesicles
and scabies, which are dermatosis that present as pru-
affecting the ritic vesicopustules, most common in infants, but that
forehead of a have been reported in the neonatal period.5
newborn

A B

Figure 8: Miliaria. A: Miliaria

crystallina: microvesicles in the
neck and chest of a newborn.
B and D: Miliaria pustulosa:
pustules on the axillary region
of a newborn. C: Miliaria rubra:
erythematous papules on the
C D trunk of an newborn

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130 Reginatto FP, De Villa D, Cestari TF

Infantile acropustulosis: neutrophils of perifollicular distribution on the scalp,

Infantile acropustulosis (IA) is characterized by and perivascular distribution on the skin. Blood count
the recurrent appearance of very pruritic vesicopus- shows leukocytosis and eosinophilia in 70% of cases. 32
tules, with palmar and plantar predominance, but that
can affect the back of the hands, feet, ankles, wrists Scabies
and scalp.5 It usually appears between the first 2 and Scabies is an infectious disease that occurs when
12 months of life, with eruptions that last between 7 the parasite Sarcoptes scabei invades the stratum corne-
to 14 days, interspersed with periods of a few weeks um. It can affect the newborn if contamination occurs
of remission, and it is rare in the neonatal period. The soon after birth. The clinical pattern of scabies in NB is
cytological examination of the lesions shows predom- different from that observed in infants, older children
inance of neutrophils and histopathological exam- and adults. In the newborn, vesicles are a frequent
ination demonstrates the presence of intraepidermal finding and there is a tendency to form pustules on
pustules with polymorphonuclear neutrophils and the initial course of the infestation.11 Irritability, poor
eosinophils. Scabies is its main differential diagnosis.34 eating and little weight gain are also characteristic.

Eosinophilic pustular folliculitis: CONCLUSION

Eosinophilic pustular folliculitis (EPF) usually Pustulous settings are common in newborns
affects infants between 5 and 10 months of life.35 It is and can be related to infections or benign skin dis-
characterized by polymorphous eruption with very eases. It is important that the benign pustulosis of the
pruritic vesicopustules that coalesce forming exuda- neonatal period, such as erythema toxicum neonato-
tive and crusted plates located mainly on the scalp and rum, transient neonatal pustular melanosis, benign
less often on the face and extremities.5 Eruptions are cephalic pustulosis and miliaria are recognized from
intermittent, lasting from one to four weeks, self-lim- the clinical setting, in order to avoid unnecessary pro-
ited, disappearing in several months to a few years. cedures.q
Microscopy shows infiltrates with eosinophils and

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How to cite this article: Reginatto FP, De Villa D, Cestari TF. Benign skin disease with pustules in the newborn. An
Bras Dermatol. 2016;91(2):124-34.

An Bras Dermatol. 2016;91(2):124-34.

132 Reginatto FP, De Villa D, Cestari TF

Questions
s
1) Facing the newborn with pustules, some maternal dis- with adult skin, but these cannot be attributed to dif-
eases should be discarded, such as: ferences in the microstructure of the skin.
a) Vulvovaginal candidiasis and syphilis c) Besides being 40% to 60% thinner than an adult’s skin,
b) Genital herpes the NB skin presents lower transepidermal water loss
c) Scabies and delay in sweat response.
d) All of the above d) The newborn skin has a higher transepidermal water
loss and delay in sweat response.
2) Regarding additional tests required in the case of diag-
nostic uncertainty in newborns with skin pustule, check 5) Regarding the maturation of intrauterine human skin is
the incorrect alternative: correct to say:
a) Direct examination of scales clarification with potassi- a) The barrier function of human skin starts to develop in
um hydroxide allows identify fungal elements and is utero with the stratification of the epidermis during the
useful for the detection of dermatophytosis and other second trimester and is incomplete at birth, in the full-
fungal infections by Malassezia or Candida spp genres. term.
b) The Tzanck smear informs about the presence of mul- b) The barrier function of human skin begins to develop
tinucleated cells and inclusion bodies is suggestive of in utero with the stratification of the epidermis during
herpes infection. the first trimester of pregnancy and it is believed to be
c) Skin biopsy is the first examination to be performed, complete by 34 weeks of gestation.
and it is essential in the presence of pustules on the skin c) The formation of vernix caseosa occurs in the second
of the newborn. trimester and contributes to the final stage of matura-
d) In specific cases, syphilis serology, culture of the blisters tion of the epidermal barrier.
content or skin biopsy should be performed. d) As the epidermal barrier function by baseline perme-
ability is not complete at birth, there is a high risk of
3) What is the main supplementary examination to be per- infections, dermatitis and percutaneous absorption of
formed in atypical cases of neonatal benign pustuloses toxic agents.
(NBP) and its respective finding?
a) Tzanck smear, which informs about the presence of 6) What are the most common pustulosis in the neonatal
multinucleated cells and inclusion bodies suggestive period?
of herpes infection, in erythema toxicum neonatorum a) T
 he erythema toxicum neonatorum, the transient neo-
shows a predominance of eosinophils, and in transient natal pustular melanosis and the benign cephalic pus-
neonatal pustular melanosis, a predominance of neu- tulosis.
trophils. b) The erythema toxicum neonatorum, the miliaria rubra
b) Skin biopsy, which shows subcorneal pustule with per- and the transient neonatal pustular melanosis.
ifollicular inflammatory infiltrate in cases of erythema c) The transient neonatal pustular melanosis, the infantile
toxicum neonatorum; inflammatory infiltrate with pre- acropustulosis and scabies.
dominance of polymorphonuclear neutrophils in cases d) The erythema toxicum neonatorum, miliaria profunda
of TNPM; and subcorneal pustule with predominance and Langerhans cell histiocytosis.
of lymphocytes in cases of benign cephalic pustulosis.
c) Q
 uantitative maternal Venereal Disease Research Labo- 7) About erythema toxicum neonatorum, check the incor-
ratory (VDRL) and, in the newborn, Fluorescent trepo- rect alternative:
nemal antibody absortion test (FTA-Abs). a) It is characterized by small erythematous papules, pus-
d) Scraping of the lesion and potassium chloride exam- tules and vesicles affecting the trunk, face, and extrem-
ination to discard dermatophytosis and congenital or ities.
neonatal candidiasis. b) It is an inflammatory skin reaction, also called neonatal
allergic erythema or neonatal erythema.
4) Regarding functional differences between newborn and c) Despite pustules of the erythema toxicum neonatorum
adult skin, check the correct alternative: are sterile, the main identified pathogen is Staphiloco-
a) Despite the NB skin is often characterized as delicate cos aureus.
and fragile; there are no functional differences between d) Lesions usually appear on the second day of life and
the newborn and adult skin. regress in 5 to 14 days; atypical settings may have a
b) The newborn skin has functional differences compared later onset.

An Bras Dermatol. 2016;91(2):124-34.

Benign skin disease with pustules in the newborn 133

8) What is the prevalence of erythema toxicum neonato- dominance of eosinophils.

rum estimated for our population? c) There is a predominance of lymphocytes.
a) 3% to 4% d) As in anatomopathological examination, cytology
b) 10% to 15% shows mixed inflammatory infiltrate.
c) 21% to 23%
d) Approximately 90% 14. When differentiating erythema toxicum neonatorum
from transient neonatal pustular melanosis, check the cor-
9. The following statements about the erythema toxicum rect alternative:
neonatorum are true: a) T he etiological mechanisms of ETN and TNPM are well
a) The etiology of erythema toxicum neonatorum is well established and are the same.
established: lesions occur as a reaction to Staphilococos b) It is likely that TNPM corresponds to a variance of ETN,
aureus toxin. because there are many cases in the literature that the
b) Its etiology remains unknown, but recent studies have same newborn presents clinical and histological find-
shown activation of immune cells in the ETN lesions, ings of ETN and TNPM.
suggesting an inflammatory reaction of the skin to mi- c) The clinical difference between TNPM and ETN is al-
crobial colonization that occurs at birth. ways clear, and there are no cases where ETN is present
c) It is more common in female newborns. at birth or where the clinical finding is of TNPM, but
d) It occurs more frequently in premature newborns com- the histology shows the characteristic findings of ETN.
pared to full-term newborns. d) ETN is more common in African-American newborns
and TNPM is usually more common in Caucasian new-
10. What alternative best describes the characteristic le- borns.
sions of erythema toxicum neonatorum:
a) Follicular pustules that mainly affects the palms and 15. Check the correct alternative regarding benign cephalic
soles. pustulosis:
b) Vesicles and pustules that develop into peripheral scal- a) It presents a benign and self-limited course.
ing and leave persistent hyperpigmented macule. b) The dermatosis is characterized by multiple inflamma-
c) Papules and pustules with an erythematous halo that tory papules and pustules on the face and scalp that
regress leaving anetodermic scars. usually begin between 5 days and 3 weeks of age.
d) Pustules surrounded by an erythematous halo of about c) The direct examination of smear of the pustule, clarified
1 to 2 cm affecting mainly the trunk, limbs and face of with potassium hydroxide, can show mycotic elements
the newborn. and culture can show Malassezia synpodialis and, less
frequently, M. furfur or M. Globosa.
11. Lesions that are usually present at birth and are char- d) All alternatives are correct.
acterized by flaccid and superficial pustules that rupture
easily forming a colarette of scales that evolve into hyper- 16) Miliaria rubra is characterized by:
pigmented macules of residual character, corresponds to: a) Numerous erythematous papules or pruritic papular
a) Erythema toxicum neonatorum vesicles grouped in areas that are not under occlusion.
b) Transient neonatal pustular melanosis b) Small vesicles on healthy skin, especially on the face,
c) Benign cephalic pustulosis neck and trunk.
d) Eosinophilic pustular folliculitis c) S
 mall erythematous papules caused by obstruction of
the eccrine sweat gland duct slightly deeper than in
12. As for transient neonatal pustular melanosis it is cor- MC, with sweat retention in the epidermis.
rect to say: d) All alternatives are correct.
a) All areas of the body can be affected, but palms and
soles are usually spared. 17) The differential diagnosis of benign neonatal pustulo-
b) Lesions usually are not present at birth. sis is conducted with:
c) There are cases of intrauterine evolution that leave re- a) M olluscum contagiosum, erythema toxicum neonato-
sidual hyperpigmented macules at birth. rum and eosinophilic folliculitis.
d) It is more common in Caucasian newborns. b) Scabies, neonatal herpes and neonatal abscess.
c) M ilia cyst, sebaceous gland hyperplasia and neonatal
13. Regarding the cytological examination of transient acne.
neonatal pustular melanosis lesions, it is true: d) Infantile acropustulosis, eosinophilic pustular folliculi-
a) The cytological examination of pustules shows poly- tis and neonatal scabies.
morphonuclear neutrophils.
b) The cytological examination of the pustules shows pre-

An Bras Dermatol. 2016;91(2):124-34.

134 Reginatto FP, De Villa D, Cestari TF

18) Infantile acropustulosis is characterized by: Answer key

a) Recurrent appearance of very pruritic vesicopustules Psoriasis: new comorbidities 2016;91(1):08-16.
with palmar and plantar dominance, but it also can af-
fect the back of the hands, feet, ankles, wrists and scalp
b) Vesicopustules that usually appear in the first days of
life. 1. C 6. B 11. C 16. A
c) E
 ruptions lasting 7 to 14 days, interspersed with peri- 2. B 7. B 12. B 17. A
ods of remission of several weeks, and common in the 3. C 8. D 13. D 18. A
neonatal period. 4. D 9. A 14. C 19. D
d) Cytology examination of the lesions shows predomi- 5. A 10. C 15. B 20. D
nance of neutrophils and in histopathological examina-
tion it’s possible to observe the presence of intraepider-
mal pustules with atypical lymphocytes. Papers
Information for all members: The EMC-D
19) The eosinophilic pustular folliculitis usually affects questionnaire is now available at the home-
infants between 5 and 10 months of life. Lesions are char- page of the Brazilian Annals of Dermatolo-
acterized by: gy: www.anaisdedermatologia.org.br. The
a) Polymorphous eruption with very pruritic vesico-pus- deadline for completing the questionnaire is
tules that converge forming exudative and crusted 30 days from the date of online publication.
plaques located mainly on the scalp and less often on
the face and extremities.
b) The eruptions are intermittent, during from one to four
weeks, self-limited, resolving in several months to a
few years.
c) Microscopy shows infiltrated with eosinophils and per-
ifollicular distribution of neutrophils in the scalp, and
perivascular distribution when located in the skin.
d) All the alternatives are correct.

20) Check the right alternative:

a) Benign neonatal pustulosis rarely occur.
b) Benign neonatal pustulosis often occur, mainly due to
erythema toxicum neonatorum and to transient neona-
tal pustular melanosis.
c) It is always necessary to perform additional tests for the
diagnosis of various benign neonatal pustuloses.
d) Genodermatosis or other conditions that can present
systemic involvement are not part of the differential di-
agnosis.

An Bras Dermatol. 2016;91(2):124-34.