Pediatric Erythema Toxicum

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Erythema toxicum neonatorum (ETN) is a benign, self-limited, asymptomatic skin condition that only occurs during the neonatal period. [1, 2, 3, 4] 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.

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. [5] 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. [6] 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 [7]

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. [8] Carr and associates studied 270 newborns and found an incidence of 48%. [9] Keitel and Yadav studied 207 consecutive newborns and found an incidence of 62%. [10]

International

Incidence is 25.3% in Spain, 33.7% in Taiwan, and 20.6% in India. [4, 11]

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. [12] 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. [13]

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. [9] 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.

The prognosis is excellent. The lesions typically resolve within 2 weeks, and no cutaneous or systemic sequelae are generally observed. This is a benign, asymptomatic, self-limited skin condition with no known sequelae.

Parents with older children often are not concerned by the appearance of erythema toxicum neonatorum, but first-time parents should be informed in the perinatal period that an evanescent rash is likely to appear within the first 2 weeks of life. They should be reassured regarding the benign, self-limited, asymptomatic nature of this and other eruptions. [14]

Review the clinical features with parents before they go home. If any concerns arise about an atypical rash, they should be comfortable contacting their primary care physician to discuss the issues. Before discharge, appropriately screen neonates who have risk factors for sepsis or neonatal herpes simplex virus infection.

Kanada KN, Merin MR, Munden A, Friedlander SF. A Prospective Study of Cutaneous Findings in Newborns in the United States: Correlation with Race, Ethnicity, and Gestational Status Using Updated Classification and Nomenclature. J Pediatr. 2012 Apr 10. [Medline].

Tarang G, Anupam V. Incidence of vesicobullous and erosive disorders of neonates. J Dermatol Case Rep. 2011 Dec 12. 5(4):58-63. [Medline]. [Full Text].

Reginatto FP, Villa DD, Cestari TF. Benign skin disease with pustules in the newborn. An Bras Dermatol. 2016 Apr. 91 (2):124-34. [Medline].

Ghosh S. Neonatal pustular dermatosis: an overview. Indian J Dermatol. 2015 Mar-Apr. 60 (2):211. [Medline].

Lehndorff H. Bartholomaeus Metlinger. A fifteenth century pediatrician. Arch Pediatr. 1951 Jul. 68(7):322-33. [Medline].

Eitzman DV, Smith RT. The nonspecific inflammatory cycle in the neonatal infant. AMA J Dis Child. 1959 Mar. 97(3):326-34. [Medline].

Bassukas ID. Is erythema toxicum neonatorum a mild self-limited acute cutaneous graft-versus-host-reaction from maternal-to-fetal lymphocyte transfer?. Med Hypotheses. 1992. 38:334-338. [Medline].

Haveri FT, Inamadar AC. A cross-sectional prospective study of cutaneous lesions in newborn. ISRN Dermatol. 2014. 2014:360590. [Medline].

Carr JA, Hodgman JE, Freedman RI, Levan NE. Relationship between toxic erythema and infant maturity. Am J Dis Child. 1966 Aug. 112(2):129-34. [Medline].

Keitel HG, Yadav V. Etiology of Toxic Erythema. Erythema Toxicum Neonatorum. Am J Dis Child. 1963 Sep. 106:306-9. [Medline].

Jawade SA, Chugh VS, Gohil SK, Mistry AS, Umrigar DD. A Clinico-Etiological Study of Dermatoses in Pediatric Age Group in Tertiary Health Care Center in South Gujarat Region. Indian J Dermatol. 2015 Nov-Dec. 60 (6):635. [Medline].

Saracli T, Kenney JA Jr, Scott RB. Common skin disorders in the newborn Negro infant. Observations based on the examination of 1,000 babies. J Pediatr. 1963 Mar. 62:359-62. [Medline].

Liu C, Feng J, Qu R. Epidemiologic study of the predisposing factors in erythema toxicum neonatorum. Dermatology. 2005. 210(4):269-72. [Medline].

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

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

[Guideline] New York State Department of Health. Dermatologic manifestations. New York State Department of Health. 2004. [Full Text].

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.

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.

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.

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.

Pediatric Erythema Toxicum

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