▶Neonatal acne may present at birth but more commonly appears during the first few weeks after birth.
▶There are likely several etiologies for acneiform eruptions in neonates, including maternal and fetal androgens and, in patients with markedly pustular lesions, a hypersensitivity response to resident yeast (eg, Malassezia [formerly Pityrosporum] species).
▶The term neonatal cephalic pustulosis has been proposed to describe the more pustular presentation (Figure 8.1).
Infantile Acne
▶Later onset than neonatal acne, usually after 4 to 6 weeks of age.
▶Considered to be androgen-driven with associated sebaceous gland hyperactivity.
▶Spontaneously resolves between 6 and 12 months in most patients.
▶Occasionally more persistent or more severe with the potential for scarring.
Neonatal Acne
▶Inflammatory, erythematous papules and pustules (Figure 8.2).
▶Primarily on the cheeks but also scattered on the entire face, extending into the scalp (see Figure 8.1).
▶Comedones typically absent; truncal involvement rare.
Infantile Acne
▶Full range of typical acneiform lesions may be seen: papules, pustules, open and closed comedones, and, occasionally, nodules (Figure 8.3).
▶Occurs primarily on the face.
▶Scarring may be present.
Look-alikes
Disorder | Differentiating Features |
Neonatal Acne | |
Miliaria rubra or pustulosa | •Erythematous papules (miliaria rubra) or pustules (miliaria pustulosa); may be difficult to differentiate from neonatal acne •Often more widely distributed on areas covered by clothing or in areas of occlusion (eg, skinfolds) |
•White papules without surrounding erythema | |
•Yellow (not erythematous) papules, typically on the nose | |
•Erythematous, scaling patches (typically lacks discrete papules) | |
•Favors intertriginous areas and occluded skin (eg, diaper area). •Pustules may rupture easily, leaving small peripheral collarettes of scale. •Skin culture reveals growth of Staphylococcus aureus. | |
Infantile Acne | |
Lesions that may mimic infantile acne include all of those listed for neonatal acne. The presence of typical acne lesions, especially comedones, helps confirm the diagnosis. | |
•Inflammatory type may mimic acne lesions. •Papules have central keratotic plug. •Facial involvement typically limited to lateral cheeks; similar lesions may be noted on extensor surfaces of upper arms and thighs. •Other atopic history may be present. •Often a positive family history. | |
Neonatal Acne
▶Neonatal acne spontaneously resolves without treatment; watchful waiting with reassurance is appropriate.
▶If treatment is requested, 2.5% benzoyl peroxide, 2% erythromycin solution or gel, or 1% clindamycin lotion can be applied sparingly on a nightly to every other night basis until resolution is noted. Alternatively, 2% ketoconazole cream may be used if neonatal cephalic pustulosis is suspected.
Infantile Acne
▶More severe or persistent infantile acne may lead to scarring, and treatment is often indicated.
▶Topical 2.5% benzoyl peroxide, topical 2% erythromycin solution or gel, or topical 1% clindamycin lotion may be useful for inflammatory papules and pustules (these may be applied once or twice daily as tolerated).
▶Topical retinoids (eg, tretinoin 0.025% cream, adapalene 0.1% cream) may be helpful for comedones as well as inflammatory lesions, but side effects of erythema and irritation can be problematic in some patients. Begin topical retinoid with application every second or third night, progressing to nightly application, if tolerated, over 2 to 3 weeks.
▶More severe variants of infantile acne may require oral antibiotics (typically erythromycin).
▶In rare cases of severe nodulocystic disease in infants, isotretinoin has been used safely and successfully; such patients merit referral to a pediatric dermatologist.
▶Neonatal acne is a self-limited disorder with no long-term sequelae.
▶Infantile acne is typically self-limited, but more persistent or severe disease may result in long-term scarring.
▶The relationship of severe infantile acne to later risk of acne vulgaris is unclear, but some investigators believe it is a risk factor for more significant adolescent and adult acne.
▶Unusually severe neonatal or infantile acne.
▶Severe or unresponsive disease may require endocrine testing to assess for excess androgens.