An 18-day-old male presented for a rash on his face for two days. The patient was born via spontaneous vaginal delivery full term without complications to a mom who has a history of genital HSV but without active lesions at delivery and on acyclovir. The patient presented with a vesicular rash on his face including around his eyes. He had conjunctival discharge noted by mom. Otherwise, he was well-appearing, acting normally, and eating/voiding/stooling normally.
General: Well appearing, acting appropriately for age
HEENT: Scalp normal. Anterior fontanelle soft and flat. Vesicular appearing rash with erythematous base in clusters noted around eyes, cheek, and chin. Fluorescein staining with corneal abrasion noted at 4 o’clock region on right eye, no dendritic pattern. Scant yellow discharge noted from left eye. TM normal bilaterally. Oropharynx clear.
Neuro: Normal tone, moving all extremities
Skin: Flaky skin, no rash noted elsewhere except as listed above (Photos taken after fluorescein)
CBC: Normal
LFTs: Normal
BMP: Unremarkable
CRP: Negative
Lab results for HSV were negative:
HSV 1 and 2 (chin): negative
HSV 1 and 2 (near eye): negative
HSV 1 and 2 (nose, mouth, rectum): negative
HSV 1 blood Igg: negative
HSV 2 blood Igg: positive (reflective of maternal antibody status)
What was once called “neonatal acne” now known as neonatal cephalic pustulosis is usually seen in the first three weeks of life. Usually, it appears as pustulo-papules on the face, around the eyes, on the cheeks, and chin. Some studies have suggested that neonatal cephalic pustulosis is caused by Malassezia species. As the rash is self-limiting, treatment is not necessary.
Take-Home Points
When a vesicular rash is in a neonate < 1 month and all over the face, consider benign neonatal pustular lesions such as neonatal cephalic pustulosis.
- Antoniou C, Dessinioti C, Stratigos AJ, Katsambas AD. Clinical and therapeutic approach to childhood acne: an update. Pediatr Dermatol. 2009 Jul-Aug;26(4):373-80. doi: 10.1111/j.1525-1470.2009.00932.x. PMID: 19689511.
- Ghosh S. Neonatal pustular dermatosis: an overview. Indian J Dermatol. 2015 Mar-Apr;60(2):211. doi: 10.4103/0019-5154.152558. PMID: 25814724; PMCID: PMC4372928.
Li Ding, MD
Kaiser Permanente Modesto
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