A 3-week-old neonate is brought to the office due to a facial rash. Three days ago, the rash started as small bumps on the forehead that subsequently spread to the entire face. The patient seems unbothered by the rash and has continued to take 3 ounces of formula every 2-3 hours. The patient was born at term via a spontaneous vaginal delivery to a mother with an uncomplicated pregnancy. The patient has an older brother who attends day care. Temperature is 36.9 C (98.4 F), heart rate is 125/min, and respirations are 37/min. On examination, the patient is awake and alert. Skin examination is shown in the exhibit. The remainder of the examination, including skin in other areas, is normal. Which of the following is the most appropriate next step in the management of this patient's rash?

Question

A 3-week-old neonate is brought to the office due to a facial rash.  Three days ago, the rash started as small bumps on the forehead that subsequently spread to the entire face.  The patient seems unbothered by the rash and has continued to take 3 ounces of formula every 2-3 hours.  The patient was born at term via a spontaneous vaginal delivery to a mother with an uncomplicated pregnancy.  The patient has an older brother who attends day care.  Temperature is 36.9 C (98.4 F), heart rate is 125/min, and respirations are 37/min.  On examination, the patient is awake and alert.  Skin examination is shown in the exhibit.  The remainder of the examination, including skin in other areas, is normal.  Which of the following is the most appropriate next step in the management of this patient's rash?

Quizplus · Accepted Answer

11ec25c8_d64a_1a19_bc81_591d09b19336_MD0003_00 This well-appearing neonate with new-onset erythematous pustules limited to the face has neonatal cephalic pustulosis. This condition may be due to an inflammatory reaction to the Malassezia species that colonize the skin. Because androgen stimulation of sebaceous glands is not involved, "neonatal cephalic pustulosis" has replaced the term "neonatal acne" used previously to describe this condition. Patients have erythematous papules and pustules that are limited to the face and scalp, with an onset typically around age 3 weeks. Comedones (hair follicles occluded by keratin) and nodulocystic lesions are not present. Patients are asymptomatic and well-appearing. Most cases of neonatal cephalic pustulosis are mild and can be managed with daily cleansing of the affected area with gentle soap and water. Oil-containing lotions or emollients should be avoided (Choice B). More severe cases can be treated with low-potency topical corticosteroids or topical ketoconazole, but the condition self-resolves within weeks to months without scarring. (Choice C) Topical mupirocin treats staphylococcal pustulosis, which presents in neonates as localized erythematous pustules, vesicles, or bullous lesions that rupture to form erosions and honey-colored crusts. These features are absent in this patient. Moreover, classic distribution involves the diaper area or a prior wound (eg, circumcision site). (Choice D) Scabies, which is treated with topical permethrin, usually causes erythematous papules but can present with pustular lesions. In contrast to this neonate, patients typically have diffuse skin involvement, particularly of the scalp, hands, and feet. In addition, lesions are intensely pruritic, which in neonates typically manifest as fussiness or poor feeding, neither of which is seen in this patient. feet (Choice E) Topical salicylic acid treats comedonal acne, which typically presents in adolescents and young adults. This medication is not used for neonatal cephalic pustulosis, characterized by a lack of comedones. comedonal acne Educational objective: Neonatal cephalic pustulosis presents with erythematous papules and pustules limited to the face and scalp around age 3 weeks. Management is typically limited to daily cleansing with gentle soap and water, and self-resolution without scarring is expected within weeks to months. References: Benign skin disease with pustules in the newborn. (http://www.ncbi.nlm.nih.gov/pubmed/27192509)

A 3-Week-Old Neonate Is Brought to the Office Due to a Facial