Understanding Common Newborn Rashes: A Paediatrician’s Guide

As a new parent, it's natural to be worried about every little bump or rash that appears on your baby's skin. Fortunately, many of the rashes that babies develop in the first few weeks of life are harmless and will clear up on their own. In this article, I will discuss some of the most common newborn rashes that parents should know.

Erythema Toxicum Neonatorum

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Also known as Erythema Neonatorum, or toxic erythema of the newborn, is a common and benign condition seen in up to 70% of newborn infants. (1)
It usually occurs within the first few days after birth, although some cases may begin as late as two weeks after the baby is born.
Despite the term toxicum, which sounds scary, the condition isn't toxic and is actually harmless to babies and in my opinion the word toxicum should be removed!
We don’t really know what causes erythema toxicum neonatorum although there are a few theories including a reaction to mechanical and heat stimuli.
The rash looks like red or yellow pimples surrounded by red patches.
It begins on the face (mainly on the cheeks and forehead) and spreads to the torso, arms and legs. Palms and soles are not usually affected.
The diagnosis is usually made based on the clinical appearance of the rash.
Your baby doesn’t need any special treatment because the rash is harmless and not contagious. It will go away by itself in 1 to 2 weeks.

When should you speak to a doctor: If the rash does not go away in about two weeks, if it gets worse with time, if your baby has a fever, not feeding well or if you have any concerns.

Key points:

Erythema toxicum neonatorum is a harmless, common rash that develops after birth and goes away after 1-2 weeks.
No treatment is needed.

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Neonatal Acne (Baby Acne)

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This is a common skin condition that affects about 20% of newborns. (2)
You’ll usually see it at about 2 weeks of age but can develop at any time before the age of 6 weeks.
It usually appears as small white or red pimples or pustules on the baby's face, particularly on the cheeks, chin and forehead but can involve the scalp, neck, back, or chest.
It is caused by maternal hormones circulating in your baby’s bloodstream.
It usually clears up on its own within a few weeks to months without leaving any scars.
When acne develops after 6 weeks of age, it’s called infantile acne. This type of acne might need further assessment and treatment as it might indicate an underlying condition.

When should you speak to a doctor: If the rash starts after the age of 6 weeks or if it does not get better after a few weeks.

Key points:

Baby Acne is common in the first few weeks and should resolve on its own.
If Acne does not get better or develops after 6 weeks, go and see your doctor.

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Milia

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Milia are small, white bumps that appear on a baby's face, particularly around the nose, chin, and cheeks and affects 40–50% of newborn babies. (3)
They are caused by blocked sweat glands filled with keratin.
They do not hurt or itch and do not affect your baby.
There is no need for any treatment as they usually clear up on their own within a few weeks.
Milia in newborns may also occur on the hard palate (Epstein's pearls) or on the gum margins (Bohn's nodules). These also resolve spontaneously after a few weeks to months.

Dr Heitner, does my baby have teeth?

When Milia occurs on the gum margins, they are called Bohn’s nodules, and can look like baby teeth!

Key points:

Milia are tiny white bumps that can appear on babies’ faces soon after birth.
Milia are harmless and go away by themselves.

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Milia inside mouth — Bohn’s nodules: close-up view. Image courtesy of Prof Richard Widmer.

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Milia in the mouth — Milia on the gums of a baby (“Bohn’s nodules”) Image courtesy of Dr Janelle Aby

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Nappy Rash

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This is a common skin condition that occurs when the skin around your baby's nappy area is red and irritated.
Most commonly, it is caused by prolonged exposure to wet or dirty nappies causing skin irritation from the chemical ammonia found in your baby's wees or poos. It can also occur from nappy friction against the skin. (4)
Sometimes nappy rash is causes by bacteria, yeasts, soaps, detergents, or baby wipes.
It appears as red, irritated skin around the baby's nappy area but can spread to involve the lower abdomen and thighs.
Some areas of skin might be raised or swollen, and in more severe cases might have ulcers. On children with darker skin, the inflammation might look a little different with brown or purple colours.
The rash can be uncomfortable and even painful, which can make your child irritable.
Skin folds in the groin are not affected when the nappy rash is caused by irritation of the skin due to urine and stool so when they are involved, this might be due to a fungal or bacterial infection.
Prevention is better than cure. Thus, changing your baby's nappies frequently and applying a barrier cream to protect the skin can prevent a nappy rash.

Treatment involves the following:

Change your baby’s nappies frequently.
Clean your baby’s skin gently. Use warm water ± bath oil and a soft cloth to cleanse the area after every change, pat gently or air dry and avoid rubbing.
Avoid soaps and bubble baths.
Apply a thick layer of barrier cream at every nappy change. You can use zinc creams or a petroleum jelly like Vaseline.
Consider using disposable nappies while rash is healing.
Allow as much nappy free time as possible.

When should you speak to a doctor: If the rash is not improving with the above treatment measures or if any concern that nappy rash is due to a cause other than prolonged contact with urine and poo.

If all these measures do not seem to help, your doctor might prescribe your baby medications such as:

Low potency topical steroid.
Topical anti-fungal therapy.
Topical or oral antibiotics for bacterial infections.

Key points:

Nappy rash makes children’s bottoms sore and inflamed.
To treat nappy rash, change nappies often, keep your child’s bottom clean and dry, apply barrier cream and use disposable nappies.
Take your child to the doctor if the rash isn’t improving or if it’s making your child upset or unwell.

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For a more in-depth look at nappy rash, explore Dr. Sam’s article: Understanding and Managing Nappy Rash: A Paediatrician's Guide for Parents.

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Cradle Cap

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Cradle cap is a common skin condition that affects many newborns. It appears as thick, waxy, yellow crusts on the baby's scalp or eyebrows. (5)

Caused by excess production of oil by the sebaceous glands which are stimulated by hormones that were passed from mum to baby. This extra oil interferes with the natural shedding of skin on your baby’s scalp and creates a build-up of dead skin over the scalp.

This condition is harmless and usually clears up on its own within a few months.

Treatment: It will get better on its own, but treatment options include:

Regularly massage the baby's scalp with baby oil or petroleum jelly like Vaseline and then use a soft brush to gently brush away the scales.
Loosen the crusts by applying a light moisturising cream or lotion to the scalp. The next morning, wash your baby's hair with a baby shampoo, gently lifting the crusts off with a soft brush (an unused soft toothbrush can be good for this).

Don’t force the crusts, because this might make your baby’s skin bleed.

When should you speak to a doctor: The cradle cap doesn’t improve after two weeks with the treatment described above. The skin underneath or around the crustiness is inflamed or weeping. Your baby seems irritated by the cradle cap or is scratching it.

In more severe cases your doctor will recommend an over-the-counter anti-dandruff shampoo such as ketoconazole 2% for a short period of time or prescribe a low potency steroid + antifungal medication such as Hydrozole cream.

Key Points:

Cradle cap is the oily, yellow, scaly crusts babies often get on their heads.
Cradle cap isn’t serious, itchy or painful. It usually clears up by itself within a few months.

In conclusion, many of the rashes that newborns develop are harmless and will clear up on their own within a few days or weeks. However, if you are concerned about a rash on your baby's skin or if it does not go away on its own, it's important to talk to your doctor. Your doctor can help you identify the cause of the rash and recommend the best course of treatment.

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Written by Dr Samuel Heitner

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Click HERE to book a consultation with Dr Sam.

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Bibliography:

1. https://dermnetnz.org/topics/toxic-erythema-of-the-newborn

https://www.uptodate.com.acs.hcn.com.au/contents/vesicular-pustular-and-bullous-lesions-in-the-newborn-and-infant

2. The Australasian College of Dermatologists: https://www.dermcoll.edu.au/atoz/neonatal-infantile-acne/

American Academy of Dermatology: https://www.aad.org/public/diseases/acne/really-acne/baby-acne

3. https://dermnetnz.org/topics/milium

4. https://www.uptodate.com.acs.hcn.com.au/contents/diaper-dermatitis