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Erythema Toxicum

What is Erythema Toxicum?

Erythema toxicum is a skin condition that affects only newborns in the early neonatal period and which is characterized by a typical rash. This skin condition is benign, self-limited and, often times, does not present any other symptoms than the said rash. Affecting half of all the healthy newborns, erythema toxicum will manifest itself a few hours after the birth or the first day of life. The condition can last for several days and it can cause great worries for the parents, even though there are no associated illnesses or severe symptoms caused by it. Sometimes, the condition is presented as flea-bite dermatitis, as the lesions present on the skin resemble the ones caused by flea bites very much. However, this is not the case.

This skin condition is also known as erythema toxicum neonatorum, urticaria neonatorum or toxic erythema of the newborn. It is more encountered in babies who were delivered full term rather than those who were premature. As for the gender, there are more male newborns diagnosed with erythema toxicum rather than female newborns. Also, this condition is more often encountered in babies who weigh more at birth and in those who are on artificial diet with powdered milk. It is very important to remember that this condition does not occur outside the neonatal period. Also, it might be harder to identify and diagnose in babies who are dark-skinned.

What does Erythema toxicum look like?

The rash characteristic of erythema toxicum constitutes of small papules that appear on the skin. These papules can either be yellow or white in color, the surrounding skin being red. Their size and number varies and they can appear mostly on the face and trunk. Sometimes, they affect the upper arms and thighs and only in very rare cases, the soles of the feet. In some newborns, there are also pustules or vesicles present on the skin.

Symptoms

Most of the cases of erythema toxicum are asymptomatic. There is no fever or swollen lymph nodes associated with this condition. The skin rash is the sole modification identified in the patient. The rash can suffer from a rapid change, as it can appear and disappear in various parts of the body, within a few hours or days. The bumps on the skin become flattened when pressure is applied to the skin. No systemic involvement is noticed in patients diagnosed with erythema toxicum. This condition can appear in newborns of maximum two weeks old. The majority of the cases appear after two days from the birth. The skin rash is generally noticed on dependent areas and it has the tendency to spread in a centripetal direction. All of the lesions are surrounded by a red halo, as it was already mentioned.

Causes of Erythema Toxicum

The exact cause that leads to the appearance of erythema toxicum has yet to be identified. However, several theories have been suggested:

Allergies – this is because there are eosinophils present within the skin lesions
Normal non-specific inflammatory response of the neonate
Increased viscosity of the neonatal skin leads an allergic response (involving eosinophils)
Reaction to maternal lymphocytes
Response of the immune system to the hair follicle commensal microbes
Inflammatory response
No infectious agent involved
No connection to the type of feeding (natural or artificial)
Increased sensitivity to laundry detergents (in bed sheets) or even clothing

Diagnosis

The diagnosis is made through the routine checkup after birth. The rash is characteristic for erythema toxicum and it is easily recognized by the medical specialists. If there are systemic symptoms, then further investigations will be required, as the rash might be caused by another medical condition. Differential diagnosis can be made with herpes simplex virus infection, impetigo, infection with listeria, neonatal sepsis and varicella. Other conditions for differential diagnosis are: folliculitis, congenital cutaneous candidiasis, cytomegalovirus infection, transient pustular melanosis, infantile acropustulosis, miliaria rubra, eosinophilic pustulosis, incontinentia pigmenti, Omenn syndrome and self-healing histiocytosis.

The microscopic analysis of the skin lesion will reveal increased numbers of eosinophils at the site of the lesion. Also, the blood count reveals increased numbers of eosinophils in the circulating blood. Further investigations are made not to confirm the diagnosis but to exclude other potential harmful and more serious conditions of the skin. Among these investigations, the following can be included in the workup: Gram or Wright stain (reveals eosinophils in the skin lesions; if there are neutrophils, then the skin lesions are caused by an infectious agent), fluorescent antibody testing (these are done for suspicion of infection with herpes simplex virus or varicella virus), test for fungal infection (with potassium hydroxide preparation) and blood cultures (for different pathogens, including Streptococcus, Listeria or E. coli). Skin biopsy is recommended only in the situation when other methods of diagnosis have failed.

Treatment

No treatment is required for erythema toxicum, as the condition goes away on its own. No pharmacological treatment has been recommended for this particular medical condition. Also, there are no prevention methods that can be used in this case. Parents are recommended to continue with the normal skin care and not make any changes when it comes to the actual routine or the products being used.

Even though the skin rash does not look great, it does not cause any discomfort to the baby. Parents are recommended to avoid washing the baby excessively, as this can lead to dry skin and complicate the condition. Also, they are advised to refrain from squeezing or breaking the pustules, as this will only expose the baby to different infectious agents.

No topical treatments are recommended for this particular skin rash; during this period, it is recommended to use normal baby moisturizers that are allergen-free and made from natural ingredients. It is important to understand that, when the rash heals, the skin is left normal, without any modifications. Only in rare cases, after pustular lesions, the skin can present erythema that resembles the one from urticaria or some mild desquamation in the affected areas. If the baby has dry skin or other modifications, they are not caused by erythema toxicum but most probably by other co-existing skin conditions. You will need to address a pediatric dermatologist in order to identify the exact cause of the skin problem.

How long does erythema toxicum last?

This is a self-limited condition that normally disappears on its own in a couple of weeks. If the condition does not go away in that period or it seems to be complicated by another medical condition, then the recommendation is to visit a specialized doctor. However, there are no complications that can be caused by this condition. Recent studies have tried to find a connection with atopic disease because of the increased number of eosinophils; however, no study has managed to confirm yet this link. The prognosis for erythema toxicum is excellent, as there are no complications or prolonged treatments to be administered. Only in very rare occasions, the rash can re-appear but the recurrences are mild in intensity. Recurrences can appear until the baby is six weeks old. Also, because there is no infectious agent involved in the appearance of erythema toxicum, it is important to highlight that this is not a contagious condition of the skin. There is no risk to be transmitted to other healthy newborns.