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Decoding Newborn Rashes: A Guide for New (and Experienced) Parents

rash-diaper rash-eczema-acne-neonatal
rash-diaper rash-eczema-acne-neonatal

As a pediatric dermatologist, I experience the joys of seeing newborns daily. Newborns are perfect. While we also want their skin to be just as perfect as they are, sometimes nature has other plans.

JiaDe (Jeff) Yu, M.D., M.S.

Member, Society for Pediatric Dermatology

There are myriad pediatric rashes that can trigger anxiety in new parents, partly because these are visible. Parents who turn to Google will be confronted with thousands of blogs touting “home remedies” from bathing the child in breast milk to cutting out everything in their diet in case their symptoms are an allergic reaction.

While it may be difficult to discern how to navigate these conditions, the good news is that most rashes in newborns are benign and short-lived.

Follow along for three common rashes in newborns, how they present, and how we, as board-certified pediatric dermatologists, would recommend you treat them. And none of those treatments include bathing your child in breastmilk.

Neonatal acne (benign cephalic pustulosis)

What? Acne in a newborn? Shouldn’t this be a condition found only in teenagers?

Actually, this is one of the most common rashes we see in newborns. Often presenting within 0-6 weeks of life, neonatal acne appears as little red bumps, pus bumps, or blackheads and whiteheads that appear on the face and can involve the upper chest and upper back as well. In darker skin, the redness may not be easily seen and, instead, dark bumps may appear. 

Though these types of rashes are generally mild and can self-resolve within three to six months, they are no doubt anxiety-inducing, especially since it’s on your baby’s face.

These are caused by harmless yeast (Malassezia) that lives in hair follicles and are typically present on the head and neck. This similar yeast is also the cause of the dreaded cradle cap. Malassezia are especially active in newborns, partly because of the hormones from the mother that passed on to the infant while in utero. The activity of these hormones usually wanes over the first 3-6 months. 

Now that your child has this, how do pediatric dermatologists treat it? For most neonates, we reassure parents that this will resolve within a few weeks or months and will not scar. During this time, we recommend gentle, fragrance-free cleansers that are safe to use in young children that we would also recommend to children with sensitive skin. Thick oils can actually make this condition worse through occlusion of the hair follicles and should be avoided.

For more severe cases, we may recommend anti-dandruff shampoos to fight the causative yeast. These can be over-the-counter or prescription anti-fungal shampoos. Rarely, anti-inflammatory therapiesm, such as hydrocortisone, are necessary.

Diaper rash

While this seemingly catch-all phrase is the bane of parents, pediatricians, and dermatologists alike, there is actually more to it than meets the eye.

The most common type of diaper rash is irritant contact dermatitis caused by urine and stool trapped in the ultra-adhesive, leak-proof diaper on your newborn’s bottom. The higher and more basic pH of the urine activates the digestive enzymes in the stool leading to skin irritation, redness, and discomfort. This type of rash usually spares the folds of the skin (since the folds are protected from coming in contact with body fluids/waste) and involves the convex surfaces — most often the buttocks and inner thighs. The skin may appear red, irritated, inflamed, and can sometimes look like a burn.

The best treatment is to apply copious amounts of diaper cream that zinc oxide (the more the better). I often recommend applying very thick layers of diapering cream, akin to what you’d use if you were frosting a cake. If this doesn’t suffice, a gentle topical anti-inflammatory cream, such as hydrocortisone 1% or the prescription 2.5% cream, can be helpful for a few days to decrease inflammation and promote healing.

Another type of diaper rash is a common yeast that lives in our digestive tracts called Candida. This yeast can cause diaper rashes that are described as being “beefy” red. The most tell-tale signs are satellite pustules or pus bumps that appear around the red patches.

Often, these rashes will involve the folds of the skin unlike irritant contact dermatitis described above. This is best treated with an anti-yeast cream. Application of copious amounts of diaper barrier cream with zinc oxide can also help and prevent future occurrences of yeast diaper rashes.

Finally, allergic contact dermatitis can also occur in the diaper region, but of the three described here, this is typically the least common. These are allergic reactions due to coming in contact with an allergen that is either in the diaper (rubber in the cuffs, adhesives in the hips), in topical creams, or wet wipes (fragrances or preservatives). These can involve areas of the buttocks that come directly in contact with the offending allergen (thighs for the rubber in cuffs, hips for the adhesive chemicals, buttocks for the creams/wipes). Diagnosis can be done through patch testing at a dermatologist’s office and the only cure is avoidance.

Eczema (atopic dermatitis)

Almost 20% of all children have atopic dermatitis, and most (80-90%) are diagnosed before the age of 5. Many parents of children I see report their child having eczema “since the moment they were born.”

In infants and newborns, eczema often first appears on the face, especially the cheeks, trunk, outer arms, front of the legs, etc. These eczema spots look like dry, red, scaly patches, and are often itchy.

In darker skin, eczema may not appear red as in lighter complexions. Instead, eczema can be small, pinpoint bumps on the arms, trunk, face, etc. Though it doesn’t look as “angry” or “red,” these are still signs of flaring eczema that need to be treated.

Older infants will often try to scratch these spots, and younger infants will often “wiggle” in place to scratch the skin on a surface like a bed, changing table, carseat, etc. Eczema can often lead to sleep disruption, breaks in the skin increasing the risk of bacterial and viral infections, and overall discomfort for both the child and their parents alike.

Many parents (and some physicians) will incorrectly attribute food or environmental allergies as the cause of eczema, though data shows that less than 10% of eczema is due to a food allergy. Therefore, food avoidance without clear evidence of allergic reactions (food allergy testing by an allergist) is not recommended by most physicians.

Most cases of eczema are genetic, with most children having a parent, grandparent, or sibling who also has eczema, asthma, hay fever, or food allergies. While it is true that many children can outgrow eczema, children with more severe eczema tend to have eczema into late adolescence and adulthood.

Treating eczema is highly individualized and rapidly advancing. If you suspect your child may have atopic dermatitis, consulting with a board-certified pediatric dermatologist is highly recommended.

First-line therapies for infants and newborns include moisturizing the skin with thick emollients, such as petrolatum-based ointments, thick oils like coconut oil or sunflower oil, and other moisturizers — the thicker the better.

For more red, itchy, and inflamed eczema, topical anti-inflammatories, such as topical steroids (i.e., hydrocortisone), can be used safely for short periods of time under the guidance of a pediatric dermatologist. Non-steroidal topical medications can also be used. Systemic medications are also available for children with severe eczema that fail conventional topical treatments.

While these newborn and infant skin rashes are usually mild, will self-resolve, and are benign, they can nevertheless be anxiety-inducing. Consulting with a pediatrician and pediatric dermatologist is reasonable and recommended.

You can source a local pediatric dermatologist through the Society for Pediatric Dermatology’s “Find a Pediatric Dermatologist” feature on its website at Parents should call a doctor if there are other concerning symptoms, including fever, weakness or lethargy, not maintaining growth curve, or acting abnormally.

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