Eur. J. Pediat. Dermatol.

25, 12-14, 2015

Neonatal cephalic pustulosis.

Kansal N.K.

Department of Dermatology and Venereology

Government Medical College, Nainital, India.
Summary

A 20-day-old newborn was first observed due to the presence of erythematous, papular
and pustular lesions of the face: the identification of a spaghetti and meatballs finding
on fresh mycological examination of the pus led to diagnose neonatal cephalic pustulosis.
According to some Authors the latter is a disease in its own right, while others classify this
disorder as neonatal acne.

Key words Rash; neonatal cephalic pustulosis; malassezia species; neonatal acne.

Differential diagnoses of neonatal cephalic

pustulosis, mainly candidiasis and neonatal acne
were considered. A lesion was de-roofed and
pustular material was sent for a 10% potassium
hydroxide (KOH) examination for fungal elements; the latter put in evidence the classic spaghetti and meatballs appearance of Malassezia
species. A diagnosis of neonatal cephalic pustulosis was made and the parents were counselled
about the benign nature of the rash. A 2% ketoconazole cream was prescribed to be applied twice a
day. At a follow up visit 10 days later, the lesions
had healed completely without any sequela.

ccording to some Authors neonatal cephalic pustulosis should be differentiated from neonatal acne and considered a
disease in its own right. A 20-day-old newborn
with erythematous, papular and pustular lesions
of the face was reported: the identification of a
spaghetti and meatballs finding on fresh mycological examination of the pus led to diagnose
neonatal cephalic pustulosis.
Case report
A 20-day-old, full-term, otherwise healthy
male neonate was brought by his anxious parents with an asymptomatic rash on the face for
the last 5 days. There were no other cutaneous
or systemic complaints. The neonate was delivered vaginally and weighed 2,400 g at birth. The
child was healthy and unperturbed by the rash,
having a sound sleep, while being photographed.
On mucocutaneous examination, the rash consisted of erythematous papules and pustules on the
cheeks and adjacent temporal regions bilaterally
(Fig. 1).

Discussion
After birth, the neonatal skin is known to be
gradually colonized during first few months by
the fungi of Malassezia species (1). This phenomenon is caused by the increased activity of
neonatal sebaceous glands, which are stimulated
by androgens from the testes in males and the
adrenal cortex in females. At present, it has been
widely accepted that fungi of Malassezia species,
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Pustolosi cefalica neonatale

Fig. 1: Neonatal cephalic pustulosis.

half of these cases are culture positive for either

Malassezia furfur or M. sympodialis (3).
Other differential diagnoses of NCP include
milia, erythema toxicum neonatorum, neonatal
pustular melanosis, miliaria rubra, sebaceous
hyperplasia, Candida infection, papulopustular
eruption of hyper-IgE syndrome and acneiform/
papulopustular eruptions due to maternal medications - e.g., lithium, phenytoin, glucocorticosteroids, etc. - (4). Smears of pustular contents
in erythema toxicum neonatorum and neonatal
pustular melanosis will respectively show eosinophils and neutrophils predominantly. Peri- and
post-partum medication history of the mother,
should also be carefully considered.
NCP has an excellent prognosis and responds
well to topical antifungal agents e.g. ketoconazole cream (2, 5) and as in our case, lesions heal
in 1-2 weeks without any scarring or recurrence.
Parents should also be counselled about the benign nature of the condition to allay any undue
anxiety.

especially M. furfur and M. sympodialis are the

causative agent of an erythematous papulopustular rash, which may occur on the face and scalp
in the neonates. This rash, though very similar to
that of neonatal acne, has been delineated (2, 5)
as neonatal cephalic pustulosis (NCP; also called
Malassezia pustulosis).
The main differential diagnosis of NCP remains neonatal acne (acne neonatorum) with an
etiopathological and nosological confusion, with
many workers considering these to be same entities. However, neonatal acne is a relatively more
common condition affecting up to 50% of otherwise healthy neonates. Distinguishing clinical feature of neonatal acne from NCP is the presence
of at least a few comedones (4), which are not
seen in NCP. The histopathological examination
of the acne lesions will demonstrate hyperplastic
sebaceous glands and keratin-plugged pilosebaceous orifices with neutrophilic or granulomatous
inflammation (4). NCP is possibly less common
with an incidence of about 10% (6); more than
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Kansal

Address to:
Naveen Kumar Kansal, MD
Assistant Professor
Department of Dermatology and Venereology
Government Medical College Haldwani
263139, Nainital, India
e-mail: kansalnaveen@gmail.com

References
1) Ayhan M., Sancak B., Karaduman A. et Al. - Colonization of neonate skin by Malassezia species: relationship with neonatal cephalic pustulosis. J. Am. Acad.
Dermatol. 57, 1012-8, 2007.
2) Bardazzi F., Patrizi A. - Transient cephalic neonatal
pustulosis. Arch. Dermatol. 133, 528-30, 1997.
3) Bernier V., Weill F.X., Hirigoyen V. et Al. - Skin colonisation by Malassezia species in neonates: a prospective study and relationship with neonatal cephalic
pustulosis (neonatal acne). Arch. Dermatol. 138, 2158, 2002.

4) Melnik B.C. - Acne. In: Irvine A., Hoeger P., Yan A.,
eds. - Harpers Textbook of Pediatric Dermatology.
3rd ed., vol. 1. Willey-Blackwell, Oxford 2011, pp.
79.14-22.
5) Niamba P., Weill F.X., Sarlangue J. et Al. - Is common
neonatal cephalic pustulosis (neonatal acne) triggered by Malassezia sympodialis? Arch. Dermatol. 134,
995-8, 1998.
6) Rapelanoro R., Mortureux P., Couprie B. et Al. - Neonatal Malassezia furfur pustulosis. Arch. Dermatol.
132, 190-3, 1996.

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