What is the recommended management for neonatal acne?

Management of Neonatal Acne

Neonatal acne is typically mild and transient, requiring no treatment in most cases beyond gentle cleansing with mild non-comedogenic cleansers and water. 1

Overview of Neonatal Acne

Neonatal acne (NA) is a common, transitory dermatosis that:

• Occurs in approximately 20% of newborns
• Typically appears between the second and fourth weeks of life
• Is more common in males (male-to-female ratio of 4.5:1)
• Presents as open and closed comedones that may evolve into papules, pustules, and rarely nodules or cysts
• Most commonly affects the forehead, cheeks, chin, and eyelids, but can spread to the scalp, neck, and trunk 1

Pathophysiology

Neonatal acne develops due to:

• Elevated production of placental and neonatal androgens
• Enlargement of sebaceous glands
• Increased sebum production 1

Assessment and Diagnosis

The diagnosis of neonatal acne is primarily clinical. Key differential diagnoses include:

• Neonatal cephalic pustulosis (caused by hypersensitivity to Malassezia furfur)
• Other neonatal vesiculopustular dermatoses
• Infectious diseases
• Acneiform reactions 1, 2

If neonatal acne is severe or persists beyond one year, evaluation for underlying conditions should be considered:

• Congenital adrenal hyperplasia
• Virilizing tumors of adrenal or gonadal origin 1, 2

Treatment Approach

First-line Management:

• Most cases resolve spontaneously without treatment
• Gentle cleansing with mild dermal cleanser and water is sufficient for most infants 1

For Persistent or More Severe Cases:

1. For comedogenic lesions (open and closed comedones):

   • Topical retinoids or
   • 20% azelaic acid 1

2. For inflammatory lesions:

   • Topical antibiotics may be considered 1

For Severe, Recalcitrant Cases:

In rare instances of severe acne that doesn't respond to topical therapy:

• Systemic erythromycin may be considered
• In extremely severe cases, oral isotretinoin at 0.5 mg/kg has been reported, though this should be reserved for exceptional circumstances and specialist consultation 3

Important Considerations

• Avoid unnecessary treatments: Most neonatal acne resolves spontaneously within weeks to months
• Skin barrier protection: Neonatal skin is more permeable to topical agents and requires particular caution with skincare regimens 4
• Product selection: Any products used should be:
  • Fragrance-free
  • Free of sensitizing agents
  • Mild or pH-neutral 4
• Monitoring: If acne fails to resolve within 1 year, further evaluation for androgen excess is warranted 2

Follow-up

• Regular assessment during routine well-child visits is sufficient for most cases
• More frequent follow-up may be needed for severe cases or if treatment is initiated
• Parental reassurance about the benign, self-limiting nature of the condition is important

Neonatal acne typically resolves without scarring or long-term sequelae, and parents can be reassured that this is a common, transient condition that rarely requires medical intervention.