What is the best treatment for a newborn with baby acne?

Baby Acne Treatment

For newborns with baby acne (neonatal acne), the best treatment is gentle cleansing with mild soap and water, as most cases resolve spontaneously within weeks to months without intervention. 1, 2

Understanding Neonatal Acne

Neonatal acne occurs in approximately 20% of newborns, typically appearing between the second and fourth weeks of life, with a strong male predominance (4.5:1 ratio). 1 The condition results from elevated placental and neonatal androgens that stimulate sebaceous gland enlargement and increased sebum production. 1

Clinical Presentation to Confirm Diagnosis

• Lesion types: Open and closed comedones that may evolve into erythematous papules and pustules; rarely nodules or cysts 1
• Distribution: Primarily affects the forehead, cheeks, chin, and eyelids, occasionally extending to scalp, neck, and trunk 1
• Timing: Appears between 2-4 weeks of life and typically resolves spontaneously 1, 2

Treatment Algorithm by Severity

Mild Cases (Most Common)

Use gentle cleansing with mild dermal cleanser and water only. 1 This approach is sufficient for the majority of cases, which are transient and benign. 2

• Apply non-alkaline, pH-neutral cleansers that are fragrance-free and sensitizing agent-free 3
• Avoid harsh soaps or scrubbing that could disrupt the developing skin barrier 4, 3
• Provide parental reassurance that spontaneous resolution is expected 2

Comedonal Lesions (Open and Closed Comedones)

If comedones persist beyond simple cleansing:

• Topical retinoids may be considered for persistent comedonal lesions 1
• 20% azelaic acid is an alternative option 1

Inflammatory Lesions (Papules and Pustules)

For inflammatory components:

• Topical antibiotics may be used for inflammatory lesions 1
• However, most cases still resolve with gentle cleansing alone 2

Critical Distinctions and Red Flags

Severe or prolonged neonatal acne requires evaluation for underlying endocrine disorders. 1 If acne is severe and long-lasting, investigate for:

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

Key Differential Diagnoses to Rule Out

• Neonatal cephalic pustulosis: Caused by Malassezia furfur hypersensitivity; managed with topical ketoconazole if severe 5
• Infectious causes: Candida, viral, or bacterial infections require evaluation if systemic illness signs present 2
• Other vesiculopustular dermatoses and acneiform reactions 1

Skin Barrier Protection During Treatment

The neonatal skin barrier is still developing and more permeable to topical agents. 3

• Use ceramide-containing moisturizers to maintain protective skin barrier function 4, 3
• Apply gentle cleansers that support skin acidification, which is vital for barrier maturation 3
• Avoid products with fragrances or sensitizing agents 3

Common Pitfalls to Avoid

• Do not use aggressive topical treatments in mild cases where gentle cleansing suffices 1, 2
• Avoid tetracycline antibiotics (doxycycline, minocycline) in neonates due to tooth discoloration risk 6
• Do not overlook severe/persistent cases that may indicate endocrine pathology requiring clinical and paraclinical examination 1
• Do not confuse with infantile acne, which starts after the neonatal period and may require more aggressive treatment 5

Follow-Up Recommendations

• Expect spontaneous resolution within weeks to months for typical cases 1, 2
• Re-evaluate if acne persists beyond 1 year, as this warrants evaluation for androgen excess 5
• Monitor for signs of systemic illness or unusual presentations that would require additional workup 2