Erythema Toxicum Neonatorum

Clinical Appearance: "Flea-bitten" appearance. Erythematous macules (2–3 cm) with a central 1–4 mm yellow or white pustule/papule.

Key Features:

• Onset: Typically appears on Day 2–3 of life (rare at birth).
• Distribution: Face, trunk, and proximal limbs.
• Sparing: Classically spares the palms and soles.
• Baby's Condition: The infant is well, afebrile, and feeding normally.

Neonatal Herpes Simplex (HSV)

• The Clue: Clustered vesicles (fluid-filled) rather than isolated pustules. May have erosion/crusting.
• Red Flag: Any vesicular rash in a neonate requires urgent exclusion of HSV.

Transient Neonatal Pustular Melanosis (TNPM)

• The Clue: Present at birth (unlike ETN). Pustules lack surrounding erythema ("non-angry").
• Evolution: Ruptures easily leaving a collarette of scale and hyperpigmented macules.

Miliaria Rubra (Heat Rash)

• The Clue: Non-follicular papules/vesicles. Associated with sweating/over-bundling.
• Location: Concentrated in skin folds (neck, groin, axilla).

🚨 Urgent Referral Required:

• Systemically Unwell: Fever, lethargy, poor feeding, or irritability (Rule out sepsis).
• Vesicular Rash: Suspicion of HSV or Staphylococcal Scalded Skin Syndrome (SSSS).
• Palms/Soles Involvement: If pustules are present on palms/soles, consider Scabies or Infantile Acropustulosis.

Reassurance & Education:

• Benign Condition: Explain that this is a normal newborn rash and is not due to "toxins" or infection.
• Self-Limiting: Typically resolves spontaneously within 5 to 14 days. Recurrence is rare after 6 weeks.

Skin Care:

• Do Not Squeeze: Picking or squeezing lesions increases risk of secondary bacterial infection.
• Avoid Topicals: No creams, lotions, or oils are necessary. Avoid steroid creams.
• Hygiene: Continue normal bathing with gentle, soap-free cleanser.

⚠️ Safety Pearl: If the rash persists beyond 2 weeks or changes morphology (e.g., becomes crusty/weeping), re-evaluate for other diagnoses.