Pediatric Dermatology: What's your DX?


A 3-year-old boy has had a rash on his face for at least six months, and no family history of skin disease.



What's your DX?

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By Bernard A. Cohen, MD

A 3-year-old boy has had a rash on his face for at least six months. Although the lesions do not usually itch or hurt, he does scratch them occasionally.

His growth and development have been normal and there is no family history of skin disease. He has a 6-year-old brother, who is also healthy and has no skin disease.

1. What are these skin lesions?

2. What is the child's diagnosis?

3. What additional evaluation would you consider?

4. What is his prognosis?




This toddler has infantile acne manifested as open and closed comedones on the cheeks. His growth curve is normal, and a complete physical examination and review of systems failed to reveal any signs of hyperandrogenism such as hirsutism, precocious puberty, or accelerated growth.

Newborn and infantile acne. Acne in the newborn period occurs in over 20% of infants and usually resolves in one to three months.1­3 Although the cause is unknown, neonatal acne appears to result from stimulation of sebaceous glands by maternal and fetal androgens, which wane in the first few months of life. Closed comedones predominate but open comedones, red papules, pustules, and cysts could also be present.

Acne rarely develops after the neonatal period, and when it does, it usually settles down by the time a child reaches 3 years of age.1­3 Cases that persist until puberty have been reported, however. The lesions are variable—comedones, inflammatory papules, and pustules. Cases that have an early onset (less than 6 months of age) and a positive family history of infantile acne tend to have a more serious course, with a resurgence of acne at puberty.2,3 The cause of infantile acne, like neonatal acne, is a temporary increase in gonadal activity. Persistent or severe infantile acne should prompt a search for an abnormal endogenous or exogenous source of androgens.

Treatment of neonatal and infantile acne is rarely indicated. In mild to moderate acne, topical retinoids, benzoyl peroxide, or antibiotics can be used for cosmetic purposes if necessary. In rare cases of severe inflammatory or cystic acne, oral antibiotics and 13-cis-retinoic acid may be required after consultation with a dermatologist. As a precaution, the general pediatrician should probably refer the patient to a dermatologist in severe cases of infantile acne.


1. Janniger CK: Neonatal and infantile acne vulgaris. Cutis 1993;52:16

2. Lucky AW: A review of infantile and pediatric acne. Dermatology 1998;196:95

3. Chew EW, Bingham A, Burrows D, et al: Incidence of acne vulgaris in patients with infatile acne. Clin Exp Dermatol 1990;15:376

THE AUTHOR is Director, Pediatric Dermatology and Cutaneous Laser Center, and Associate Professor of Pediatrics and Dermatology at Johns Hopkins University School of Medicine, Baltimore. He is a Contributing Editor for Contemporary Pediatrics.

The next installment of "Pediatric Dermatology: What's your DX?" will appear in October.


Bernard Cohen. Pediatric Dermatology: What's your DX?. Contemporary Pediatrics 2000;7:29.

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