Neonatal Cephalic Pustulosis

Background

This is also known as neonatal acne and may be related to a common organism found on normal skin, Malassezia, a yeast.

OUTLINE

Epidemiology

Pathogenesis

Prognosis and Treatment

Commonly Used Terms

EPIDEMIOLOGY CHARACTERIZATION

SYNONYMS Neonatal acne

INCIDENCE

AGE RANGE-MEDIAN Newborn

PATHOGENESIS CHARACTERIZATION

MALASSEZIA

Is common neonatal cephalic pustulosis (neonatal acne) triggered by Malassezia sympodialis?

Niamba P, Weill FX, Sarlangue J, Labreze C, Couprie B, Taieh A.

Pediatric Dermatology Unit, Hopital Pellegrin-Enfants, Bordeaux, France.
Arch Dermatol 1998 Aug;134(8):995-8 Abstract quote
BACKGROUND: A type of neonatal cephalic pustulosis that is clinically similar to classic neonatal acne recently has been linked to Malassezia furfur infection. To correlate the mycological and clinical findings in neonates with cephalic pustulosis, we carried out a prospective case-control study in a neonatal unit from February to April 1997 using new techniques for classifying Malassezia species.

OBSERVATIONS: Nineteen patients with cephalic pustulosis and 19 controls younger than 45 days were studied among 161 consecutively hospitalized infants. Cultures from swabs and smears of pustules were obtained from patients, and swabs from healthy site-matched skin were obtained from controls. Three patients were excluded from the study because another cause of pustulosis was found. A blank sampling of pustules was obtained from 2 patients. Test results for 6 of 16 patients were positive for Malassezia sympodialis on contralateral nonpustular skin, and 4 of those patients also had positive cultures for M sympodialis. Cultures from 6 to 19 controls were positive (4 for M furfur and 2 for M sympodialis). The prevalence of Malassezia species increased with age, and the severity of the pustulosis was correlated with the isolation of M sympodialis.

CONCLUSION: Our data suggest that M sympodialis triggers the severe form of common cephalic pustulosis in infants with this benign disorder.

Skin Colonization by Malassezia Species in Neonates

A Prospective Study and Relationship With Neonatal Cephalic Pustulosis

Vincent Bernier, MD; François X. Weill, MD; Virginie Hirigoyen, MD; Christophe Elleau, MD; Anne Feyler, MD; Christine Labrèze, MD; Jean Sarlangue, MD; Geneviève Chène, MD; Bernard Couprie, MD; Alain Taïeb, MD

Arch Dermatol. 2002;138:220-224 Abstract quote

Objectives
To assess skin colonization by Malassezia species in full-term healthy newborns, to investigate factors associated with colonization, and to look at acnelike cephalic pustulosis associated with this carriage.

Design
Samples were obtained from neonates and their mothers 0 to 5 days after birth and again 3 weeks later. Clinical patterns of common acnelike pustulosis were reported as mild (<10 papulopustules), moderate (10 papulopustules), or absent. Direct examination and culture of sample. Identification of yeasts was based on microscopic and physiologic criteria.

Setting
A maternity hospital and the pediatric dermatology unit of a university hospital.

Participants
Consecutive series of 102 neonates and their mothers.

Main Outcome Measures
Incidence of skin colonization and type of Malassezia species found in neonates and correlation with neonatal cephalic pustulosis (neonatal acne).

Results
At the first visit, 11 neonates and 36 mothers had cultures positive for Malassezia. Malassezia sympodialis and Malassezia globosa were preferentially cultured. At 3 weeks, 29 (52%) of 56 neonates and 18 (32%) of 56 mothers had cultures positive for only M sympodialis and M globosa. Breastfeeding was not associated with a higher prevalence of Malassezia carriage in neonates. Malassezia colonization was higher when pustulosis was more severe and M sympodialis was found in pustules.

Conclusions
Malassezia colonization begins at birth and increases in the first weeks of life. A high prevalence of M sympodialis in neonates is noted from birth. Its association with neonatal acne is confirmed. Further investigation is needed to study the role of sebum secretion rate and quality in the neonatal period.

PROGNOSIS AND TREATMENT CHARACTERIZATION

PROGNOSTIC FACTORS

TREATMENT

Neonatal Malassezia furfur pustulosis.

Rapelanoro R, Mortureux P, Couprie B, Maleville J, Taieb A.

Pediatric Dermatology Unit, Pellegrin Children's Hospital, Bordeaux, France.
Arch Dermatol 1996 Feb;132(2):190-3 Abstract quote
BACKGROUND: Papulopustular eruptions of the face in neonates are frequently referred to as neonatal acne or sebaceous miliaria. Our findings suggest that there is an association between this type of eruption and Malassezia furfur infection.

OBSERVATIONS: Direct examination of pustule smears showed M furfur yeasts in eight of 13 cases involving neonates with erythema and papulopustules of the face, neck, and scalp (mean age at onset, 22 days [range, 7 to 30 days]). The pustules were predominantly neutrophilic. Treatment with 2% ketoconazole cream applied topically twice daily was effective in 1 week.

CONCLUSION: Malassezia furfur is frequently associated with a common nonfollicular pustulosis of the newborn, probably improperly termed neonatal acne.

In vitro susceptibility of the seven Malassezia species to ketoconazole, voriconazole, itraconazole and terbinafine.

Gupta AK, Kohli Y, Li A, Faergemann J, Summerbell RC.

Division of Dermatology, Department of Medicine, Sunnybrook and Women's College Health Sciences Center (Sunnybrook Site) and the University of Toronto, Canada.
Br J Dermatol 2000 Apr;142(4):758-65 Abstract quote
Fifty-five strains, either authentic or ex-type, of seven Malassezia species were investigated for in vitro susceptibility to various concentrations (0.03-64.0 microg/mL) of three azole drugs, ketoconazole, voriconazole and itraconazole, as well as the allylamine terbinafine, using the agar dilution method.

All strains of the seven Malassezia species were susceptible to the three azole drugs at low concentrations. M. furfur, M. sympodialis, M. slooffiae, M. pachydermatis, M. globosa, M. obtusa and M. restricta were most sensitive to ketoconazole and itraconazole, with minimum inhibitory concentrations (MICs) ranging from < or = 0.03 to 0.125 microg/mL.

The recently introduced antifungal, voriconazole, was also very effective, with MIC80 values < or = 0.03 microg/mL for 80% of strains. MICs of terbinafine against the seven Malassezia species ranged from </= 0.03 to 64.0 microg/mL. There were variations in susceptibility of the seven Malassezia species to ketoconazole, voriconazole, itraconazole and terbinafine. Strains of M. furfur, M. globosa and M. obtusa were more tolerant to terbinafine than the remaining Malassezia species; M. sympodialis was highly susceptible. M. furfur strains tested with terbinafine ranged from highly susceptible to relatively resistant.

Correct identification of Malassezia species could facilitate selection of appropriate antifungal therapy.

Henry JB. Clinical Diagnosis and Management by Laboratory Methods. Twentieth Edition. WB Saunders. 2001.
Rosai J. Ackerman's Surgical Pathology. Eight Edition. Mosby 1996.
Sternberg S. Diagnostic Surgical Pathology. Third Edition. Lipincott Williams and Wilkins 1999.
Weedon D. Weedon's Skin Pathology. Churchill Livingstone. 1997.
Fitzpatrick's Dermatology in General Medicine. 5th Edition. McGraw-Hill. 1999.

Commonly Used Terms

Rash

Last Updated 3/4/2002

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PATHOGENESIS	CHARACTERIZATION
MALASSEZIA
Is common neonatal cephalic pustulosis (neonatal acne) triggered by Malassezia sympodialis? Niamba P, Weill FX, Sarlangue J, Labreze C, Couprie B, Taieh A. Pediatric Dermatology Unit, Hopital Pellegrin-Enfants, Bordeaux, France.	Arch Dermatol 1998 Aug;134(8):995-8 Abstract quote BACKGROUND: A type of neonatal cephalic pustulosis that is clinically similar to classic neonatal acne recently has been linked to Malassezia furfur infection. To correlate the mycological and clinical findings in neonates with cephalic pustulosis, we carried out a prospective case-control study in a neonatal unit from February to April 1997 using new techniques for classifying Malassezia species. OBSERVATIONS: Nineteen patients with cephalic pustulosis and 19 controls younger than 45 days were studied among 161 consecutively hospitalized infants. Cultures from swabs and smears of pustules were obtained from patients, and swabs from healthy site-matched skin were obtained from controls. Three patients were excluded from the study because another cause of pustulosis was found. A blank sampling of pustules was obtained from 2 patients. Test results for 6 of 16 patients were positive for Malassezia sympodialis on contralateral nonpustular skin, and 4 of those patients also had positive cultures for M sympodialis. Cultures from 6 to 19 controls were positive (4 for M furfur and 2 for M sympodialis). The prevalence of Malassezia species increased with age, and the severity of the pustulosis was correlated with the isolation of M sympodialis. CONCLUSION: Our data suggest that M sympodialis triggers the severe form of common cephalic pustulosis in infants with this benign disorder.
Skin Colonization by Malassezia Species in Neonates A Prospective Study and Relationship With Neonatal Cephalic Pustulosis Vincent Bernier, MD; François X. Weill, MD; Virginie Hirigoyen, MD; Christophe Elleau, MD; Anne Feyler, MD; Christine Labrèze, MD; Jean Sarlangue, MD; Geneviève Chène, MD; Bernard Couprie, MD; Alain Taïeb, MD	Arch Dermatol. 2002;138:220-224 Abstract quote Objectives To assess skin colonization by Malassezia species in full-term healthy newborns, to investigate factors associated with colonization, and to look at acnelike cephalic pustulosis associated with this carriage. Design Samples were obtained from neonates and their mothers 0 to 5 days after birth and again 3 weeks later. Clinical patterns of common acnelike pustulosis were reported as mild (<10 papulopustules), moderate (10 papulopustules), or absent. Direct examination and culture of sample. Identification of yeasts was based on microscopic and physiologic criteria. Setting A maternity hospital and the pediatric dermatology unit of a university hospital. Participants Consecutive series of 102 neonates and their mothers. Main Outcome Measures Incidence of skin colonization and type of Malassezia species found in neonates and correlation with neonatal cephalic pustulosis (neonatal acne). Results At the first visit, 11 neonates and 36 mothers had cultures positive for Malassezia. Malassezia sympodialis and Malassezia globosa were preferentially cultured. At 3 weeks, 29 (52%) of 56 neonates and 18 (32%) of 56 mothers had cultures positive for only M sympodialis and M globosa. Breastfeeding was not associated with a higher prevalence of Malassezia carriage in neonates. Malassezia colonization was higher when pustulosis was more severe and M sympodialis was found in pustules. Conclusions Malassezia colonization begins at birth and increases in the first weeks of life. A high prevalence of M sympodialis in neonates is noted from birth. Its association with neonatal acne is confirmed. Further investigation is needed to study the role of sebum secretion rate and quality in the neonatal period.

Epidemiology
Pathogenesis
Prognosis and Treatment
Commonly Used Terms

EPIDEMIOLOGY	CHARACTERIZATION
SYNONYMS	Neonatal acne
INCIDENCE
AGE RANGE-MEDIAN	Newborn

PROGNOSIS AND TREATMENT	CHARACTERIZATION
PROGNOSTIC FACTORS
TREATMENT
Neonatal Malassezia furfur pustulosis. Rapelanoro R, Mortureux P, Couprie B, Maleville J, Taieb A. Pediatric Dermatology Unit, Pellegrin Children's Hospital, Bordeaux, France.	Arch Dermatol 1996 Feb;132(2):190-3 Abstract quote BACKGROUND: Papulopustular eruptions of the face in neonates are frequently referred to as neonatal acne or sebaceous miliaria. Our findings suggest that there is an association between this type of eruption and Malassezia furfur infection. OBSERVATIONS: Direct examination of pustule smears showed M furfur yeasts in eight of 13 cases involving neonates with erythema and papulopustules of the face, neck, and scalp (mean age at onset, 22 days [range, 7 to 30 days]). The pustules were predominantly neutrophilic. Treatment with 2% ketoconazole cream applied topically twice daily was effective in 1 week. CONCLUSION: Malassezia furfur is frequently associated with a common nonfollicular pustulosis of the newborn, probably improperly termed neonatal acne.
In vitro susceptibility of the seven Malassezia species to ketoconazole, voriconazole, itraconazole and terbinafine. Gupta AK, Kohli Y, Li A, Faergemann J, Summerbell RC. Division of Dermatology, Department of Medicine, Sunnybrook and Women's College Health Sciences Center (Sunnybrook Site) and the University of Toronto, Canada.	Br J Dermatol 2000 Apr;142(4):758-65 Abstract quote Fifty-five strains, either authentic or ex-type, of seven Malassezia species were investigated for in vitro susceptibility to various concentrations (0.03-64.0 microg/mL) of three azole drugs, ketoconazole, voriconazole and itraconazole, as well as the allylamine terbinafine, using the agar dilution method. All strains of the seven Malassezia species were susceptible to the three azole drugs at low concentrations. M. furfur, M. sympodialis, M. slooffiae, M. pachydermatis, M. globosa, M. obtusa and M. restricta were most sensitive to ketoconazole and itraconazole, with minimum inhibitory concentrations (MICs) ranging from < or = 0.03 to 0.125 microg/mL. The recently introduced antifungal, voriconazole, was also very effective, with MIC80 values < or = 0.03 microg/mL for 80% of strains. MICs of terbinafine against the seven Malassezia species ranged from </= 0.03 to 64.0 microg/mL. There were variations in susceptibility of the seven Malassezia species to ketoconazole, voriconazole, itraconazole and terbinafine. Strains of M. furfur, M. globosa and M. obtusa were more tolerant to terbinafine than the remaining Malassezia species; M. sympodialis was highly susceptible. M. furfur strains tested with terbinafine ranged from highly susceptible to relatively resistant. Correct identification of Malassezia species could facilitate selection of appropriate antifungal therapy.