Diaper Dermatitis – Causes, Symptoms, Diagnosis, Treatment and Ongoing care

Basics

Description

  • Diaper dermatitis is a rash occurring under the covered area of a diaper. The rash may be a direct result of wearing the diaper, aggravated by the diaper, or coincidental with a rash that appears elsewhere on the body.
  • System(s) affected: Skin/Exocrine
  • Synonym(s): Diaper rash

Geriatric Considerations

Incontinence is a significant cofactor.

Epidemiology

Incidence

  • The most common dermatitis found in infancy
  • Peak incidence: 7–12 months of age, then decreases

Prevalence

Prevalence has been variably reported from 4–35% in the 1st 2 years of life.

Risk Factors

  • Infrequent diaper changes
  • Waterproof diapers
  • Improper laundering
  • Family history of dermatitis
  • Hot, humid weather
  • Recent treatment with oral antibiotics
  • Diarrhea (>3 stools per day increases risk)
  • Dye allergy
  • Prior history of eczema may increase risk.

General Prevention

Attention to hygiene during bouts of diarrhea

Pathophysiology

  • Fecal proteases and lipases are irritants.
  • Superhydrase urease enzyme found in the stratum cornium liberates ammonia from cutaneous bacteria.
  • Fecal lipase and protease activity is increased by acceleration of GI transit; thus a higher incidence of irritant diaper dermatitis is observed in babies who have had diarrhea in the previous 48 h.
  • Once the skin is compromised, secondary infection by Candida albicans is common. 40–75% of diaper rashes that last >3 days are colonized with C. albicans.
  • Bacteria may play a role in diaper dermatitis through reduction of fecal pH and resulting activation of enzymes.
  • Allergy is exceedingly rare as a cause in infants.

Etiology

  • Wet skin from prolonged contact with urine or feces resulting in susceptibility to chemical, enzymatic, and physical injury; wet skin is also penetrated more easily.
  • Some have raised the possibility of contact allergy from the dye in disposable diapers.

Commonly Associated Conditions

  • Contact (allergic or irritant) dermatitis
  • Seborrheic dermatitis
  • Psoriasis
  • Candidiasis
  • Atopic dermatitis

Seborrhoeic dermatitis, Irritant diaper dermatitis, Contact dermatitis, Skin Disorders, Eczema, disposable diapers,

Diagnosis

History

  • Onset, duration, and change in the nature of the rash
  • Presence of rashes outside the diaper area
  • Associated scratching or crying
  • Contact with infants with a similar rash
  • Recent illness, diarrhea, or antibiotic use
  • Fever
  • Pustular drainage
  • Lymphangitis

Physical Exam

  • Mild forms consist of shiny erythema ± scale.
  • Margins are not always evident.
  • Moderate cases have areas of papules, vesicles, and small superficial erosions.
  • It can progress to well-demarcated ulcerated nodules that measure 1 cm or more in diameter.
  • It is found on the prominent parts of the buttocks, medial thighs, mons pubis, and scrotum.
  • Skin folds are spared or involved last.
  • Tidemark dermatitis refers to the bandlike form of erythema of irritated diaper margins.
  • Diaper dermatitis can cause an id (autoeczematous) reaction outside the diaper area.

Diagnostic Tests & Interpretation

Lab

Initial lab tests

  • Rarely needed
  • Consider a culture of lesions or a KOH preparation.

Follow-Up & Special Considerations

  • The finding of anemia in association with hepatosplenomegaly and the appropriate rash may suggest a diagnosis of Langerhans cell histiocytosis or congenital syphilis.
  • Finding mites, ova, or feces on a mineral oil preparation of a burrow scraping can confirm the diagnosis of scabies.

Pathological Findings

  • Biopsy is rare.
  • Histology may reveal acute, subacute, or chronic spongiotic dermatitis.

Differential Diagnosis

  • Contact dermatitis
  • Seborrheic dermatitis
  • Candidiasis
  • Atopic dermatitis
  • Scabies
  • Acrodermatitis enteropathica
  • Letterer-Siwe disease
  • Congenital syphilis
  • Child abuse
  • Streptococcal infection
  • Kawasaki disease
  • Biotin deficiency
  • Psoriasis
  • HIV infection

Treatment

See “General Measures” for 1st-line approach.

Medication

First Line

  • For a pure contact dermatitis, a low-potency topical steroid (hydrocortisone 0.5–1% t.i.d.) and removal of the offending agent should suffice.
  • If candidiasis is suspected or diaper rash persists, use an antifungal such as miconazole nitrate 2% cream, miconazole powder, econazole (Spectazole), clotrimazole (Lotrimin), or ketoconazole (Nizoral) cream at each diaper change (1)[B].
  • If inflammation is prominent, consider a very low-potency steroid cream such as hydrocortisone 0.5–1% t.i.d. along with an antifungal cream ± a combination product such as clioquinol-hydrocortisone (Vioform–hydrocortisone) cream (1)[B].
  • If a secondary bacterial infection is suspected, use an antistaphylococcal oral antibiotic or mupirocin (Bactroban) ointment topically.
  • Precautions: Avoid high- or moderate-potency steroids often found in combination steroid antifungal mixtures (1)[B].

Second Line

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Sucralfate paste for resistant cases

Additional Treatment

General Measures

  • Expose the buttocks to air as much as possible (1).
  • Avoid waterproof pants during treatment (day or night); they keep the skin wet and subject to rash or infection.
  • Change diapers frequently, even at night, if the rash is extensive (2).
  • Superabsorbable diapers are beneficial (1,2)[B].
  • Discontinue using baby lotion, powder, ointment, or baby oil (except zinc oxide).
  • Disposable baby wipes contain substances that induce contact or irritant dermatitis, such as fragrance, benzalkonium chloride, and isothiazolinone or alcohol.
  • Apply zinc oxide ointment or other barrier cream to the rash at the earliest sign and b.i.d. or t.i.d. (e.g., Desitin or Balmex). Thereafter, apply to clean, thoroughly dry skin (1).
  • Use mild soap, and pat dry.
  • Cornstarch can reduce friction. Talc powders that do not enhance the growth of yeast can provide protection against frictional injury in diaper dermatitis but do not form a continuous lipid barrier layer over the skin and obstruct the skin pores. These treatments are not recommended.

Issues for Referral

Consider if a systemic disease such as Langerhans cell histiocytosis, acrodermatitis enteropathica, or HIV infection is suspected.

In-Patient Considerations

Admission Criteria

  • Febrile neonates
  • Recalcitrant rash suggestive of immunodeficiency
  • Toxic-appearing infants

Nursing

Assist 1st-time parents with hygiene education.

Ongoing Care

Follow-Up Recommendations

Patient Monitoring

Recheck weekly until clear; then at times of recurrence.

Patient Education

Patient education is vital to the treatment and prevention of recurrent cases.

Prognosis

  • Quick, complete clearing with appropriate treatment
  • Secondary candidal infections may last a few weeks after treatment is begun.

Complications

  • Secondary bacterial infection [consider community-acquired methicillin-resistant Staphylococcus aureus (MRSA) in pustular dermatitis that does not respond to normal therapy]
  • Rare complication is inoculation with group A β-hemolytic Streptococcusresulting in necrotizing fascitis.
  • Secondary yeast infection

References

1. Scheinfeld N. Diaper dermatitis: A review and brief survey of eruptions of the diaper area. Am J Clin Derm. 2005;6:273–81.

2. Janniger CK, Thomas I. Diaper dermatitis: an approach to prevention employing effective diaper care. Cutis. 1993;52:153–5.

Additional Reading

Alberta L, et al. Diaper dye dermatitis. Pediatrics. 2005;116(3):450–2.

Kazaks EL, et al. Diaper dermatitis. Pediatr Clin North Am. 2000;47(4):909–19.

See Also (Topic, Algorithm, Electronic Media Element)

Algorithm: Rash, Focal

Codes

ICD9

  • 112.3 Candidiasis of skin and nails
  • 691.0 Diaper or napkin rash

Snomed

  • 91487003 diaper rash (disorder)
  • 240711004 diaper candidiasis (disorder)

Clinical Pearls

  • Hygiene is the main preventative measure.
  • Look for secondary infection in persistent cases.

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