AUTHOR AND EDITOR INFORMATION

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• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Diaper rash, or diaper dermatitis, is a general term describing any of a number of inflammatory skin conditions that can occur in the diaper area. These disorders can be conceptually divided into 3 categories:

1. Rashes that are directly or indirectly caused by the wearing of diapers. This category includes dermatoses, such as irritant contact dermatitis, miliaria, intertrigo, candidal diaper dermatitis, and granuloma gluteal infantum.
2. Rashes that appear elsewhere but can be exaggerated in the groin area due to the irritating effects of wearing a diaper. This category includes atopic dermatitis, seborrheic dermatitis, and psoriasis.
3. Rashes that appear in the diaper area irrespective of diaper use. This category includes rashes associated with bullous impetigo, Langerhans cell histiocytosis (Letterer-Siwe disease, a rare and potentially fatal disorder of the reticuloendothelial system), acrodermatitis enteropathica (zinc deficiency), congenital syphilis, scabies, and HIV.

Allergic contact dermatitis is exceedingly rare in the infant and is not discussed here. The focus of this chapter is on the pathophysiology, diagnosis, and treatment of the rashes in the first category. By definition, these are truly diaper rashes because they present as a rash in the diaper area and can be cured by a change in diapering practices. The dermatoses within the other 2 categories do not typically appear as a diaper rash alone, nor do they necessarily respond to diapering modifications. These more generalized diseases are mentioned in terms of helping the emergency physician make the correct diagnosis. However, details about their etiology and management are beyond the scope of this chapter.

Pathophysiology

The precise etiology of most diaper rashes is not clearly defined. They likely result from a combination of factors that begin with prolonged exposure to moisture and the contents of the diaper (ie, urine and feces).

The main irritants in this situation are fecal proteases and lipases, whose activity is increased greatly by elevated pH. An acidic skin surface is also essential for the maintenance of the normal microflora, which provides innate antimicrobial protection against invasion by pathogenic bacteria and yeasts. Fecal lipase and protease activity is also greatly increased by acceleration of gastrointestinal transit; this is the reason for the high incidence of irritant diaper dermatitis observed in babies who have had diarrhea in the previous 48 hours.

The wearing of diapers causes a significant increase in skin wetness and pH. Prolonged wetness leads to maceration (softening) of the stratum corneum, the outer, protective layer of the skin, which is associated with extensive disruption of intercellular lipid lamellae. Weakening of its physical integrity makes the stratum corneum more susceptible to damage by (1) friction from the surface of the diaper, and (2) local irritants.

At full term, the skin of infants is an effective barrier to disease and is equal to adult skin with regard to permeability. However, dampness, lack of air exposure, acidic or irritant exposures, and increases in skin friction begin to break down the skin barrier.

The normal pH of the skin is between 4.5 and 5.5. When urea from the urine and stool mix, urease breaks down the urine, decreasing the hydrogen ion concentration (increasing pH). Elevated pH levels increase the hydration of the skin and make the skin more permeable.

Previously, ammonia was believed to be the primary cause of diaper dermatitis. Recent studies have disproved this, showing that when ammonia or urine is placed on the skin for 24-48 hours, no apparent skin damage occurs.

Miliaria

Obstruction of eccrine sweat glands when the stratum corneum becomes excessively hydrated and edematous is believed to cause miliaria.

Intertrigo

Intertrigo occurs when wet skin, which is more fragile and has a higher coefficient of friction, becomes damaged from maceration and chafing.

Contact dermatitis

Irritant contact dermatitis is most likely made up of some combination of intertrigo and miliaria. In addition, it has been shown to result from the irritating effects of mixing urine with feces. Urine in the presence of fecal urease becomes more alkaline due to the production of ammonia. This alkaline urine causes activation of fecal lipases, ureases, and proteases. These, in turn, irritate the skin directly and increase its permeability to other low molecular weight irritants.

Candidal diaper dermatitis

Once the skin is compromised, secondary infection by Candida albicans is common. Between 40% and 75% of diaper rashes that last for more than 3 days are colonized with Candida albicans. Candida has a fecal origin, and is not an organism normally found on perineal skin. Amoxicillin was found to increase the colonization by Candida and worsens the diaper dermatitis.

Bacterial diaper dermatitis

Bacteria may play a role in diaper dermatitis through reduction of fecal pH and the resultant activation of enzymes. Additionally, fecal microorganisms probably contribute to secondary infections, when they occur. This is particularly evident with bullous impetigo in the diaper area, which causes bullae that are flaccid but sometimes tense due to Staphylococcus aureus infection, or a cellulitis due to cutaneous streptococci, or even a folliculitis due to S aureus infection.

Polymicrobial growth is documented in at least half of diaper rash cultures. Staphylococcus species are the most commonly grown organisms, followed by Streptococcus species and organisms from the family Enterobacteriaceae. Nearly 50% of isolates also contain anaerobes.

Granuloma gluteal infantum

Granuloma gluteal infantum is a rare disorder. It is not very well understood, but it probably represents an unusual inflammatory response to long-standing irritation, candidiasis, or fluorinated corticosteroids.

Frequency

United States

Diaper rash is the most common dermatitis found in infancy. Prevalence has been variably reported from 4-35% in the first 2 years of life. Incidence triples in babies with diarrhea. It is not unusual for every child to have at least 1 episode of diaper rash by the time he or she is toilet-trained.

Because fewer than 10% of all diaper rashes are reported by the family, the actual incidence of this condition is likely underestimated if office visits are used as the screening site.

The incidence is lower among breastfed infants—perhaps due to the less acidic nature of their urine and stool. Babies wearing superabsorbent disposable diapers with a central gelling material have fewer episodes of diaper dermatitis compared with their counterparts wearing cloth diapers. However, keep in mind that superabsorbent diapers contain dyes that were suspected to cause allergic contact dermatitis (ACD). One study reviewed the effect on the skin of dye-free diapers as compared with dye-containing diapers. A patch testing result with dye similar to that in diapers was positive in 2 out of 4 patients. This study also reported improvement with dye-free diapers for all of the patients. This would support the hypotheses that these children had allergic contact dermatitis attributable to the various dyes in the diapers. The patterns of eruption and the responses to dye-free diapers support a diagnosis of ACD. Colors are added to diapers primarily for aesthetic purposes or absorbency

potential.

International

Few investigations have been reported regarding prevalence outside of the US. However, one study performed in Italy showed a prevalence of 15.2%, and a peak incidence of 19.4% in those aged 3-6 months.

One large British study reported diaper dermatitis in 25% of children aged 1 month.

A Nigerian study conducted in 1995-1996 identified diaper dermatitis in 7% of children.

A study in Kuwait noted that diaper dermatitis occurs in 4% of pediatric dermatology cases.

These studies do not distinguish between common or generic diaper dermatitis and secondary diaper dermatitis.

Mortality/Morbidity

• This disease is not usually life threatening; however, it may cause significant distress for parents.
• Morbidity for the child mostly is in the form of pain and itching in the affected areas.
• In one report, diaper rash accounted for nearly 20% of pediatric office visits.

Race

Atopic dermatitis and related diaper dermatitis are more common among African American patients.

Sex

No sexual predilection exists.

Age

• Diaper rashes can start in the neonatal period as soon as the child begins to wear diapers.
• The incidence peaks in those aged 7-12 months, then decreases with age.
• Diaper rash stops being a problem once the child is toilet trained, usually around age 2 years.

CLINICAL

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

One study review performed in the United Kingdom reported that irritant diaper dermatitis does not usually develop immediately after birth; onset is generally between 3 weeks and 2 years of age, with prevalence highest between 9 and 12 months. This study showed that one fifth of all pediatric dermatology visits for children up to the age of 5 years were to treat diaper dermatitis.

• Diagnosis of diaper dermatitis is based largely on the physical examination. A careful history, however, could elicit clues that aid in narrowing the differential diagnosis.
• Important points to obtain on history include the following:
• • 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
• Assessment of current diapering practices (eg, change frequency, type of diapers used, creams or ointments applied, methods used to clean the diaper area)
• Irritant contact dermatitis, miliaria (heat rash), and intertrigo
  • Usually follows a bout of diarrhea
  • Exacerbated by scrubbing and the use of commercial wipes or strong detergents
  • Lasts less than 3 days after more diligent diaper changing practices are initiated
  • Asymptomatic (except for miliaria)
• Candidal diaper dermatitis
  • Lasts even after more diligent diaper changing practices are started
  • Should be suspected in all rashes lasting more than 3 d (Candida is isolated in 45-75% of such cases)
  • Painful - Parents often report severe crying during diaper changes or with urination and defecation.
  • May follow recent antibiotic use
• Secondary bacterial infection
  • Fever
  • Pustular drainage
  • Lymphangitis
• Granuloma gluteal infantum
  • Rash lasts months
  • Resistant to treatments with barrier creams, antifungal agents, and topical steroids
  • Asymptomatic
• Atopic dermatitis
  • Family or personal history of allergic rhinitis, hay fever, or asthma is common.
  • Pruritic
  • Associated with current or previous flares of rash on the face and extensor limb surfaces in infants
• Seborrheic dermatitis
  • Usually occurs in infants aged 2 weeks to 3 months
  • Consists of an eruption of an oily, scaly, crusted dermatitis of the scalp (cradle cap), face, retroauricular regions, axilla, and presternal areas
  • Asymptomatic
  • Any child with widespread seborrheic dermatitis, diarrhea, and failure to thrive should be evaluated for Leiner disease, a functional defect of the C5 component of complement.
• Psoriasis
  • A family history of psoriasis can be a clue.
  • Not responsive to barrier creams, antifungal agents, and standard topical steroids
  • Involved areas include the scalp and nails
• Impetigo
  • Common in the first 6 months of life
  • Usually occurs during the warmer summer months
• Langerhans cell histiocytosis
  • Severe hemorrhagic diaper dermatitis unresponsive to any treatment
  • Other involved areas include the scalp and retroauricular areas
  • Diarrhea
• Acrodermatitis enteropathica
  • Associated with diarrhea, hair loss, and erosive perioral dermatitis
  • Patient may have a predisposition for malabsorption (ie, cystic fibrosis) or malnutrition
• Scabies
  • Acute onset
  • Pruritic
  • History of close contacts with recent onset of a similar erythematous serpiginous eruption
  • Concurrent rash may be found in web spaces of hands or feet
• Human immunodeficiency virus
  • History of HIV exposure or risk factors
  • Associated cytomegalovirus or herpes infection

Physical

The pertinent physical examination focuses on the skin in the diaper area. Findings vary depending on which subset of diaper rash is most prominent.

• Irritant contact dermatitis
  • Mild forms consist of shiny erythema with or without 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 a centimeter 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 with reaction outside the diaper area.
• Intertrigo
  • Occurs in skin creases where skin surfaces are in apposition
  • Characterized by slight to severe erythema in the inguinal area, intergluteal area, or folds of the thighs
  • Pustules or erosions are not present.
• Miliaria
  • Consists of multiple discrete, pruritic, erythematous papulovesicles, and sterile vesiculopustules.
  • Similar lesions on the face, neck, and axilla may be present.
• Candidal dermatitis
  • Distinctive clusters of erythematous papules and pustules are present, which later coalesce into a beefy red confluent rash with sharp borders.
  • Satellite lesions frequently are found beyond these borders.
  • Skin folds commonly are involved.
  • White scales may be observed occasionally.
  • The oropharynx should be inspected for the white plaques of thrush.
• Secondary bacterial infection
  • Edema
  • Erythema
  • Tenderness
  • Purulent discharge
  • Red streaking
• Granuloma gluteal infantum
  • Uncommon disorder
  • Painless reddish-brown to purplish nodules are observed.
  • These granulomatous nodules can have large, raised erosions with rolled margins and a purple, almost Kaposi sarcoma–like color.
  • Nodules range in size from 0.5-4 cm.
  • Limited to prominent areas of the groin, such as the thighs, abdomen, and genitalia.
  • Axilla and neck involvement has been reported.
  • Jacquet diaper dermatitis (dermatitis syphiloids posterosiva) is a term used to describe a severe noduloerosive lesion with an umbilicated or craterlike presentation in the diaper area. It is probably closely related to granuloma gluteal and is a variant of diaper dermatitis.
• Atopic dermatitis
  • Acute lesions appear as poorly demarcated, erythematous, scaly, weepy, and crusted.
  • Chronic lesions are poorly defined, thickened, hyperpigmented, and often excoriated.
  • Lichenification can occur with chronic disease.
  • Distribution rarely involves the diaper area. It is more commonly observed on the face and extensor limb surfaces in children of diaper-wearing age.
• Seborrheic dermatitis
  • Well-demarcated erythematous patches or plaques with an occasional greasy yellow scale.
  • When found in the groin area, the skin creases show more severe involvement.
  • Skin folds are not spared.
  • There are no satellite lesions.
  • Oily, scaly, crusted lesions also can be found in areas with a predominance of sebaceous glands (eg, scalp, face, retroauricular regions, axilla, presternal area).
• Psoriasis
  • Bright, red, well-defined plaques
  • Unlike typical psoriatic lesions elsewhere, silvery scales usually are not present in the diaper area due to the dampness of the area.
  • Inguinal folds typically are involved.
  • Involvement outside the diaper area is most common (>90% of cases) and may appear as retroauricular erythema or as nail dystrophy or pitting.
• Impetigo
  • Vesicles, pustules, bullae, or crusts are commonly found in the periumbilical area.
  • In the diaper area, bullae are not usually intact.
  • They actually present as superficial erosions with a thin peripheral rim of bullous tissue.
• Langerhans cell histiocytosis
  • Discrete, yellow-brown scaly or erythematous papules, purpuric papules, petechiae, deep ulcerations, and skin atrophy are present.
  • Hemorrhagic features are typical.
  • Usually involves skin folds
  • May have associated anemia, lymphadenopathy, and hepatosplenomegaly
  • May have associated involvement of the CNS, lungs, bones, and bone marrow
• Acrodermatitis enteropathica
  • Typically involves the perioral, perineal, and acral areas
  • Erythematous, well-demarcated, scaly plaques and erosions
  • Alopecia and growth failure
  • Irritability
• Congenital syphilis
  • Symmetric desquamation of palms and soles can be found.
  • Papulosquamous, reddish-brown lesions are observed in the diaper area. Rarely, these can be erosive or bullous.
  • Associated with anemia, hepatosplenomegaly, jaundice, and osseous lesions
• Scabies
  • Papules, vesicles, burrows, nodules, and excoriations are found.
  • The generalized distribution has a predilection for the palms, soles, face, scalp, and genitalia.
• Human immunodeficiency virus
  • When this presents as a diaper rash, severe erosions and ulcerations are often present.
  • Distribution to the perineal area, especially the gluteal cleft, may be observed.
• Perianal pseudoverrucous papules
  • This condition is characterized by 2-8 shiny, smooth, red, moist, flat-topped, round lesions with acanthosis or psoriasiform spongiotic dermatitis.
  • Whereas granuloma gluteal can be confused with Kaposi sarcoma, perianal pseudoverrucous papules are most commonly confused with genital warts.
  • Perianal pseudoverrucous papules and nodules can occur in the context of Hirschsprung disease.

Causes

• A precise etiology of common diaper rashes has not been determined. Rashes have been associated with the following:
• • Infrequent diaper changes
  • Improper cleansing and drying of the diaper area
  • Failure to apply topical preparations to protect the skin
  • Diarrhea
• Candida is a common cause of secondary infection.
• Other possible sources of secondary infection include species of Staphylococcus, Streptococcus, and enteric anaerobes (Bacteroides and Peptostreptococcus species).

DIFFERENTIALS

Section 4 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to be Considered

Seborrheic dermatitis
Letterer-Siwe disease
Acrodermatitis enteropathica
Chronic bullous dermatitis of childhood
Overtreatment dermatitis
Perianal dermatitis
Steroid induced dermatitis ("topica")
Bullous pemphigoid
Pemphigoid
Incontinentia pigmenti
Molluscum contagiosum
Hand-foot-mouth disease
Kaposi sarcoma

WORKUP

Section 5 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• The primary forms of diaper rash generally can be diagnosed clinically. Laboratory studies have few indications and limited utility.
• A complete blood count may be helpful, especially if a fever is present and a secondary bacterial infection is suspected.
• The finding of anemia in association with hepatosplenomegaly and the appropriate rash may suggest a diagnosis of Langerhans cell histiocytosis or congenital syphilis.
• • When suspecting congenital syphilis, relevant serology should be sent.
  • Dark field microscopic examination for spirochetes from any bullous lesion scrapings can be performed.
• Serum zinc level of less than 50 mcg/dL can confirm acrodermatitis enteropathica.
• Gram stain or culture of the characteristic bullae of impetigo for S aureus can confirm this diagnosis.
• Routine cultures demonstrate polymicrobial infections (eg, streptococci, Enterobacteriaceae, and anaerobes) in nearly one half of cases.

Other Tests

• Potassium hydroxide (KOH) scrapings from a fresh papular or pustular lesion may demonstrate pseudohyphae in suspected cases of candidiasis. However, these may be absent in long-standing cases.
• Finding mites, ova, or feces on a mineral oil preparation of a burrow scraping can confirm the diagnosis of scabies.

Procedures

• Skin biopsy can be performed to help differentiate granuloma gluteal infantum from granulomatous and neoplastic processes.
• • Histopathology, granuloma gluteal presents as nonspecific dermal inflammatory infiltrate composed of neutrophils, lymphocytes, histiocytes, plasma cells, occasional giant cells, and eosinophils, sometimes with an increase in the number of capillaries.
  • Examination of granuloma gluteal using an electron microscope reveals 3 types of giant cells: in the first type, the cells have widely enlarged endoplasmic reticulum; in the second type, they phagocytize erythrocytes; and in the third type, they have vesicles and granules and are similar to histiocytes. The name granuloma gluteal infantum is a misnomer since no granulomas are found in these lesions.
  • Skin biopsy also is used to confirm the diagnosis of Langerhans cell histiocytosis.

TREATMENT

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• Medication
• Follow-up
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Emergency Department Care

The emergency physician's role in this disease is to make a proper diagnosis, to educate the care givers, and to treat any acute complications that have occurred due to an untreated rash.

• Irritant contact dermatitis, miliaria, and intertrigo often can be treated nonmedically through changes in diapering practices.
• The emergency physician should advise the parent to keep the skin in the diaper area as dry as possible.
• This may entail the following:
  • More frequent diaper changes to limit the amount of time the skin is exposed to urine and feces
  • Exposing the skin under the diaper to open air as much as possible throughout the day
  • Switching to a disposable brand of diapers containing superabsorbent gelling material: Superabsorbent disposable diapers contain an absorbent gelling material (AGM) that wicks away moisture. Studies suggest that these diapers are associated with less-severe diaper rashes. Conventional disposable diapers were not found to be superior to reusable cloth diapers.
  • Exposing the skin under the diaper to open air as much as possible throughout the day
• Tight-fitting diapers should be avoided.
• Recently, 3 new types of diapers have been devised which further reduce the incidence of diaper rash.
  • A disposable diaper, which continuously administers a topical petrolatum formulation to the skin, has been shown to reduce the severity of diaper rash significantly compared with a conventional disposable diaper.
  • Breathable disposable diapers have been shown to reduce the incidence of candidal infection by 38-50% and to also reduce the survival of Candida colonies by two thirds. The prevalence of diaper rash in this study was inversely related to the breathability of the diaper.
  • Another innovation is the insertion of a water impermeable but vapor permeable membrane within diaper layers. This selectively permeable membrane allows the water vapor to escape, but prevents urine leak, and thus keeps the skin dry. In a study, this diaper has been shown to reduce the incidence of severe and mild diaper dermatitis by 39% and 18%, respectively.
• The use of barrier creams, such as zinc oxide paste or petroleum jelly, is recommended to minimize urine and fecal contact with the skin. Other useful creams include vitamin A & D ointment and Burow solution.
  • The principal functional effects of damage to the stratum corneum will be, firstly, an increase in the outward permeation of water, known as transepidermal water loss (TEWL), and secondly, an increase in the inward permeation of a wide variety of potentially harmful molecules and microbes. Barrier preparations work in 2 ways, either by providing a lipid film over the surface of the skin and/or by providing lipids that can penetrate into the stratum corneum, simulating the effects of normal intercellular lipids.
  • Effective treatment of diaper rash with bufexamac (Parfenac) lipid ointment has been reported in one study.
  • Application of 2% eosin is effective in treating diaper area dermatitis.
  • Some have claimed that topical application of vitamin A ameliorates diaper dermatitis. In a Cochrane Database Systematic Review, a review studying the use of topical vitamin A for the treatment of napkin dermatitis there was no evidence to support or refute the use of topical vitamin A preparations (Davies, 2005). For the prevention of napkin dermatitis, no evidence suggested that topical vitamin A alters the development of napkin dermatitis. Further, RCTs are required to determine whether topical vitamin A is efficacious in treating or preventing napkin dermatitis.
  • Topical sucralfate has been reported effective for erosive irritant diaper dermatitis in a patient with chronic diarrhea.
  • Cornstarch can reduce friction, and talc powders that do not enhance the growth of yeast can provide protection against frictional injury in diaper dermatitis, but it does not form a continuous lipid barrier layer over the skin and obstruct the skin pores. These treatments are not recommended.
  • Topical cholestyramine ointment may be a safe and efficacious treatment option for perianal irritation due to bile acids and high output stools.
  • White soft paraffin BP is not really recommended for routine use. It is exceptionally occlusive when compared with other emollients and is, therefore, less than ideal for continuous use, since complete occlusion can prevent the recovery of damaged stratum corneum.
  • Two clinical trials have demonstrated that an ointment containing dexpanthenol, Bepanthen Ointment (Roche Consumer Health, UK), can help prevent and treat IDD.
  • Some formulations also contains lanolin, which is one of the most physiological emollient constituents currently available, containing many of the lipid groups present in the human stratum corneum and having the advantage of permitting water exchange.
• Oral zinc was found to be helpful in one study.
• Parents should be taught how to clean the diaper area.
  • Excessive scrubbing should be avoided.
  • Instead, urine can be rinsed away with warm tap water and feces can be removed with warm water and mild nonperfumed soap.
  • Commercial baby wipes and cornstarch should not be used due to the irritant effect of their contents on skin. Disposable baby wipes contain substances that induce contact or irritant dermatitis, such as fragrance, benzalkonium chloride, and isothiazolinone or alcohol.
• If changing in diapering practice is followed, irritant contact dermatitis, miliaria, and intertrigo should resolve very quickly.
• If a mild, irritant, noninfected dermatitis is found, a cream may be all that is needed.
  • A cream containing zinc oxide will be appropriate.
  • An ointment is a thicker barrier with petrolatum and offers more protection.
  • A severe diaper rash requires aggressive treatment. A paste is the topical agent of choice. Pastes are thicker, contain petrolatum, higher concentrations of zinc oxide, karaya powder in some, moisturizers, and other additives to aid in protection, prevention, healing, and comfort.
  • It is suggested with some of these products to cover the paste with a thin layer of petroleum jelly so that the paste does not stick to the diaper or to prevent opposing skin surfaces from sticking together.
• For the typical irritant dermatitis or intertrigo, a nonfluorinated, low-potency corticosteroid ointment or cream (ie, 1% hydrocortisone) can be prescribed for no longer than 2 weeks.
  • The ointment or cream should be applied to the affected areas 4 times daily with diaper changes.
  • The parent should be advised to avoid fixed combination medications, such as Mycolog II or Lotrisone. The steroids in these compounds are too potent to be safely used in the occlusive diaper environment. Usage can cause skin atrophy, striae, adrenal suppression, and Cushing syndrome.
• If candidal infection is suspected, topical ointments or creams, such as nystatin, clotrimazole, miconazole, or ketoconazole can be applied to the rash with every diaper change.
  • Combination antifungal-steroid agents, such as Mycolog II or Lotrisone, should not be used because the high steroid concentration in the occlusive diaper area might cause Cushing syndrome. A review studied the use of a combination product of miconazole and hydrocortisone preparation and compared it with a combination product of nystatin/benzalkonium chloride/dimethicone/hydrocortisone preparation, both were found to improve the appearance of diaper dermatitis.
  • If oral thrush or perianal candidiasis is present or if repeated bouts of candidal dermatitis have occurred, oral nystatin should also be prescribed.
  • Ciclopirox was used and studied for the treatment of candidal diaper dermatitis and was found to be safe and effective.
• For mild bacterial infections, a topical antibiotic ointment (ie, bacitracin) should be prescribed.
  • More severe infections caused by gram-positive organisms and anaerobes can be treated with a broad-spectrum oral antibiotic (ie, amoxicillin/clavulanate, 40-mg amoxicillin component/kg/d for 7-10 d).
  • Impetigo can be treated with dicloxacillin 12.5-25 mg/kg/d or erythromycin 50 mg/kg/d for 7-10 d.
  • Congenital syphilis can be treated with 1 dose of IM penicillin G 50,000 U/kg.
• In the case of granuloma gluteal infantum, recovery seems to be slow (several months), but complete.
  • Low potency topical steroids may accelerate resolution in some patients.
  • Management of this disease is beyond the scope of emergency care.
  • Referral to a dermatologist for management and long-term follow-up care is recommended.

  Skin Care Ingredients Found in Diaper Rash Creams, Ointments, and Pastes

  Several products are available for the care, management, and maintenance of skin integrity. The following are examples of ingredients frequently found in skin care products.
  Petrolatum	Skin protectant, water repellant, a barrier
  Zinc oxide	Skin protectant, soothes irritated skin
  Dimethicone	Skin protectant
  Vitamins A and D	Skin conditioner
  Karaya	Viscosity modifier and absorbs moisture
  Mineral oil, lanolin, glycerin	Emollient, softens and soothes irritated skin, a lubricant Humectant, hydroscopic (brings water to the surface of the skin producing a moisturizing effect)
  Vitamin E acetate	Skin conditioner
  Isopropyl palmitate	Skin conditioner
  Purified water	Diluent
  Chloroxylenenol (PCMX)	Antimicrobial, kills or inhibits bacteria
  Isopropol alcohol	Antimicrobial
  Miconazole nitrate	Antifungal
  Carboxymethylcelluse sodium	Viscosity modifier
  Methyl glucose dioleate	Emulsifier, added to water-oil preparations to prevent the oil from separating from the water
  Stearate acid	Emulsifier
  Butylparaben	Preservative, prevents breakdown of product and destroys or prevents growth of bacteria
  Methylparaben	Preservative
  Triethaolamine	pH adjuster (normal pH of skin is 4.5-5.5)
  Aminomethyl proponol	pH adjuster
  Cetyl alcohol	Emollient and thickening agent

  Adapted from Pediatr Nurs. 2004 Nov-Dec; 30(6): 467-70.

Consultations

• Most diaper rashes cared for by emergency physicians do not require consultation.
• If a systemic disease such as Langerhans cell histiocytosis, acrodermatitis enteropathica, or HIV is suspected, consultation with a pediatrician or an infectious disease specialist and consideration for admission is appropriate.

MEDICATION

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• Miscellaneous
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Medical treatment of diaper rash primarily involves topical corticosteroids to reduce the inflammatory response in irritated areas of skin and antifungal or antibiotic agents to treat secondary infections.

Drug Category: Corticosteroid, topical

Suppresses inflammation and itching.

Drug Category: Antifungal agents

For use in candidal diaper dermatitis. Binds to sterols in fungal cell membrane allowing for leakage of cellular contents. Oral antifungals are indicated if coexisting thrush is found.

Drug Category: Antibiotics, topical

Used in treating mild bacterial superimposed infections.

Drug Category: Antibiotics, oral

Used in treating more aggressive bacterial superimposed infections.

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Further Inpatient Care

• The following should be admitted to a pediatric ward for further workup.
  • Febrile neonates
  • Toxic appearing patients
  • Children with a severe recalcitrant rash suggestive of immunodeficiency

Further Outpatient Care

• Arrange for follow-up care with a pediatrician in 1-2 days.

Deterrence/Prevention

• Expose the buttocks to air as much as possible.
• Do not use waterproof pants during treatment, as they keep skin wet and subject to rash or infection.
• Change diapers frequently.
• Superabsorbent diapers are beneficial.

Complications

• Because of maceration and abrasion of the skin under the diaper, skin ulceration and secondary infection by C albicans or bacteria are common.
• Prevalence of a secondary bacterial infection is uncertain, but it is frequent. Multiple organisms, both aerobic and anaerobic, contribute to the development of this condition.
• Psoriasis id reaction refers to a psoriaticlike eruption of papules and plaques after the initiation of treatment to a candidal infection.
  • Involves the torso and the upper body and usually spares the extremities
  • Occurs days after antifungal therapy is started
  • Is poorly understood but can be treated with low or intermediate potency steroids
• Jacquet dermatitis is a complicated form of the irritant chafing type of diaper rash.
  • It involves the development of erosive ulcerations with elevated margins.
  • Some nodular patterns also are described in severe chronic irritant dermatitis.
  • Cases remain surprisingly asymptomatic and usually are not secondarily infected.
• Psoriasiform napkin dermatitis refers to a clinical presentation that combines features of seborrheic and candidal diaper rashes.
• Secondary bacterial and yeast infections

Prognosis

• Most cases completely resolve after a concerted effort by the parents toward diaper hygiene.
• The time to resolution is typically a few days for uncomplicated irritant dermatitis, intertrigo, and miliaria.
• Candidal infections last a few weeks after treatment is begun.
• At least one half of the cases of atopic dermatitis resolve by the third year of life.
• Granuloma gluteal infantum tends to resolve spontaneously over the course of a few months.
• Langerhans cell histiocytosis is usually a fatal disease.

Patient Education

• The parents of the patient should be educated about proper diaper hygiene and the need for frequent diaper changes to prevent future episodes.
• Parents should be taught how to recognize changes in the rash indicative of a secondary infection and should be advised to seek medical attention in such instances.
• For excellent patient education resources, visit eMedicine's Children's Health Center. Also, see eMedicine's patient education articles Diaper Rash, Skin Rashes in Children, and Yeast Infection Diaper Rash.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Failure to consider serious systemic illness, such as Letterer-Siwe or acrodermatitis enteropathica, especially in a child with physical findings other than rash
• Prescribing a topical steroid that is too potent for the occlusive environment under the diaper
• Failure to recognize and treat a bacterial cellulitis
• Exacerbating a case of herpes zoster by treatment with steroids

MULTIMEDIA

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Diaper rash.
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Media file 2:  Diaper rash.
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Media type:  Photo

Media file 3:  Diaper rash.
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Media type:  Photo

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

• Alberta L, Sweeney SM, Wiss K. Diaper dye dermatitis. Pediatrics. Sep 2005;116(3):e450-2. [Medline].
• Atherton D. Maintaining healthy skin in infancy using prevention of irritant napkin dermatitis as a model. Community Pract. Jul 2005;78(7):255-7. [Medline].
• Atherton D, Mills K. What can be done to keep babies' skin healthy?. RCM Midwives. Jul 2004;7(7):288-90. [Medline].
• Atherton DJ. A review of the pathophysiology, prevention and treatment of irritant diaper dermatitis. Curr Med Res Opin. May 2004;20(5):645-9. [Medline].
• Berg RW. Etiology and pathophysiology of diaper dermatitis. Adv Dermatol. 1988;3:75-98. [Medline].
• Berg RW, Buckingham KW, Stewart RL. Etiologic factors in diaper dermatitis: the role of urine. Pediatr Dermatol. Feb 1986;3(2):102-6. [Medline].
• Borkowski S. Diaper rash care and management. Pediatr Nurs. Nov-Dec 2004;30(6):467-70. [Medline].
• Brook I. Microbiology of secondarily infected diaper dermatitis. Int J Dermatol. Oct 1992;31(10):700-2. [Medline].
• Buckingham KW, Berg RW. Etiologic factors in diaper dermatitis: the role of feces. Pediatr Dermatol. Feb 1986;3(2):107-12. [Medline].
• Davies MW, Dore AJ, Perissinotto KL. Topical vitamin A, or its derivatives, for treating and preventing napkin dermatitis in infants. Cochrane Database Syst Rev. 2005;CD004300. [Medline].
• Davis JA, Leyden JJ, Grove GL, et al. Comparison of disposable diapers with fluff absorbent and fluff plus absorbent polymers: effects on skin hydration, skin pH, and diaper dermatitis. Pediatr Dermatol. Jun 1989;6(2):102-8. [Medline].
• Gallup E, Plott T. A multicenter, open-label study to assess the safety and efficacy of ciclopirox topical suspension 0.77% in the treatment of diaper dermatitis due to Candida albicans. J Drugs Dermatol. Jan-Feb 2005;4(1):29-34. [Medline].
• Herbert J. The prevention and treatment of nappy rash. Some fresh insights into an old problem. Prof Care Mother Child. 1997;7(3):67-70. [Medline].
• Honda M. Differential diagnosis of unusual skin diseases in infants. Pediatrician. 1987;14 Suppl 1:15-7. [Medline].
• Janniger CK, Thomas I. Diaper dermatitis: an approach to prevention employing effective diaper care. Cutis. Sep 1993;52(3):153-5. [Medline].
• Jordan WE, Lawson KD, Berg RW, et al. Diaper dermatitis: frequency and severity among a general infant population. Pediatr Dermatol. Jun 1986;3(3):198-207. [Medline].
• Lin RL, Tinkle LL, Janniger CK. Skin care of the healthy newborn. Cutis. Jan 2005;75(1):25-30. [Medline].
• Longhi F, Carlucci G, Bellucci R, et al. Diaper dermatitis: a study of contributing factors. Contact Dermatitis. Apr 1992;26(4):248-52. [Medline].
• Obalek S, Janniger C, Jablonska S, et al. Sporadic cases of Heck disease in two Polish girls: association with human papillomavirus type 13. Pediatr Dermatol. Sep 1993;10(3):240-4. [Medline].
• Prasad HR, Srivastava P, Verma KK. Diapers and skin care: merits and demerits. Indian J Pediatr. Oct 2004;71(10):907-8. [Medline].
• Prasad HR, Srivastava P, Verma KK. Diaper dermatitis--an overview. Indian J Pediatr. Aug 2003;70(8):635-7. [Medline].
• Rasmussen JE. Classification of diaper dermatitis: an overview. Pediatrician. 1987;14 Suppl 1:6-10. [Medline].
• Scheinfeld N. Diaper dermatitis: a review and brief survey of eruptions of the diaper area. Am J Clin Dermatol. 2005;6(5):273-81. [Medline].
• Singalavanija S, Frieden IJ. Diaper dermatitis. Pediatr Rev. Apr 1995;16(4):142-7. [Medline].
• Singleton JK. Pediatric dermatoses: three common skin disruptions in infancy. Nurse Pract. Jun 1997;22(6):32-3, 37, 43-4 passim. [Medline].
• Sires UI, Mallory SB. Diaper dermatitis. How to treat and prevent. Postgrad Med. Dec 1995;98(6):79-84, 86. [Medline].
• Walsh SS, Robson WJ. Granuloma gluteale infantum: an unusual complication of napkin dermatitis. Arch Emerg Med. Jun 1988;5(2):113-5. [Medline].
• Wilson PA, Dallas MJ. Diaper performance: maintenance of healthy skin. Pediatr Dermatol. Sep 1990;7(3):179-84. [Medline].
• Zimmerer RE, Lawson KD, Calvert CJ. The effects of wearing diapers on skin. Pediatr Dermatol. Feb 1986;3(2):95-101. [Medline].

Article Last Updated: Oct 10, 2006