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Diaper Rash, Emergency Medicine

Basics

Description

- Chemicals: - Prolonged exposure to stool enzymes and urine - Scents or moisturizers in wipes or soap - Diaper material or adhesive used to hold diaper in place

- Seborrheic diaper dermatitis - Atopic diaper dermatitis (contact dermatitis) - Risk factors: - Oral thrush - Number of previous episodes of diaper rash - Duration of use of diapers - Diarrhea

- Seborrheic diaper dermatitis: - Lesions with erythematous base and greasy yellow or gray scale - Infant will likely have similar lesions on other body surfaces, especially scalp.

- Inquire about diaper-changing habits and urinary and fecal habits. - Examine other body areas to identify associated rashes. - Consider child abuse or neglect: - Childs overall hygiene - Burns or other trauma

  • Very common dermatologic disorder of infancy
  • Most common in 1st month of life and again at 12-24 mo
  • Incidence in adult incontinent patients is reported from 5.7% to more than 42% and appears to be strongly associated with age
  • Primary irritant/contact dermatitis:Outer skin layers are broken down, leading to inflammation, impairment of normal skin microflora, and loss of protective barrier function.Increased skin moisture encourages growth of microorganisms on the surface of the skin.Secondary fungal or bacterial infection can cause more severe forms of diaper dermatitis.
  • Also known as irritant diaper dermatitis

Etiology

  • Irritants:Moisture:Prolonged overhydration owing to infrequent diaper changes, poorly absorbing diapers or cloth diapers, urinary or faecal incontinence in adultsFriction:Diaper rubbing on skin or loose-fitting diaperChemicals:Prolonged exposure to stool enzymes and urineScents or moisturizers in wipes or soapDiaper material or adhesive used to hold diaper in place
  • Infection:Candida albicans:Isolated in up to 80% of infantsOvergrowth common after systemic antibiotic useBacterialOften complication of other causes of dermatitis:Staphylococcus aureus, Streptococcus, Escherichia coli are common; Peptostreptococcus and Bacteroides may also be encountered.
  • Seborrheic diaper dermatitis
  • Atopic diaper dermatitis (contact dermatitis)
  • Risk factors:Oral thrushNumber of previous episodes of diaper rashDuration of use of diapersDiarrhea

Diagnosis

Diagnosis often empiric based on appearance of rash á

Signs and Symptoms

History

Child may cry with diaper changes or wiping diaper area or may be irritable. á

Physical Exam

  • Irritant:Beefy-red confluent patches with distinct borders at diaper edges, typically sparing skin folds
  • Infectious:Candida-demarcated erythematous rash with satellite pustules or papules, typically involves skin foldsBacterial-superficial erosions with yellow crust and occasionally bullae
  • Seborrheic diaper dermatitis:Lesions with erythematous base and greasy yellow or gray scaleInfant will likely have similar lesions on other body surfaces, especially scalp.
  • Atopic diaper dermatitis:Similar appearance to irritant dermatitis, but lesions also on other body surfaces such as the face.
  • Variations include:Jacquet form-erosive variant with ulcers or erosions with elevated margins usually seen with persistent diarrhea or adult urinary incontinence.Psoriasiform-erythema, silvery surface scales and spared skin folds; also likely to have similar lesions on other body surfaces.Granuloma gluteale infantum-violaceous papules and nodules on the buttocks and in the groin with a self-limited course, resolving in weeks or months, often with residual scarring.

Essential Workup

  • Inquire about diaper-changing habits and urinary and fecal habits.
  • Examine other body areas to identify associated rashes.
  • Consider child abuse or neglect:Childs overall hygieneBurns or other trauma

Diagnosis Tests & Interpretation

Lab

  • Lab evaluation usually not necessary for management of diaper dermatitis.
  • Bacterial cultures usually not indicated except in complicated cases.
  • Skin surface scrapings with KOH prep and/or culture may help distinguish between Candida and atypical seborrheic dermatitis:Look for budding yeast and/or pseudohyphae.

Differential Diagnosis

  • Child abuse or neglect
  • Infection:ImpetigoScabiesHerpes simplexVaricellaCongenital syphilis
  • Psoriasis
  • Atopic dermatitis
  • Seborrheic dermatitis
  • Papular urticaria
  • Bullous pemphigoid
  • Epidermolysis bullosa
  • Acrodermatitis enteropathica
  • Acrodermatitis enteropathica-like eruption
  • Langerhans cell histiocytosis

Treatment

Ed Treatment/Procedures

The management of diaper dermatitis should include reducing moisture in the diaper area, minimizing contact with urine and feces and eradicating infectious microorganism á

  • Environmental adjustments:Education of parents and caregivers is essential:Cleanse skin frequently using cotton balls and water.Wet wipes and talcum powders are not recommended.Frequent diaper changes, up to q1h for neonates and q3-4h for infants and adults.Gentle rinsing of affected area with warm water or saline.Avoid harsh soaps or alcohol wipes.Leave area uncovered as much as possible; allow time to air dry.Highly absorbant diapers have less incidence of diaper rash than cloth diapers.Cloth diapers are not recommended for patients with irritant diaper dermatitis.New diapers that are "breathable"Ł or contain top sheet of zinc oxide/petroleum and stearyl alcohol lining have been shown to decrease incidence.
  • Barrier creams:Many preparations available containing zinc oxide, petroleum, lanolin.Should be applied after each diaper change and continued after rash resolves to minimize recurrenceA substantial negative relationship exists between barrier cream use and number of previous episodes of diaper dermatitis.If Candidal infection present, apply over antifungal medication.
  • Corticosteroids:For moderate to severe cases not responding to other therapyShould not be stronger than 1% hydrocortisone: Anything stronger can cause serious side effects.Discontinue after 3-5 days.
  • Antifungals:Nystatin cream, powder, or ointment:Expect improvement in 1-2 days.Ointment best tolerated on macerated skin.Clotrimazole applied topically after diaper change.Miconazole applied topically after diaper change.Lotion is preferred in intertriginous areas.Cream should be applied sparingly to avoid maceration effects.Ciclopirox applied topically after diaper change.Generally continue 1-2 days after clearingAntifungal agent also found to have some antibacterial activity and anti-inflammatory properties.Consider oral agent if concurrent cutaneous or oral candidiasis is present or in recalcitrant case because stool may be colonized with C. albicans.
  • Antibacterials:Typically concurrent with other therapies if suspicion of bacterial infectionMupirocin (Bactroban) applied after diaper changesSystemic antibiotics rarely needed

Medication

  • Ciclopirox 0.77% cream, gel, or suspension: Applied topically BID after diaper change
  • Clotrimazole 1% cream: Applied topically BID after diaper change
  • Hydrocortisone 0.5-1% topical cream: Applied BID
  • Miconazole topical 2% cream: Applied BID after diaper change
  • Miconazole nitrate 0.25% ointment: Apply after diaper change and bathing
  • Mupirocin 2% ointment or cream (Bactroban): Applied topically 3-5 times daily after diaper changes (for infants >3 mo of age)
  • Nystatin 100,000 U/g cream, powder, or ointment: Apply BID after diaper change

Follow-Up

Disposition

Admission Criteria

  • Evidence of child abuse or neglect
  • Evidence of sepsis

Additional Reading

  • Adalat áS, Wall áD, Goodyear áH. Diaper dermatitis-frequency and contributory factors in hospital attending children. Pediatr Dermatol. 2007;24(5):483-488.
  • Adam áR. Skin care of the diaper area. Pediatr Dermatol. 2008;25(4):427-433.
  • Heimall áLM, Storey áB, Stellar áJJ, et al. Beginning at the bottom: Evidence-based care of diaper dermatitis. MCN Am J Matern Child Nurs. 2012;37(1):10-16.
  • Ravanfar áP, Wallace áJS, Pace áNC. Diaper dermatitis: A review and update. Curr Opin Pediatr. 2012;24(4):472-479.
  • Van áL, Harting áM, Rosen áT. Jacquet erosive diaper dermatitis: A complication of adult urinary incontinence. Cutis. 2008;82(1):72-74.

Codes

ICD9

691.0 Diaper or napkin rash á

ICD10

L22 Diaper dermatitis á

SNOMED

  • 91487003 Diaper rash (disorder)