Basics
Description
- 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 adults
- Friction:
- Diaper rubbing on skin or loose-fitting diaper
- 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
- Infection:
- Candida albicans:
- Isolated in up to 80% of infants
- Overgrowth common after systemic antibiotic use
- Bacterial
- Often 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 thrush
- Number of previous episodes of diaper rash
- Duration of use of diapers
- Diarrhea
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 folds
- Bacterial-superficial erosions with yellow crust and occasionally bullae
- 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.
- 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 hygiene
- Burns 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:
- Impetigo
- Scabies
- Herpes simplex
- Varicella
- Congenital 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 recurrence
- A 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 therapy
- Should 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 clearing
- Antifungal 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 infection
- Mupirocin (Bactroban) applied after diaper changes
- Systemic 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)