Basics
Description
Diaper dermatitis is a general term used to describe any inflammatory skin rash that develops in the perineal region. Also known as diaper or napkin rash, there are several causes of diaper dermatitis. Most often, diaper rash is caused by an acute irritant contact dermatitis, which is the focus of this chapter.
Alert
Severe cases of diaper dermatitis may be complicated by bacterial or fungal infection which may require treatment with topical or systemic antibiotics and/or antifungals.
If severe cases fail to respond to conventional therapies, consider other diagnoses such as Langerhans cell histiocytosis, acrodermatitis enteropathica, or seborrheic dermatitis.
Epidemiology
Incidence
- The reported incidence varies worldwide due to differences in diaper use, toilet training, hygiene, and child-rearing practices.
- Can develop in the 1st week of life, but unlikely once the child is no longer in diapers
Prevalence
- Estimated prevalence ranges from 7 to 35%.
Risk Factors
- Diarrhea increases the risk of irritant diaper rash.
- The presence of oral thrush or recent antibiotic use increases the risk of secondary Candida albicans infection.
- Formula-fed infants may have higher risk of diaper dermatitis due to higher stool pH.
General Prevention
- Frequent diaper changes and proper skin care help prevent diaper rash.
- Diapers should be changed as often as every 2 hours or sooner if diaper is wet and/or soiled.
- Super absorbent diapers (disposable diapers containing gelling materials) keep moisture away from skin and may prevent diaper dermatitis compared to cloth diapers.
- Some experts recommend soft cloths and water for cleansing due to preservatives in baby wipes. As manufacturers have decreased the number of additives, contact dermatitis due to wipes has become less common.
- Petrolatum and/or zinc oxide provide effective barriers against potential perineal skin irritants and moisture. Several authors advise caregivers to refrain from rubbing barrier products off completely during diaper changes to prevent further skin damage.
Etiology
The pathophysiology is multifactorial, including moisture, friction, warmth, urine and feces.
- Friction: Rubbing of wet diapers against exposed skin can result in chafing, maceration, and irritation.
- Moisture trapped against skin causes increased permeability and susceptibility to damage from friction.
- Irritation: Urine raises the pH which activates fecal enzymes resulting in skin damage.
- As the skin barrier breaks down, microbes are more likely to cause a secondary infection.
- Common causes of secondary infections include C. albicans, group A β-hemolytic Streptococcus, and Staphylococcus aureus.
Diagnosis
History
- Associated symptoms: Acute or chronic diarrhea suggests a primary irritant dermatitis.
- The presence of oral thrush or recent antibiotic use increases the risk of secondary C. albicans infection. Presence of the rash for >3 days also increases likelihood of candidal infection.
- Treatment with topical corticosteroid, antifungal, or antibacterial products can change the appearance of the rash.
- Chemicals, dyes, and fragrances in lotions, wipes, diapers, and detergents can cause irritant or allergic contact dermatitis.
- Infrequent or poor hygiene can result in diaper rash, whereas excessive bathing may result in increased friction on the skin and worsening of a preexisting rash.
- Moderate to severe rashes and rashes infected with group A β-hemolytic Streptococcus or Staphylococcus aureus cause discomfort for the child.
Physical Exam
- Ranges from asymptomatic, generalized erythema to skin breakdown leading to an open wound
- Irritant and allergic dermatitis occurs on skin surfaces in direct contact with the diaper, urine, and feces. Skinfolds are typically spared.
- Affected intertriginous areas suggest seborrheic dermatitis, candidal infection, or group A β-hemolytic Streptococcus infection.
- Perianal rashes suggest group A β-hemolytic Streptococcus (more common) or S. aureus (less common) infection.
- The morphology of the dermatitis is important:
- Well-demarcated, shiny, erosive, erythematous perianal patches suggest group A β-hemolytic Streptococcus.
- Scattered inflammatory papules or pustules suggest S. aureus.
- Erythematous patches with peripheral erythematous papules (satellite lesions) suggest candidal infection.
- Greasy erythema and scaling suggests seborrheic dermatitis.
- A complete physical exam may reveal other features of the underlying diagnosis:
- Scalp seborrhea (cradle cap) suggests seborrheic dermatitis.
- Thrush (oral candidiasis) raises the possibility of a candidal infection.
- Hepatosplenomegaly suggests Langerhans cell histiocytosis.
Diagnostic Tests & Interpretation
Lab
- Rarely helpful
- Candidal infections can be verified by a potassium hydroxide preparation or fungal culture of skin scraping if diagnosis is unclear.
- Group A β-hemolytic Streptococcus and S. aureus infection can be confirmed by swabbing affected area for bacterial culture.
Pathologic Findings
- Skin biopsy is rarely required unless the rash is atypical and unresponsive to therapy.
- Helpful in diagnosing psoriasis, Langerhans cell histiocytosis, or granuloma gluteale infantum
Differential Diagnosis
- Candidal dermatitis: Irritant dermatitis may become secondarily infected with C. albicans, which results in beefy red plaques with satellite lesions and superficial pustules. Common during or after antibiotic use.
- Allergic contact dermatitis: can result from allergens in the diaper, wipes, or topical creams including dyes, detergents, fragrances, or elastic
- Impetigo: due to group A β-hemolytic Streptococcus (common) or S. aureus (less common): 1-2 mm pustules and honey-colored, crusted erosions. Bullous impetigo appears as large, fluid-filled bullae.
- Perianal group A β-hemolytic Streptococcus presents as bright red, sharply demarcated perianal rash with pain or pruritus. May also have streptococcal pharyngitis.
- Seborrheic dermatitis: associated with scalp, face, and skinfold involvement. In the diaper region, it is characterized by well-circumscribed erythematous papules and plagues.
- Atopic dermatitis: usually spares the diaper region due to the moist environment. If affected, characterized by increased skin lines and excoriations due to scratching.
- Psoriasis: may involve the diaper area either exclusively or may occur in the setting of more diffuse presentation, including other intertriginous areas and the face and scalp. Presents with sharply demarcated erythematous and silvery scaly papules and plaques.
- Scabies: Pruritic, erythematous papules and nodules may involve the genitalia, abdomen, web spaces of extremities, and axilla; often there is a history of multiple affected family members and more widespread involvement.
- Herpes simplex virus may manifest as grouped vesicular, papular, or pustular lesions. May be transmitted through sexual contact or herpetic whitlow.
- Child abuse: An unusual history or morphology suggests the possibility of abuse, especially if the lesions appear geometric or resemble scalds, burns, or bruises or if sexually transmitted disease diagnosed.
- Langerhans cell histiocytosis: usually presents with multiple reddish-brown crusted papules and/or vesicles and petechiae in conjunction with hepatosplenomegaly and anemia
- Acrodermatitis enteropathica, which is caused by impaired zinc metabolism (either inherited or acquired), leads to an erosive acrodermatitis involving the face in a perioral and periocular distribution, the diaper area, and the hands and feet.
- Jacquet erosive diaper dermatitis is rare and likely represents severe irritant diaper dermatitis. Characterized by well-demarcated papules, nodules, and punched out ulcerations.
- Granuloma gluteale infantum is a rare, benign inflammatory dermatosis associated with use of high-potency topical corticosteroids. Characterized by reddish-purple nodules.
Treatment
Additional Treatment
General Measures
- Similar to primary prevention, frequent diaper changes and proper skin care are the primary treatments for diaper dermatitis.
- Skin should be gently washed with a mild cleanser and/or infant wipe and patted dry or air-dried. Vigorous rubbing of the skin or use of washcloths may cause further irritation and skin breakdown.
- Frequent diaper changes are helpful in minimizing exposure to irritants.
- If feasible, remove diaper and expose skin to air to avoid friction and trapped moisture.
- Routine use of a barrier ointment and pastes such as zinc oxide with each diaper change is recommended. Barriers should be applied thickly and can be covered with petroleum jelly to prevent sticking to the diaper.
- Candidal infections should be treated with topical antifungal cream such as nystatin, miconazole, ketoconazole, or clotrimazole cream.
- If secondary bacterial infection is present, topical antibiotics such as mupirocin or oral antibiotics are necessary. Neomycin and bacitracin can incite an allergic contact dermatitis, so they should be avoided.
- Low-potency topical steroids, such as hydrocortisone and hydrocortisone acetate, may be used sparingly in moderate to severe cases.
- Topical application of sucralfate suspension can be useful in recalcitrant cases. It acts as a physical barrier and has antibacterial activity.
Alert
- Mid- to high-potency topical corticosteroids should not be used because absorption is increased in areas of thin skin and under occlusion. Skin atrophy or systemic effects may result.
- Similarly, prolonged use of any potency topical steroids (>7 days) in the diaper area should be avoided.
- Combination topical corticosteroids and antifungal creams should not be used because these contain mid- to high-potency corticosteroids. Separate corticosteroid and antifungal creams allow the discontinuation of corticosteroid earlier (when the rash starts to improve) while continuing antifungal until rash resolves.
- Products containing boric acid, camphor, phenol, benzocaine, and salicylates should be avoided because of the potential for systemic toxicity.
- Use of powders such as talcum is controversial. Powders can reduce moisture and friction but pose the risk of accidental aspiration.
Ongoing Care
Follow-up Recommendations
Patient Monitoring
With proper care, the rash should improve within 4-7 days. If it does not resolve with appropriate treatment, other causes must be sought.
Prognosis
- Diaper dermatitis usually resolves with the institution of appropriate skin care and the treatment of any underlying cause.
- Irritant diaper dermatitis resolves once the child is potty trained.
Complications
- Generally no longer term complications, although secondary bacterial or fungal infections may lead to ulceration.
- Chronic topical corticosteroid use in diaper area may lead to skin atrophy or systemic effects.
- Some experience postinflammatory hypo- or hyperpigmentation that is typically self-limited.
Additional Reading
- Adam R. Skin care of the diaper area. Pediatr Dermatol. 2008;25(4):427-433. [View Abstract]
- Kazaks EL, Lane AT. Diaper dermatitis. Pediatr Clin North Am. 2000;47(4):909-919.
- Ravanfar P, Wallace JS, Pace NC. Diaper dermatitis: a review and update. Curr Opin Pediatr. 2012;24(4):472-479. [View Abstract]
- Scheinfeld N. Diaper dermatitis: a review and brief survey of eruptions of the diaper area. Am J Clin Dermatol. 2005;6(5):273-281. [View Abstract]
Codes
ICD09
- 691 Diaper or napkin rash
- 112.3 Candidiasis of skin and nails
ICD10
- L22 Diaper dermatitis
- B37.2 Candidiasis of skin and nail
SNOMED
- 91487003 Diaper rash (disorder)
- 49883006 candidiasis of skin (disorder)
FAQ
- Q: Should I switch from cloth to disposable diapers?
- A: This is controversial, although there are some studies that indicate that the superabsorbent disposable diapers may be better for preventing diaper rashes. Cloth diapers used with plastic outer layer probably irritate the skin more because they trap moisture against the skin. Frequent changing of diapers and the use of a barrier paste are very helpful in preventing diaper rash.
- Q: Is the diaper rash due to not keeping the skin clean enough?
- A: Although stool and urine may release enzymes that help break down skin integrity, vigorous and frequent scrubbing with relatively abrasive materials on the damaged skin can be more harmful. This rough cleaning allows introduction of bacteria and yeast into the skin and results in a diaper rash. Gentle cleaning materials should be used. It is not usually necessary to clean the skin of barrier ointments every time; rather, patting the infant dry with a soft cloth or baby wipe, gently reapplying barrier products, and then replacing the diaper is all that is generally required.