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Dermatitis, Diaper
Dennis E. Hughes, DO, FACEP
image BASICS
DESCRIPTION
  • Diaper dermatitis is a rash occurring under the covered area of a diaper. It is usually initially a contact dermatitis.
  • System(s) affected: skin/exocrine
  • Synonym(s): diaper rash; nappy rash; napkin dermatitis
Geriatric Considerations
Incontinence is a significant cofactor.
EPIDEMIOLOGY
Incidence
  • The most common dermatitis found in infancy
  • Peak incidence: 7 to 12 months of age, then decreases
  • Lower incidence reported in breastfed babies due to lower pH, urease, protease, and lipase activity.
Prevalence
Prevalence has been variably reported from 4-35% in the first 2 years of life.
ETIOLOGY AND PATHOPHYSIOLOGY
  • Immature infant skin with histologic, biochemical, functional differences compared to mature skin (1)
  • Wet skin is central in the development of diaper dermatitis, as prolonged contact with urine or feces results in susceptibility to chemical, enzymatic, and physical injury; wet skin is also penetrated more easily.
  • Fecal proteases and lipases are irritants.
  • Superhydrase urease enzyme found in the stratum corneum 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 hours.
  • 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.
RISK FACTORS
  • Infrequent diaper changes
  • Improper laundering (cloth diapers)
  • Family history of dermatitis
  • Hot, humid weather
  • Recent treatment with oral antibiotics
  • Diarrhea (>3 stools per day increases risk)
  • Dye allergy
  • Eczema may increase risk.
GENERAL PREVENTION
Attention to hygiene during bouts of diarrhea
COMMONLY ASSOCIATED CONDITIONS
  • Contact (allergic or irritant) dermatitis
  • Seborrheic dermatitis
  • Psoriasis
  • Candidiasis
  • Atopic dermatitis
image DIAGNOSIS
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 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 reaction (autoeczematous) outside the diaper area.
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
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
Rarely needed
Follow-Up Tests & Special Considerations
  • Consider a culture of lesions or a potassium hydroxide (KOH) preparation.
  • 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.
Test Interpretation
  • Biopsy is rare.
  • Histology may reveal acute, subacute, or chronic spongiotic dermatitis.
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image TREATMENT
Prevention is the key to treatment of this condition.
GENERAL MEASURES
  • Expose the buttocks to air as much as possible.
  • Use mild, slightly acidic cleanser with water; no rubbing and pat dry.
  • Avoid impermeable 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.
  • Superabsorbable diapers are beneficial, as they wick urine away from skin and still allow air to permeate (2)[C].
  • Discontinue using baby lotion, powder, ointment, or baby oil (except zinc oxide).
  • Use of appropriately formulated baby wipes (fragrance-free) is safe and as effective as water (3)[B].
  • Apply zinc oxide ointment or other barrier cream to the rash at the earliest sign and BID or TID (e.g., Desitin or Balmex). Thereafter, apply to clean, thoroughly dried skin (4)[C].
  • 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.
MEDICATION
First Line
  • For a pure contact dermatitis, a low-potency topical steroid (hydrocortisone 0.5-1% TID for 3 to 5 days) and removal of the offending agent (urine, feces) 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.
  • If inflammation is prominent, consider a very low-potency steroid cream such as hydrocortisone 0.5-1% TID along with an antifungal cream ± a combination product such as clioquinol-hydrocortisone (Vioform-Hydrocortisone) cream.
  • 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 of steroid antifungal mixtures—these should never be used in the diaper area.
Second Line
Sucralfate paste for resistant cases
ISSUES FOR REFERRAL
Consider if a systemic disease such as Langerhans cell histiocytosis, acrodermatitis enteropathica, or HIV infection is suspected
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
  • Febrile neonates
  • Recalcitrant rash suggestive of immunodeficiency
  • Toxic-appearing infants
Nursing
Assist first-time parents with hygiene education.
image 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 has begun.
REFERENCES
1. Stamatas GN, Tierney NK. Diaper dermatitis: etiology, manifestations, prevention, and management. Pediatr Dermatol. 2014;31(1):1-7.
2. Erasala GN, Romain C, Merlay I. Diaper area and disposable diapers. Curr Probl Dermatol. 2011;40: 83-89.
3. Lavender T, Furber C, Campbell M, et al. Effect on skin hydration of using baby wipes to clean the napkin area of newborn babies: assessor-blinded randomised controlled equivalence trial. BMC Pediatr. 2012;12:59.
4. Humphrey S, Bergman JN, Au S. Practical management strategies for diaper dermatitis. Skin Therapy Lett. 2006;11(7):1-6.
Additional Reading
&NA;
Serdaroĝlu S, Üstünbaş TK. Diaper dermatitis (napkin dermatitis, nappy rash). J Turk Acad Dermatol. 2010;4(4):04401r.
See Also
&NA;
Algorithm: Rash, Focal
Codes
&NA;
ICD10
  • L22 Diaper dermatitis
  • B37.2 Candidiasis of skin and nail
Clinical Pearls
&NA;
  • Hygiene is the main preventative measure.
  • Look for secondary infection in persistent cases.