AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• 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

A prototypical example of irritant contact dermatitis, diaper dermatitis is caused by overhydration of the skin, maceration, prolonged contact with urine and feces, retained diaper soaps, and topical preparations. Signs and symptoms are restricted in most individuals to the area covered by diapers.

Pathophysiology

Diaper rash affects the areas within the confines of the diaper. Increased wetness in the diaper area makes the skin more susceptible to damage by physical, chemical, and enzymatic mechanisms. Wet skin increases the penetration of irritant substances. Superhydration urease enzyme found in the stratum corneum liberates ammonia from cutaneous bacteria. Urease has a mild irritant effect on nonintact skin. Lipases and proteases in feces mix with urine on nonintact skin and cause an alkaline surface pH, adding to the irritation. (Feces in breastfed infants have a lower pH, and breastfed infants are less susceptible to diaper dermatitis.) The bile salts in the stools enhance the activity of fecal enzymes, adding to the effect.

Candida albicans has been identified as another contributing factor to diaper dermatitis; infection often occurs after 48-72 hours of active eruption. Whether C albicans is the cause or the effect is controversial; however, it was isolated from the perineal area in as many as 92% of children with diaper dermatitis. Other microbial agents have been isolated less frequently, perhaps more as a result of secondary infections.

Mortality/Morbidity

• With the exception of an individual who is immunocompromised, no mortality is associated with diaper rash when correctly diagnosed. However, a rash incorrectly diagnosed as diaper dermatitis certainly may lead to significant morbidity and mortality if associated with a serious illness.
• Morbidity associated with diaper dermatitis is discomfort and the possibility of secondary bacterial or candidal infection, which may be more severe in an individual who is immunocompromised.

Race

No racial difference exists.

Sex

No sexual difference exists.

Age

• Diaper dermatitis commonly affects infants, with peak incidence occurring when the individual is aged 9-12 months. One study determined that at any given time, diaper dermatitis is prevalent in 7-35% of the infant population.
• Diaper dermatitis can affect persons of any age who wear diapers, in particular, elderly people.

CLINICAL

Section 3 of 11  

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

History

• Children with a previous medical history of eczema or atopic dermatitis may be more susceptible to diaper dermatitis.
• Nutritional history may also be an important factor to consider in diaper dermatitis.
• • A biotin-poor diet, such as occurs with elemental formula alone, may result in perioral erythema, developmental delay, loss of hair, and hypotony (in addition to diaper dermatitis).
  • Lack of zinc-binding ligands in the intestine, such as in the autosomal recessive disorder acrodermatitis enteropathica, may result in a triad of hair loss, dermatitis, and diarrhea. Generally, a decrease in zinc in the diet may be associated with relative alopecia and diaper dermatitis. One study found the lowest levels of zinc in the hair of infants aged 8 months. Low serum zinc level testing should be repeated for laboratory error. Zinc deficiency is easily treated with oral supplement.
• Another factor to consider in a child's medical history is the immune status; patients who are immunocompromised are more susceptible to infections by C albicans and other bacterial superinfections.

Physical

• Patients with diaper dermatitis present with an erythematous scaly diaper area often with papulovesicular or bullous lesions, fissures, and erosions.
• The eruption may be patchy or confluent, affecting the abdomen from the umbilicus down to the thighs and encompassing the genitalia, perineum, and buttocks. Genitocrural folds are spared.
• Children with diaper dermatitis have marked discomfort from intense inflammation.
• Rule out a secondary yeast or bacterial infection, which may occur in the area.

Causes

• Overhydration of the skin
• Maceration
• Prolonged contact with urine and feces
• Retained diaper soaps
• Topical preparations
• More than 3 diarrheal stools per day

DIFFERENTIALS

Section 4 of 11  

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

Other Problems to be Considered

Psoriasis

WORKUP

Section 5 of 11  

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

Lab Studies

• Diagnosis of candidal dermatitis can be established by potassium hydroxide (KOH) preparation or culture, but it is usually not necessary.

TREATMENT

Section 6 of 11  

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

Medical Care

• Provide education to patient, parents, and/or caregivers (see Patient Education).
• Ideally, the first-line therapy for individuals with diaper dermatitis is zinc oxide ointment or various products containing zinc oxide. Zinc oxide is an inexpensive treatment with the following properties:
• • Antiseptic and astringent
  • Significant role in wound healing
  • Low risk for allergic or contact dermatitis
• Acetyl tocopherol has been evaluated in the neonatal intensive care unit (NICU) setting and proved to be safe and more effective than the commonly used skin ointments in the topical treatment of exulcerative skin lesions in neonates.
• Various over-the-counter (OTC) diaper rash medications may confuse parents and/or caregivers. Incidence of allergic contact dermatitis (ACD) due to emollients is increasing; however, toxicity is rare.
• • The safest OTC emollient available for newborns is pure white petrolatum ointment, which acts by trapping water beneath the epidermis.
  • Another safe alternative is Aquaphor ointment, which is composed principally of white petrolatum, mineral oil, and wood wax alcohol. It is more expensive than pure white petrolatum ointment.
• If candidiasis is suspected or proven by KOH preparation or culture, an antifungal agent effective against yeast is indicated. The following are commonly used topical antifungal agents:
• If a fungal component is suspected along with irritant diaper dermatitis, the author has good experience in using hydrocortisone cream (1%) twice per day and nystatin cream after every diaper change or at least 4 times per day.
• • Nystatin cream or ointment
  • Econazole nitrate cream

Surgical Care

• Generally, no surgical intervention is needed. However, if a diagnosis other than diaper dermatitis is suspected from the presentation or the lack of response to traditional treatment, a biopsy may be indicated.
• In very rare incidents of diaper dermatitis, a break in the skin can lead to the inoculation of group A beta hemolytic streptococci (GABHS) or other aerobic and anaerobic organisms, causing necrotizing fascitis (NF).
• • Recognition of this condition is extremely important because disease tends to progress quickly through the fascial plane.
  • Initially, the skin may appear erythematous and edematous, but crepitus, cutaneous ulceration, necrosis, bullae, and abscesses soon develop.
  • Early recognition, empirical treatment with antibiotics, and surgical debridement is essential for lower morbidity and mortality.

Consultations

• A pediatric dermatologist consultation may be indicated for the following:
• • Atypical incidents of diaper dermatitis
  • Patients who are immunocompromised
  • Individuals who present with comorbidities

Activity

The diaper area may be left open to air or covered with a topical emollient.

MEDICATION

Section 7 of 11  

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

Medical therapy for diaper dermatitis includes the use of protective topical agents, topical anticandidal agents, and, possibly, topical low-potency steroids.

Drug Category: Protective topical agents

Ideally, first-line therapy for diaper dermatitis is zinc oxide ointment. The safest OTC emollient available for newborns is pure white petrolatum ointment. Another safe alternative is Aquaphor ointment, which is principally composed of white petrolatum, mineral oil, and wood wax alcohol. It is more expensive than pure white petrolatum ointment.

Drug Category: Antifungal agents

These agents are indicated for suspected candidiasis or proven candidal infection by KOH preparation or culture. Commonly used topical antifungal agents are nystatin cream or ointment and econazole nitrate cream.

Drug Category: Topical steroids

Limit potent topical steroid use to a few days and to a small quantity. Avoid combination topical steroid/antifungal cream in the diaper area.

FOLLOW-UP

Section 8 of 11  

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

Deterrence/Prevention

• Prevention can be summarized with the acronym ABCDE, ie, air, barrier, cleansing, diaper, and education.
  

Complications

• Candidal diaper rash leading to confluent diaper area with tomato-red plaques, papules, pustules, and satellite papules
• Miliaria rubra evident as tiny red papules and papulovesicles at elasticized openings of the diaper

Prognosis

• If treated using the ABCDE acronym (see Deterrence/Prevention), the prognosis is excellent for most patients with diaper dermatitis. 

Patient Education

• Providing education to the parents and/or caregivers of the patient is very important in the treatment and further prevention of diaper dermatitis.
• Keep the skin clean and dry.
• Provide diaper education.
  
  
  • Frequently change diapers.
  • Use disposable diapers with superabsorbent material.
  • When compared to cloth diapers, disposable diapers provide a lower prevalence and severity of diaper dermatitis.
• Wash genitalia with warm water and mild soap.
• Frequently apply a bland protective topical agent after thorough washing.
• For excellent patient education resources, visit eMedicine’s Skin, Hair, and Nails Center and Children’s Health Center. Also, see eMedicine’s patient education articles Diaper Rash, Contact Dermatitis, and Skin Rashes in Children.

MISCELLANEOUS

Section 9 of 11  

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

Medical/Legal Pitfalls

• Failing to educate patients, parents, and caregivers about potentially toxic herbal diaper rash treatments unregulated by the Food and Drug Administration that are advertised on the World Wide Web
• Diagnosing a dermatologic presentation of a more serious illness as diaper dermatitis
• Prescribing high-potency topical steroids
• Prescribing topical steroids for an extended period

MULTIMEDIA

Section 10 of 11  

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

Media file 1:  A 3-week-old female infant with diaper rash. Satellite lesions can be observed. The patient was diagnosed clinically with candidal dermatitis and successfully treated with nystatin ointment.
	View Full Size Image
Media type:  Photo

REFERENCES

Section 11 of 11

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

• Berg RW, Milligan MC, Sarbaugh FC. Association of skin wetness and pH with diaper dermatitis. Pediatr Dermatol. Mar 1994;11(1):18-20. [Medline].
• Boiko S. Treatment of diaper dermatitis. Dermatol Clin. Jan 1999;17(1):235-40, x. [Medline].
• Collipp PJ, Kuo B, Castro-Magana M, et al. Hair zinc, scalp hair quantity, and diaper rash in normal infants. Cutis. Jan 1985;35(1):66-70. [Medline].
• Darmstadt GL, Dinulos JG. Neonatal skin care. Pediatr Clin North Am. Aug 2000;47(4):757-82. [Medline].
• Ferrera PC, Dupree ML, Verdile VP. Dermatologic problems encountered in the emergency department. Am J Emerg Med. Oct 1996;14(6):588-601. [Medline].
• Gokalp AS, Aldirmaz C, Oguz A, et al. Relation between the intestinal flora and diaper dermatitis in infancy. Trop Geogr Med. Jul 1990;42(3):238-40. [Medline].
• Higuchi R, Mizukoshi M, Koyama H, et al. Intractable diaper dermatitis as an early sign of biotin deficiency. Acta Paediatr. Feb 1998;87(2):228-9. [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].
• Kazaks EL, Lane AT. Diaper dermatitis. Pediatr Clin North Am. Aug 2000;47(4):909-19. [Medline].
• Lane AT. Resolving controversies in diaper dermatitis. In: Contemporary Pediatrics. 1986;3:45-55.
• Longhi F, Carlucci G, Bellucci R, et al. Diaper dermatitis: a study of contributing factors. Contact Dermatitis. Apr 1992;26(4):248-52. [Medline].
• Manzoni P, Gomirato G. [Effectiveness of topical acetate tocopherol for the prevention and treatment of skin lesions in newborns: a 5 years experience in a 3rd level Italian Neonatal Intensive Care Unit]. Minerva Pediatr. Oct 2005;57(5):305-11. [Medline].
• Metry DW, Hebert AA. Topical therapies and medications in the pediatric patient. Pediatr Clin North Am. Aug 2000;47(4):867-76. [Medline].

Article Last Updated: Jun 28, 2006