This article presents an overview of diaper dermatitis for the pediatric community. The pathogenesis, differential diagnosis, and management of this common condition in infancy are reviewed. This information will assist in making the appropriate diagnosis and managing this irritant contact dermatitis of the diaper area. With conservative management, most cases of irritant diaper dermatitis are self-limited. When the condition persists, one must consider other diagnoses.
Key points
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Diaper dermatitis is an irritant contact dermatitis that is typically self-limited.
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An impaired barrier function of the skin develops because of the presence of moisture, friction, and irritants from the contents of urine and feces.
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Attempts to minimize irritants with the use of modern disposable diapers and barrier emollients decrease the incidence of diaper dermatitis.
Introduction
Overview
Diaper dermatitis is the most common skin disorder in infants and is often a concern for parents and caretakers. It is an irritant contact dermatitis secondary to impairment of the normal skin barrier due to the presence of moisture, friction, urine, and feces. The condition typically resolves with conservative management. It is important to distinguish diaper dermatitis from other dermatoses that may develop in the diaper area.
Pathophysiology
The interaction of a variety of factors contributes to the development of diaper dermatitis ( Fig. 1 ). The moist environment and presence of friction in the diaper area lead to disruption of the stratum corneum, the outer layer of the skin that provides a barrier from external irritants.
The presence of urine allows the skin to become overly hydrated, increasing its permeability to potential irritants. Urine also increases the pH of the diaper environment by breaking down urea when fecal urease is present. Bile salts as well as proteases and lipases from feces also contribute to the erythema and epidermal barrier disruption of the skin. A correlation between the number of bowel movements per day and the frequency of diaper dermatitis has been reported.
Microbes do not seem to play a direct role in the development of diaper dermatitis. Bacterial counts were evaluated on the skin of infants with and without diaper dermatitis and no difference was found. Candida sp have also been isolated from the skin and feces of infants with and without diaper dermatitis.
Epidemiology
Diaper dermatitis is a common condition affecting 50% of patients in the at-risk age range of the pediatric population. It has been observed most frequently in infants 9 to 12 months in one series and toddlers in the 12- to 24-months age group in another series. There is no difference in its prevalence between genders or among races.
With the advent of superabsorbent gel disposable diapers, the overall incidence of diaper dermatitis has decreased. Breast-fed infants seem to be less likely to develop moderate to severe diaper dermatitis in comparison to formula-fed infants. Pediatricians and family physicians provide more than 90% of physician services for patients with diaper dermatitis.
Prognosis
The course of diaper dermatitis is typically episodic. Each episode is self-limiting with a mean duration per episode of 2 to 3 days. A small minority of those affected will go on to develop moderate to severe disease. The condition is effectively cured once the child is fully toilet trained and discontinues the use of diapers.
Introduction
Overview
Diaper dermatitis is the most common skin disorder in infants and is often a concern for parents and caretakers. It is an irritant contact dermatitis secondary to impairment of the normal skin barrier due to the presence of moisture, friction, urine, and feces. The condition typically resolves with conservative management. It is important to distinguish diaper dermatitis from other dermatoses that may develop in the diaper area.
Pathophysiology
The interaction of a variety of factors contributes to the development of diaper dermatitis ( Fig. 1 ). The moist environment and presence of friction in the diaper area lead to disruption of the stratum corneum, the outer layer of the skin that provides a barrier from external irritants.
The presence of urine allows the skin to become overly hydrated, increasing its permeability to potential irritants. Urine also increases the pH of the diaper environment by breaking down urea when fecal urease is present. Bile salts as well as proteases and lipases from feces also contribute to the erythema and epidermal barrier disruption of the skin. A correlation between the number of bowel movements per day and the frequency of diaper dermatitis has been reported.
Microbes do not seem to play a direct role in the development of diaper dermatitis. Bacterial counts were evaluated on the skin of infants with and without diaper dermatitis and no difference was found. Candida sp have also been isolated from the skin and feces of infants with and without diaper dermatitis.
Epidemiology
Diaper dermatitis is a common condition affecting 50% of patients in the at-risk age range of the pediatric population. It has been observed most frequently in infants 9 to 12 months in one series and toddlers in the 12- to 24-months age group in another series. There is no difference in its prevalence between genders or among races.
With the advent of superabsorbent gel disposable diapers, the overall incidence of diaper dermatitis has decreased. Breast-fed infants seem to be less likely to develop moderate to severe diaper dermatitis in comparison to formula-fed infants. Pediatricians and family physicians provide more than 90% of physician services for patients with diaper dermatitis.
Prognosis
The course of diaper dermatitis is typically episodic. Each episode is self-limiting with a mean duration per episode of 2 to 3 days. A small minority of those affected will go on to develop moderate to severe disease. The condition is effectively cured once the child is fully toilet trained and discontinues the use of diapers.
Clinical features
History
A thorough history including the infant’s bathing, cleansing, and diapering routine should be obtained. Encourage the patient’s family to bring in all of the products that have been used in case specific ingredients need to be checked. Factors to consider when evaluating for diaper dermatitis are listed in Box 1 .
Duration of eruption
Symptoms
Pain, itch
Cleansing routine
Frequency
Cleanser or soap product
Wash cloth vs baby wipes
Texture, fragrance
Diapers
Disposable vs cloth
Presence of elastics, dyes
Presence of zinc oxide and petrolatum
Frequency of changing
Daytime, overnight
Frequency of urination
Defecation
Frequency, consistency
Products applied to the diaper area
Barrier emollient creams and pastes
Powders
Home remedies
Amount of time exposed to air
Diet
Breast milk vs formula
Introduction of new foods
Medications
Oral antibiotic
Senna-containing laxative
Concurrent or recent viral gastroenteritis
Physical Examination
Common areas involved in diaper dermatitis include the convex surfaces in contact with the diaper, such as the buttocks, lower abdomen, medial thighs, labia majora, and scrotum. Due to the passage of feces, the perianal area is also at risk for irritant diaper dermatitis. In classic diaper dermatitis, the skin folds are spared because they are protected from exposure to the contents of the diaper.
Clinical Findings of Diaper Dermatitis
Clinical findings of diaper dermatitis are listed in Box 2 ( Figs. 2–6 ).
Early disease
Scattered pinpoint erythematous papules
Asymptomatic
Mild disease
Mild erythema over limited surface areas
Minimal maceration and chafing
Asymptomatic
Moderate disease (see Fig. 2 )
More extensive erythema with maceration or superficial erosions
Pain discomfort
Severe disease
Punched-out lesions or erosions with elevated borders (Jacquet’s)
Pseudoverrucous eroded papules and nodules (see Fig. 3 )
Pain
Consider infection
Maceration present >72 hours
Satellite superficial erythematous papules and pustules ( Candida ) (see Fig. 4 )
Superficial vesicles or bullae, erosions (bacterial) (see Fig. 5 )
Follicular based erythematous papules and pustules (bacterial) (see Fig. 6 )
Punched out grouped erosions (HSV)
Comorbidities
Comorbidities for diaper dermatitis include a viral gastroenteritis or a change in diet that leads to a change in stooling frequency and consistency. Fecal incontinence or encopresis secondary to significant constipation or an underlying gastrointestinal disorder may also be present in this population.
Differential diagnosis
There is a broad differential for eruptions that may develop in the diaper area ( Table 1 ).
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Inflammatory Conditions
Several inflammatory conditions present in the diaper area. Intertrigo presents as erythematous patches in the body folds where skin folds are in close opposition. Heat, moisture, sweat retention, and friction contribute to the irritation and maceration in the affected areas. The symptoms typically resolve once the affected areas are exposed to air. A short course of a low-potency topical cortisone may help to alleviate the erythema.
Seborrheic dermatitis manifests around 3 to 4 weeks of life as asymptomatic erythema and scaling of the scalp that spreads to the face, behind the ears, and to the body folds ( Fig. 7 ). It responds well to a short course of a low-potency topical cortisone. Seborrheic dermatitis typically resolves by 3 to 4 months of age. If it persists and is recalcitrant to treatment in the setting of recurrent infections, vomiting, diarrhea, failure to thrive, hepatosplenomegaly, arthritis, adenopathy, and hematologic abnormalities, an immunodeficiency or Langerhans cell histiocytosis should be considered.
