DIAPER DERMATITIS
Diaper dermatitis generally refers to the irritant contact dermatitis that may result from multiple factors in the area: macerated skin (softened by being wet), rubbing and wiping, and possibly the presence of ammonia in urine and proteases and lipases in stool—all of which cause skin irritation and breakdown. It can become complicated by secondary bacterial or yeast infections as well.
INSIGHT
The so-called “Greek method” of washing the soiled diaper area under a running tap of warm water rather than using abrasive wipes is said to prevent diaper dermatitis.
SYNONYMS Diaper rash, nappy rash.
AGE Most babies develop some form of diaper dermatitis during their diaper-wearing years. The peak incidence is between ages 9 and 12 months.
GENDER M = F.
PREVALENCE At any one point in time, up to one-third of infants may have diaper dermatitis. The prevalence of severe diaper dermatitis (defined as erythema with ulcerations, oozing papules, and pustules) is 5%.
ETIOLOGY Excessive hydration of the skin and frictional injury lead to a compromised skin barrier, compounded by irritation from ammonia, feces, cleansing products, fragrances, and possible superinfection with Candida albicans or bacteria.
SEASON Reportedly highest during winter months, perhaps due to less frequent diaper changing.
The warm moist environment inside the diaper and frictional damage decrease the protective barrier function of the skin in the diaper area. Additional predisposing factors such as seborrhea, atopic dermatitis, and systemic disease— as well as activating factors such as allergens (in detergents, rubbers, and plastic), primary irritants (ammonia from urine and feces), and infection (by yeast or bacteria)—lead to a rash in the diaper area. Diarrheal illnesses may acutely worsen diaper dermatitis given the frequent wet diapers with fecal material and propensity for maceration.
TYPE OF LESION Ranges from macular erythema (Fig. 3-1) to papules, plaques, vesicles, erosions, and rarely ulcerated nodules.
COLOR Ranges from mild erythema to diffuse beefy redness.
PALPATION Ranges from nonindurated to prominently elevated lesions.
DISTRIBUTION Diaper area, convex surfaces involved, folds spared. Severe cases may involve folds and have characteristic C. albicans satellite pustules if superinfected.
DIAGNOSIS The diagnosis of diaper dermatitis may be made clinically, although refractory response to conventional treatments should raise the suspicion of less common rashes in the diaper area.
DIFFERENTIAL DIAGNOSIS Diaper dermatitis must be differentiated from psoriasis, granuloma gluteale infantum (likely a foreign body reaction, typically to baby powder, or topical steroids), primary candidiasis (perianal or intertriginous involvement with satellite lesions), perianal streptococcal infection, seborrheic dermatitis, acrodermatitis enteropathica (AE; caused by zinc deficiency), and Langerhans cell histiocytosis (LCH).
Most episodes of diaper dermatitis are self-limited with a duration of 3 days or less. Severe cases of diaper dermatitis are usually caused by chronic irritants or secondary infection with candida or bacteria.
The following help minimize rashes in the diaper area:
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Keeping the diaper area clean and dry with gentle cleansing of the area (cotton balls dipped in warm water or nondetergent cleanser) and frequent diaper changes promptly after defecation and urination.
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Remove any irritating agent or allergen from the diaper environment; hypoallergenic or cloth diapers may be less irritating. Similarly, fragrance-free, alcohol-free, or hypoallergenic wipes should be used sparingly to avoid contributing to further irritation.
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Exposing the skin to air periodically will help keep it dry.
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Protective creams and ointments such as zinc oxide (Desitin, Triple Paste), petrolatum (Hydrolatum, Vaseline), mineral oils, baby oils, lanolin, or vitamins A and D (A&D ointment) may protect the skin from moisture and help heal the infant’s skin. These can be applied as a thick layer to the involved area with each diaper change, and may also be used as prophylaxis against future irritation by creating a barrier between the skin and urinary or fecal material.
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For severe inflammation, mild topical steroids (2.5% hydrocortisone ointment) may be used sparingly. Since the diaper area is always under occlusion the steroid effects will be augmented in the already very sensitive baby skin of the groin area.
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Cutaneous candidiasis requires topical antifungal treatment with nystatin or clotrimazole creams. Avoid anticandidal preparations that are mixed with cortisone to prevent steroid side effects in the occluded diaper area.
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Bacterial infections may be treated with topical mupirocin; caution is advised with bacitracin and neomycin preparations as the incidence of allergic contact dermatitis is very high. Oral antibiotics may be indicated in severe cases.
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Powders (talc, baby powder, cornstarch, magnesium stearate, zinc stearate, and baking soda) can be used to absorb moisture and reduce friction but should be applied carefully and sparingly so accidental inhalation does not occur.
RASHES IN THE DIAPER AREA
Psoriasis can first manifest itself as a recalcitrant diaper rash, and should be considered if conventional diaper rash remedies are not effective. Other stigmata of early psoriasis include seborrhea, nail pitting, and intergluteal erythema. A family history of psoriasis can also suggest this diagnosis.
AGE Any age, typically seen first in the diaper area of children younger than 2 years.
GENDER F > M.
INCIDENCE Uncommon.
ETIOLOGY Unclear.
GENETICS Possible autosomal dominant inheritance with incomplete penetrance. Associated with HLA Cw6 (strongest association with early-onset or childhood psoriasis), as well as HLA B13, HLA B17, and HLA B57.
In normal skin, the cells mature, shed, and are replaced every 3 to 4 weeks. In psoriasis, there is shortening of the cell cycle to 3 to 4 days. This leads to increased epidermal cell turnover with decreased shedding and, hence, the accumulation of dead cells as layers of silvery-white scale. However, psoriasis in the diaper area may not show the characteristic silvery-white scale given the constant dampness of the local environment.
TYPE Scattered erythematous papules, may coalesce into a well-delineated erythematous plaque. May demonstrate maceration in the diaper region.
COLOR Dark-red plaques, silvery mica-like scale variably present.
SIZE Pinpoint to several centimeters.
DISTRIBUTION Anogenital area; may also involve intergluteal cleft, umbilicus, behind or inside the ears, scalp, extremities (Fig. 3-2). Involvement of the inguinal folds may help distinguish from irritant diaper dermatitis.
NAILS May have pinpoint pits indicative of psoriasis.
The well-delineated bright-red plaque and silvery mica-like scale is characteristic of psoriasis. Removal of the scale may result in punctate bleeding (Auspitz sign). Macerated plaques without scale may be mistaken for irritant diaper dermatitis or allergic contact dermatitis.
DERMATOPATHOLOGY Epidermal thickening with edema of dermal papillae, thinning of suprapapillary area.
Chronic course with remissions and exacerbations, very unpredictable. Some children progress to mild disease with intermittent exacerbations. Other children have a more severe course with recurrent flares, and 5% develop an associated arthritis.

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