Diaper dermatitis

 

Diaper dermatitis is caused by overhydration of the skin, maceration, prolonged contact with urine and feces, retained diaper soaps, and topical preparations and is a prototypical example of irritant contact dermatitis. Signs and symptoms are restricted in most individuals to the area covered by diapers.¹

The photograph below depicts a 3-week-old female neonate with diaper rash.

 

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. It is 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

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.³ Low serum zinc level testing should be repeated for laboratory error. Zinc deficiency is easily treated with oral supplements.⁴

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 in irritant dermatitis, but often involved in primary candidal dermatitis.

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

The following causes have been noted:

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

Medical Care

Provide education regarding diaper dermatitis 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.⁵ 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 potassium hydroxide (KOH) preparation or culture, an antifungal agent effective against yeast is indicated. The author has good experience in using hydrocortisone cream (1%) twice daily and antifungal (nystatin cream, powder, or ointment; clotrimazole 1% cream; econazole nitrate cream; miconazole 2% ointment; or amphotericin cream or ointment) cream after every diaper change or at least 4 times per day. If significant inflammation is obvious, hydrocortisone 1% can be used for the first 1-2 days. Avoid higher strength topical steroids including combination including clotrimazole/betamethasone and nystatin/triamcinolone.

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 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

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

Protective topical agents

Ideally, first-line therapy for diaper dermatitis is zinc oxide ointment. The safest over-the-counter (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 lanolin. It is more expensive than pure white petrolatum ointment.

Petrolatum (Vaseline, Aquaphor, Aquabase)

Traps water beneath the epidermis.