Diaper Rash Clinical Presentation

One study review performed in the United Kingdom reported that irritant diaper dermatitis does not usually develop immediately after birth; onset is generally between 3 weeks and 2 years of age, with prevalence highest between 9 and 12 months. This study showed that one fifth of all pediatric dermatology visits for children up to the age of 5 years were to treat diaper dermatitis.

• Diagnosis of diaper dermatitis is based largely on the physical examination. A careful history, however, could elicit clues that aid in narrowing the differential diagnosis.
• Important points to obtain on history include the following:

  • Onset, duration, and change in the nature of the rash
  • Presence of rashes outside the diaper area
  • Associated scratching or crying
  • Contact with infants with a similar rash
  • Recent illness, diarrhea, or antibiotic use
• Assessment of current diapering practices (eg, change frequency, type of diapers used, creams or ointments applied, methods used to clean the diaper area)
• Irritant contact dermatitis, miliaria (heat rash), and intertrigo

  • Usually follows a bout of diarrhea
  • Exacerbated by scrubbing and the use of commercial wipes or strong detergents
  • Lasts less than 3 days after more diligent diaper changing practices are initiated
  • Asymptomatic (except for miliaria)
• Candidal diaper dermatitis

  • Lasts even after more diligent diaper changing practices are started
  • Should be suspected in all rashes lasting more than 3 d (Candida is isolated in 45-75% of such cases)
  • Painful - Parents often report severe crying during diaper changes or with urination and defecation.
  • May follow recent antibiotic use
• Secondary bacterial infection

  • Fever
  • Pustular drainage
  • Lymphangitis
• Granuloma gluteal infantum

  • Rash lasts months
  • Resistant to treatments with barrier creams, antifungal agents, and topical steroids
  • Asymptomatic
• Atopic dermatitis

  • Family or personal history of allergic rhinitis, hay fever, or asthma is common.
  • Pruritic
  • Associated with current or previous flares of rash on the face and extensor limb surfaces in infants
• Seborrheic dermatitis

  • Usually occurs in infants aged 2 weeks to 3 months
  • Consists of an eruption of an oily, scaly, crusted dermatitis of the scalp (cradle cap), face, retroauricular regions, axilla, and presternal areas
  • Asymptomatic
  • Any child with widespread seborrheic dermatitis, diarrhea, and failure to thrive should be evaluated for Leiner disease, a functional defect of the C5 component of complement.
• Psoriasis

  • A family history of psoriasis can be a clue.
  • Not responsive to barrier creams, antifungal agents, and standard topical steroids
  • Involved areas include the scalp and nails
• Impetigo

  • Common in the first 6 months of life
  • Usually occurs during the warmer summer months
• Langerhans cell histiocytosis

  • Severe hemorrhagic diaper dermatitis unresponsive to any treatment
  • Other involved areas include the scalp and retroauricular areas
  • Diarrhea
• Acrodermatitis enteropathica

  • Associated with diarrhea, hair loss, and erosive perioral dermatitis
  • Patient may have a predisposition for malabsorption (ie, cystic fibrosis) or malnutrition
• Scabies

  • Acute onset
  • Pruritic
  • History of close contacts with recent onset of a similar erythematous serpiginous eruption
  • Concurrent rash may be found in web spaces of hands or feet
• Human immunodeficiency virus

  • History of HIV exposure or risk factors
  • Associated cytomegalovirus or herpes infection

The pertinent physical examination focuses on the skin in the diaper area. Findings vary depending on which subset of diaper rash is most prominent.

• Irritant contact dermatitis

  • Mild forms consist of shiny erythema with or without 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 a centimeter or more 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 (autoeczematous) reaction with reaction outside the diaper area.
• Intertrigo

  • Occurs in skin creases where skin surfaces are in apposition
  • Characterized by slight to severe erythema in the inguinal area, intergluteal area, or folds of the thighs
  • Pustules or erosions are not present.
• Miliaria

  • Consists of multiple discrete, pruritic, erythematous papulovesicles, and sterile vesiculopustules.
  • Similar lesions on the face, neck, and axilla may be present.
• Candidal dermatitis

  • Distinctive clusters of erythematous papules and pustules are present, which later coalesce into a beefy red confluent rash with sharp borders.
  • Satellite lesions frequently are found beyond these borders.
  • Skin folds commonly are involved.
  • White scales may be observed occasionally.
  • The oropharynx should be inspected for the white plaques of thrush.
• Secondary bacterial infection

  • Edema
  • Erythema
  • Tenderness
  • Purulent discharge
  • Red streaking
• Granuloma gluteal infantum

  • Uncommon disorder
  • Painless reddish-brown to purplish nodules are observed.
  • These granulomatous nodules can have large, raised erosions with rolled margins and a purple, almost Kaposi sarcoma–like color.
  • Nodules range in size from 0.5-4 cm.
  • Limited to prominent areas of the groin, such as the thighs, abdomen, and genitalia.
  • Axilla and neck involvement has been reported.
  • Jacquet diaper dermatitis (dermatitis syphiloids posterosiva) is a term used to describe a severe noduloerosive lesion with an umbilicated or craterlike presentation in the diaper area. It is probably closely related to granuloma gluteal and is a variant of diaper dermatitis.
• Atopic dermatitis

  • Acute lesions appear as poorly demarcated, erythematous, scaly, weepy, and crusted.
  • Chronic lesions are poorly defined, thickened, hyperpigmented, and often excoriated.
  • Lichenification can occur with chronic disease.
  • Distribution rarely involves the diaper area. It is more commonly observed on the face and extensor limb surfaces in children of diaper-wearing age.
• Seborrheic dermatitis

  • Well-demarcated erythematous patches or plaques with an occasional greasy yellow scale.
  • When found in the groin area, the skin creases show more severe involvement.
  • Skin folds are not spared.
  • There are no satellite lesions.
  • Oily, scaly, crusted lesions also can be found in areas with a predominance of sebaceous glands (eg, scalp, face, retroauricular regions, axilla, presternal area).
• Psoriasis

  • Bright, red, well-defined plaques
  • Unlike typical psoriatic lesions elsewhere, silvery scales usually are not present in the diaper area due to the dampness of the area.
  • Inguinal folds typically are involved.
  • Involvement outside the diaper area is most common (>90% of cases) and may appear as retroauricular erythema or as nail dystrophy or pitting.
• Impetigo

  • Vesicles, pustules, bullae, or crusts are commonly found in the periumbilical area.
  • In the diaper area, bullae are not usually intact.
  • They actually present as superficial erosions with a thin peripheral rim of bullous tissue.
• Langerhans cell histiocytosis

  • Discrete, yellow-brown scaly or erythematous papules, purpuric papules, petechiae, deep ulcerations, and skin atrophy are present.
  • Hemorrhagic features are typical.
  • Usually involves skin folds
  • May have associated anemia, lymphadenopathy, and hepatosplenomegaly
  • May have associated involvement of the CNS, lungs, bones, and bone marrow
• Acrodermatitis enteropathica

  • Typically involves the perioral, perineal, and acral areas
  • Erythematous, well-demarcated, scaly plaques and erosions
  • Alopecia and growth failure
  • Irritability
• Congenital syphilis

  • Symmetric desquamation of palms and soles can be found.
  • Papulosquamous, reddish-brown lesions are observed in the diaper area. Rarely, these can be erosive or bullous.
  • Associated with anemia, hepatosplenomegaly, jaundice, and osseous lesions
• Scabies

  • Papules, vesicles, burrows, nodules, and excoriations are found.
  • The generalized distribution has a predilection for the palms, soles, face, scalp, and genitalia.
• Human immunodeficiency virus

  • When this presents as a diaper rash, severe erosions and ulcerations are often present.
  • Distribution to the perineal area, especially the gluteal cleft, may be observed.
• Perianal pseudoverrucous papules

  • This condition is characterized by 2-8 shiny, smooth, red, moist, flat-topped, round lesions with acanthosis or psoriasiform spongiotic dermatitis.
  • Whereas granuloma gluteal can be confused with Kaposi sarcoma, perianal pseudoverrucous papules are most commonly confused with genital warts.
  • Perianal pseudoverrucous papules and nodules can occur in the context of Hirschsprung disease.

• A precise etiology of common diaper rashes has not been determined. Rashes have been associated with the following:

  • Infrequent diaper changes
  • Improper cleansing and drying of the diaper area
  • Failure to apply topical preparations to protect the skin
  • Diarrhea
• Candida is a common cause of secondary infection.
• Other possible sources of secondary infection include species of Staphylococcus, Streptococcus, and enteric anaerobes (Bacteroides and Peptostreptococcus species).