eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Diaper Rash

Author: Rania Dib, MD, Pediatric Senior Specialist, Procare Riaya Hospital, Al Khobar, Saudia Arabia
Coauthor(s): A Antoine Kazzi, MD, Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon
Contributor Information and Disclosures

Updated: Jul 8, 2009

Introduction

Background

Diaper rash, or diaper dermatitis, is a general term describing any of a number of inflammatory skin conditions that can occur in the diaper area. These disorders can be conceptually divided into 3 categories:

• Rashes that are directly or indirectly caused by the wearing of diapers: This category includes dermatoses, such as irritant contact dermatitis, miliaria, intertrigo, candidal diaper dermatitis, and granuloma gluteal infantum.
• Rashes that appear elsewhere but can be exaggerated in the groin area due to the irritating effects of wearing a diaper: This category includes atopic dermatitis, seborrheic dermatitis, and psoriasis.
• Rashes that appear in the diaper area irrespective of diaper use: This category includes rashes associated with bullous impetigo; Langerhans cell histiocytosis (Letterer-Siwe disease, a rare and potentially fatal disorder of the reticuloendothelial system); acrodermatitis enteropathica (zinc deficiency); congenital syphilis; scabies; and HIV.

Allergic contact dermatitis is exceedingly rare in the infant and is not discussed here. The focus of this article is on the pathophysiology, diagnosis, and treatment of the rashes in the first category. By definition, these are truly diaper rashes because they present as a rash in the diaper area and can be cured by a change in diapering practices. The dermatoses within the other 2 categories do not typically appear as a diaper rash alone, and they do not necessarily respond to diapering modifications. These more generalized diseases are mentioned in terms of helping the emergency physician make the correct diagnosis. However, details about their etiology and management are beyond the scope of this article.

Pathophysiology

The precise etiology of most diaper rashes is not clearly defined. They likely result from a combination of factors that includes wetness, friction, urine and feces, and the presence of microorganisms. Anatomically, this skin region features numerous folds and creases, which present a problem with regard to both efficient cleansing and control of the microenvironment.

The main irritants in this situation are fecal proteases and lipases, whose activity is increased greatly by elevated pH. An acidic skin surface is also essential for the maintenance of the normal microflora, which provides innate antimicrobial protection against invasion by pathogenic bacteria and yeasts. Fecal lipase and protease activity is also greatly increased by acceleration of gastrointestinal transit; this is the reason for the high incidence of irritant diaper dermatitis observed in babies who have had diarrhea in the previous 48 hours.

The wearing of diapers causes a significant increase in skin wetness and pH. Prolonged wetness leads to maceration (softening) of the stratum corneum, the outer, protective layer of the skin, which is associated with extensive disruption of intercellular lipid lamellae. A series of diaper studies conducted mainly in the late 1980s found a significant decrease in skin hydration following the introduction of diapers with a superabsorbent core.¹ Recent studies confirm that this trend is ongoing.^2,3,4 Weakening of its physical integrity makes the stratum corneum more susceptible to damage by (1) friction from the surface of the diaper and (2) local irritants.

At full term, the skin of infants is an effective barrier to disease and is equal to adult skin with regard to permeability. Some studies reported infant’s transepidermal water loss to be lower than that of adult skin. However, dampness, lack of air exposure, acidic or irritant exposures, and increases in skin friction begin to break down the skin barrier.

The normal pH of the skin is between 4.5 and 5.5. When urea from the urine and stool mix, urease breaks down the urine, decreasing the hydrogen ion concentration (increasing pH). Elevated pH levels increase the hydration of the skin and make the skin more permeable.

Previously, ammonia was believed to be the primary cause of diaper dermatitis. Recent studies have disproved this, showing that when ammonia or urine is placed on the skin for 24-48 hours, no apparent skin damage occurs.

A series of studies has shown that the pH of cleansing products can change the microbiological spectrum of the skin.^5,6 High soap pH values encourage propionibacterial growth on skin, whereas syndets (ie, synthetic detergents) with a pH of 5.5 did not cause changes in the microflora.

Miliaria

Obstruction of eccrine sweat glands when the stratum corneum becomes excessively hydrated and edematous is believed to cause miliaria.

Intertrigo

Intertrigo occurs when wet skin, which is more fragile and has a higher coefficient of friction, becomes damaged from maceration and chafing.

Contact dermatitis

Irritant contact dermatitis is most likely made up of some combination of intertrigo and miliaria. In addition, it has been shown to result from the irritating effects of mixing urine with feces. Urine in the presence of fecal urease becomes more alkaline due to the production of ammonia. This alkaline urine causes activation of fecal lipases, ureases, and proteases. These, in turn, irritate the skin directly and increase its permeability to other low molecular weight irritants.

Candidal diaper dermatitis

Once the skin is compromised, secondary infection by Candida albicans is common. Between 40% and 75% of diaper rashes that last for more than 3 days are colonized with C albicans. Candida has a fecal origin and is not an organism normally found on perineal skin. Amoxicillin was found to increase the colonization by Candida and worsens the diaper dermatitis.

Bacterial diaper dermatitis

Bacteria may play a role in diaper dermatitis through reduction of fecal pH and the resultant activation of enzymes. Additionally, fecal microorganisms probably contribute to secondary infections when they occur. This is particularly evident with bullous impetigo in the diaper area, which causes bullae that are flaccid but sometimes tense due to Staphylococcus aureus infection, or a cellulitis due to cutaneous streptococci, or even a folliculitis due to S aureus infection.

Polymicrobial growth is documented in at least half of diaper rash cultures. Staphylococcus species are the most commonly grown organisms, followed by Streptococcus species and organisms from the family Enterobacteriaceae. Nearly 50% of isolates also contain anaerobes.

Granuloma gluteal infantum

Granuloma gluteal infantum is a rare disorder.⁷ It is not very well understood, but it probably represents an unusual inflammatory response to long-standing irritation, candidiasis, or fluorinated corticosteroids.

Frequency

United States

Diaper rash is the most common dermatitis found in infancy. Prevalence has been variably reported from 4-35% in the first 2 years of life. Incidence triples in babies with diarrhea. It is not unusual for every child to have at least 1 episode of diaper rash by the time he or she is toilet-trained.

Because fewer than 10% of all diaper rashes are reported by the family, the actual incidence of this condition is likely underestimated if office visits are used as the screening site.

The incidence is lower among breastfed infants—perhaps due to the less acidic nature of their urine and stool.

Babies wearing superabsorbent disposable diapers with a central gelling material have fewer episodes of diaper dermatitis compared with their counterparts wearing cloth diapers. However, keep in mind, that superabsorbent diapers contain dyes that were suspected to cause allergic contact dermatitis (ACD). One study reviewed the effect on the skin of dye-free diapers as compared with dye-containing diapers.⁸ A patch testing result with dye similar to that in diapers was positive in 2 out of 4 patients. This study also reported improvement with dye-free diapers for all of the patients. This would support the hypotheses that these children had allergic contact dermatitis attributable to the various dyes in the diapers. The patterns of eruption and the responses to dye-free diapers support a diagnosis of allergic contact dermatitis. Colors are added to diapers primarily for aesthetic purposes or absorbency potential.

International

Few investigations have been reported regarding prevalence outside of the United States. However, one study performed in Italy showed a prevalence of 15.2%, and a peak incidence of 19.4% in those aged 3-6 months.⁹

One large British study reported diaper dermatitis in 25% of children aged 1 month.

A Nigerian study conducted in 1995-1996 identified diaper dermatitis in 7% of children.

A study in Kuwait noted that diaper dermatitis occurs in 4% of pediatric dermatology cases.

These studies do not distinguish between common or generic diaper dermatitis and secondary diaper dermatitis.

Mortality/Morbidity

• This disease is not usually life threatening; however, it may cause significant distress for parents.
• Morbidity for the child mostly is in the form of pain and itching in the affected areas.
• In one report, diaper rash accounted for nearly 20% of pediatric office visits.

Race

Atopic dermatitis and related diaper dermatitis are more common among African American patients.

Sex

No sexual predilection exists.

Age

• Diaper rashes can start in the neonatal period as soon as the child begins to wear diapers.
• The incidence peaks in those aged 7-12 months, then decreases with age.
• Diaper rash stops being a problem once the child is toilet trained, usually around age 2 years.

Clinical

History

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

Physical

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.

Causes

• 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).

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