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Diaper Rash

  • Author: Rania Dib, MD; Chief Editor: Kirsten A Bechtel, MD  more...
 
Updated: Aug 17, 2015
 

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:

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.

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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.

The cycle of diaper rash is shown in the illustration below.

Diaper rash pathophysiology scheme. Diaper rash pathophysiology scheme.

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.  A study looked to explain the relationship between skin barrier function in 4-day-old infants and the occurrence of diaper dermatitis during the first month of life. The study concluded that early neonatal skin pH may predict the risk of diaper dermatitis during the first month of life. These results may be useful in devising strategies to prevent diaper dermatitis.[7]

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.[8] It is not very well understood, but it probably represents an unusual inflammatory response to long-standing irritation, candidiasis, or fluorinated corticosteroids.

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Epidemiology

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.[9] 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.[10]

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

See the list below:

  • 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

See the list below:

  • 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.
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Contributor Information and Disclosures
Author

Rania Dib, MD Pediatric Senior Specialist, Procare Riaya Hospital, Al Khobar, Saudia Arabia

Disclosure: Nothing to disclose.

Coauthor(s)

A Antoine Kazzi, MD Deputy Chief of Staff, American University of Beirut Medical Center; Associate Professor, Department of Emergency Medicine, American University of Beirut, Lebanon

A Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Additional Contributors

Jerry R Balentine, DO, FACEP, FACOEP Vice President, Medical Affairs and Global Health, New York Institute of Technology; Professor of Emergency Medicine, New York Institute of Technology College of Osteopathic Medicine

Jerry R Balentine, DO, FACEP, FACOEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, American College of Osteopathic Emergency Physicians, American Association for Physician Leadership, American Osteopathic Association

Disclosure: Nothing to disclose.

References
  1. Davis JA, Leyden JJ, Grove GL, Raynor WJ. Comparison of disposable diapers with fluff absorbent and fluff plus absorbent polymers: effects on skin hydration, skin pH, and diaper dermatitis. Pediatr Dermatol. 1989 Jun. 6(2):102-8. [Medline].

  2. Prasad HR, Srivastava P, Verma KK. Diapers and skin care: merits and demerits. Indian J Pediatr. 2004 Oct. 71(10):907-8. [Medline].

  3. Prasad HR, Srivastava P, Verma KK. Diaper dermatitis--an overview. Indian J Pediatr. 2003 Aug. 70(8):635-7. [Medline].

  4. Wilson PA, Dallas MJ. Diaper performance: maintenance of healthy skin. Pediatr Dermatol. 1990 Sep. 7(3):179-84. [Medline].

  5. Adam R. Skin care of the diaper area. Pediatr Dermatol. 2008 Jul-Aug. 25(4):427-33. [Medline].

  6. Korting HC, Braun-Falco O. The effect of detergents on skin pH and its consequences. Clin Dermatol. 1996 Jan-Feb. 14(1):23-7. [Medline].

  7. Yonezawa K, Haruna M, Shiraishi M, Matsuzaki M, Sanada H. Relationship between skin barrier function in early neonates and diaper dermatitis during the first month of life: a prospective observational study. Pediatr Dermatol. 2014 Nov-Dec. 31 (6):692-7. [Medline].

  8. Walsh SS, Robson WJ. Granuloma gluteale infantum: an unusual complication of napkin dermatitis. Arch Emerg Med. 1988 Jun. 5(2):113-5. [Medline].

  9. Alberta L, Sweeney SM, Wiss K. Diaper dye dermatitis. Pediatrics. 2005 Sep. 116(3):e450-2. [Medline].

  10. Longhi F, Carlucci G, Bellucci R, di Girolamo R, Palumbo G, Amerio P. Diaper dermatitis: a study of contributing factors. Contact Dermatitis. 1992 Apr. 26(4):248-52. [Medline].

  11. Borkowski S. Diaper rash care and management. Pediatr Nurs. 2004 Nov-Dec. 30(6):467-70. [Medline].

  12. Atherton DJ. A review of the pathophysiology, prevention and treatment of irritant diaper dermatitis. Curr Med Res Opin. 2004 May. 20(5):645-9. [Medline].

  13. Nield LS, Kamat D. Prevention, diagnosis, and management of diaper dermatitis. Clin Pediatr (Phila). 2007 Jul. 46(6):480-6. [Medline].

  14. Baer EL, Davies MW, Easterbrook KJ. Disposable nappies for preventing napkin dermatitis in infants. Cochrane Database Syst Rev. 2006 Jul 19. CD004262. [Medline].

  15. Blume-Peytavi U, Hauser M, Lünnemann L, Stamatas GN, Kottner J, Garcia Bartels N. Prevention of diaper dermatitis in infants--a literature review. Pediatr Dermatol. 2014 Jul-Aug. 31 (4):413-29. [Medline].

  16. Davies MW, Dore AJ, Perissinotto KL. Topical vitamin A, or its derivatives, for treating and preventing napkin dermatitis in infants. Cochrane Database Syst Rev. 2005 Oct 19. CD004300. [Medline].

  17. Ehretsmann C, Schaefer P, Adam R. Cutaneous tolerance of baby wipes by infants with atopic dermatitis, and comparison of the mildness of baby wipe and water in infant skin. J Eur Acad Dermatol Venereol. 2001 Sep. 15 Suppl 1:16-21. [Medline].

  18. Gallup E, Plott T. A multicenter, open-label study to assess the safety and efficacy of ciclopirox topical suspension 0.77% in the treatment of diaper dermatitis due to Candida albicans. J Drugs Dermatol. 2005 Jan-Feb. 4(1):29-34. [Medline].

  19. Bonifaz A, Tirado-Sánchez A, Graniel MJ, Mena C, Valencia A, Ponce-Olivera RM. The efficacy and safety of sertaconazole cream (2 %) in diaper dermatitis candidiasis. Mycopathologia. 2013 Apr. 175(3-4):249-54. [Medline]. [Full Text].

  20. Adalat S, Wall D, Goodyear H. Diaper dermatitis-frequency and contributory factors in hospital attending children. Pediatr Dermatol. 2007 Sep-Oct. 24(5):483-8. [Medline].

  21. Atherton D. Maintaining healthy skin in infancy using prevention of irritant napkin dermatitis as a model. Community Pract. 2005 Jul. 78(7):255-7. [Medline].

  22. Atherton D, Mills K. What can be done to keep babies' skin healthy?. RCM Midwives. 2004 Jul. 7(7):288-90. [Medline].

  23. Berg RW. Etiology and pathophysiology of diaper dermatitis. Adv Dermatol. 1988. 3:75-98. [Medline].

  24. Berg RW, Buckingham KW, Stewart RL. Etiologic factors in diaper dermatitis: the role of urine. Pediatr Dermatol. 1986 Feb. 3(2):102-6. [Medline].

  25. Brook I. Microbiology of secondarily infected diaper dermatitis. Int J Dermatol. 1992 Oct. 31(10):700-2. [Medline].

  26. Buckingham KW, Berg RW. Etiologic factors in diaper dermatitis: the role of feces. Pediatr Dermatol. 1986 Feb. 3(2):107-12. [Medline].

  27. Heimall LM, Storey B, Stellar JJ, Davis KF. Beginning at the bottom: evidence-based care of diaper dermatitis. MCN Am J Matern Child Nurs. 2012 Jan-Feb. 37(1):10-6. [Medline].

  28. Herbert J. The prevention and treatment of nappy rash. Some fresh insights into an old problem. Prof Care Mother Child. 1997. 7(3):67-70. [Medline].

  29. Honda M. Differential diagnosis of unusual skin diseases in infants. Pediatrician. 1987. 14 Suppl 1:15-7. [Medline].

  30. Janniger CK, Thomas I. Diaper dermatitis: an approach to prevention employing effective diaper care. Cutis. 1993 Sep. 52(3):153-5. [Medline].

  31. Jordan WE, Lawson KD, Berg RW, Franxman JJ, Marrer AM. Diaper dermatitis: frequency and severity among a general infant population. Pediatr Dermatol. 1986 Jun. 3(3):198-207. [Medline].

  32. Lin RL, Tinkle LL, Janniger CK. Skin care of the healthy newborn. Cutis. 2005 Jan. 75(1):25-30. [Medline].

  33. Obalek S, Janniger C, Jablonska S, Favre M, Orth G. Sporadic cases of Heck disease in two Polish girls: association with human papillomavirus type 13. Pediatr Dermatol. 1993 Sep. 10(3):240-4. [Medline].

  34. Rasmussen JE. Classification of diaper dermatitis: an overview. Pediatrician. 1987. 14 Suppl 1:6-10. [Medline].

  35. Scheinfeld N. Diaper dermatitis: a review and brief survey of eruptions of the diaper area. Am J Clin Dermatol. 2005. 6(5):273-81. [Medline].

  36. Singalavanija S, Frieden IJ. Diaper dermatitis. Pediatr Rev. 1995 Apr. 16(4):142-7. [Medline].

  37. Singleton JK. Pediatric dermatoses: three common skin disruptions in infancy. Nurse Pract. 1997 Jun. 22(6):32-3, 37, 43-4 passim. [Medline].

  38. Sires UI, Mallory SB. Diaper dermatitis. How to treat and prevent. Postgrad Med. 1995 Dec. 98(6):79-84, 86. [Medline].

  39. Zimmerer RE, Lawson KD, Calvert CJ. The effects of wearing diapers on skin. Pediatr Dermatol. 1986 Feb. 3(2):95-101. [Medline].

 
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Diaper rash.
Diaper rash.
Diaper rash.
Diaper rash pathophysiology scheme.
Table. Skin Care Ingredients Found in Diaper Rash Creams, Ointments, and Pastes
Several products are available for the care, management, and maintenance of skin integrity. The following are examples of ingredients frequently found in skin care products.
Petrolatum Skin protectant, water repellant, a barrier
Zinc oxide Skin protectant, soothes irritated skin
Dimethicone Skin protectant
Vitamins A and D Skin conditioner
Karaya Viscosity modifier and absorbs moisture
Mineral oil, lanolin, glycerin Emollient, softens and soothes irritated skin, a lubricant



Humectant, hygroscopic (brings water to the surface of the skin producing a moisturizing effect)



Vitamin E acetate Skin conditioner
Isopropyl palmitate Skin conditioner
Purified water Diluent
Chloroxylenol (PCMX) Antimicrobial, kills or inhibits bacteria
Isopropyl alcohol Antimicrobial
Miconazole nitrate Antifungal
Carboxymethylcellulose sodium Viscosity modifier
Methyl glucose dioleate Emulsifier, added to water-oil preparations to prevent the oil from separating from the water
Stearate acid Emulsifier
Butylparaben Preservative, prevents breakdown of product and destroys or prevents growth of bacteria
Methylparaben Preservative
Triethanolamine pH adjuster (normal pH of skin is 4.5-5.5)
Aminomethyl propanol pH adjuster
Cetyl alcohol Emollient and thickening agent
Adapted from Pediatr Nurs. 2004 Nov-Dec; 30(6): 467-70.[11]
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