eMedicine Specialties > Pediatrics: General Medicine > Dermatology

Diaper Dermatitis

Author: Ruchir Agrawal, MD,, Chief, Allergy and Immunology, Aurora Sheboygan Clinic
Coauthor(s): Vijay Sammeta, MD, Medical Information Services, Adventis Pharmaceutical; Isabelle Thomas, MD, Associate Professor, Department of Dermatology, University of Medicine and Dentistry of New Jersey, New Jersey Medical School; Chief of Dermatology Service, Veterans Affairs Medical Center of East Orange
Contributor Information and Disclosures

Updated: Mar 13, 2009

Introduction

Background

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

A 3-week-old female infant with diaper rash. Sate...

A 3-week-old female infant with diaper rash. Satellite lesions can be observed. The patient was diagnosed clinically with candidal dermatitis and successfully treated with nystatin ointment.

[ CLOSE WINDOW ]
A 3-week-old female infant with diaper rash. Sate...

A 3-week-old female infant with diaper rash. Satellite lesions can be observed. The patient was diagnosed clinically with candidal dermatitis and successfully treated with nystatin ointment.


Pathophysiology

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.

Mortality/Morbidity

With the exception of an individual who is immunocompromised, no mortality is associated with diaper rash when correctly diagnosed. However, a rash incorrectly diagnosed as diaper dermatitis certainly may lead to significant morbidity and mortality if associated with a serious illness.

Morbidity associated with diaper dermatitis is discomfort and the possibility of secondary bacterial or candidal infection, which may be more severe in an individual who is immunocompromised.

Race

No racial difference is observed.

Sex

No sexual difference is noted.

Age

Diaper dermatitis commonly affects infants, with peak incidence occurring when the individual is aged 9-12 months. One study determined that at any given time, diaper dermatitis is prevalent in 7-35% of the infant population.2

Diaper dermatitis can affect persons of any age who wear diapers, in particular, elderly people.

Clinical

History

  • 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

  • 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

More on Diaper Dermatitis

Overview: Diaper Dermatitis
Differential Diagnoses & Workup: Diaper Dermatitis
Treatment & Medication: Diaper Dermatitis
Follow-up: Diaper Dermatitis
Multimedia: Diaper Dermatitis
References
[ CLOSE WINDOW ]

References

  1. Runeman B. Skin interaction with absorbent hygiene products. Clin Dermatol. Jan-Feb 2008;26(1):45-51. [Medline].

  2. Jordan WE, Lawson KD, Berg RW, et al. Diaper dermatitis: frequency and severity among a general infant population. Pediatr Dermatol. Jun 1986;3(3):198-207. [Medline].

  3. Collipp PJ, Kuo B, Castro-Magana M, et al. Hair zinc, scalp hair quantity, and diaper rash in normal infants. Cutis. Jan 1985;35(1):66-70. [Medline].

  4. Benedix F, Hermann U, Brod C, et al. [Transient zinc deficiency in preterm infants]. Hautarzt. Jul 2008;59(7):563-6. [Medline].

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

  6. Berg RW, Milligan MC, Sarbaugh FC. Association of skin wetness and pH with diaper dermatitis. Pediatr Dermatol. Mar 1994;11(1):18-20. [Medline].

  7. Boiko S. Treatment of diaper dermatitis. Dermatol Clin. Jan 1999;17(1):235-40, x. [Medline].

  8. Darmstadt GL, Dinulos JG. Neonatal skin care. Pediatr Clin North Am. Aug 2000;47(4):757-82. [Medline].

  9. Ferrera PC, Dupree ML, Verdile VP. Dermatologic problems encountered in the emergency department. Am J Emerg Med. Oct 1996;14(6):588-601. [Medline].

  10. Gokalp AS, Aldirmaz C, Oguz A, et al. Relation between the intestinal flora and diaper dermatitis in infancy. Trop Geogr Med. Jul 1990;42(3):238-40. [Medline].

  11. Higuchi R, Mizukoshi M, Koyama H, et al. Intractable diaper dermatitis as an early sign of biotin deficiency. Acta Paediatr. Feb 1998;87(2):228-9. [Medline].

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

  13. Kazaks EL, Lane AT. Diaper dermatitis. Pediatr Clin North Am. Aug 2000;47(4):909-19. [Medline].

  14. Lane AT. Resolving controversies in diaper dermatitis. In: Contemporary Pediatrics. Vol 3. 1986:45-55.

  15. Longhi F, Carlucci G, Bellucci R, et al. Diaper dermatitis: a study of contributing factors. Contact Dermatitis. Apr 1992;26(4):248-52. [Medline].

  16. Manzoni P, Gomirato G. [Effectiveness of topical acetate tocopherol for the prevention and treatment of skin lesions in newborns: a 5 years experience in a 3rd level Italian Neonatal Intensive Care Unit]. Minerva Pediatr. Oct 2005;57(5):305-11. [Medline].

  17. Martin E. Weisse Stephen C. Aronoff. Candida. In: Kliegman. Nelson Textbook of Pediatrics. 18th ed. Saunders; 2007:231.

  18. Metry DW, Hebert AA. Topical therapies and medications in the pediatric patient. Pediatr Clin North Am. Aug 2000;47(4):867-76. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

diaper dermatitis, diaper rash, perianal dermatitis, diaper candidiasis, Candida albicans, allergic contact dermatitis, ACD, eczema, atopic dermatitis, acrodermatitis enteropathica, diarrhea, immunocompromise, diagnosis, treatment

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Ruchir Agrawal, MD,, Chief, Allergy and Immunology, Aurora Sheboygan Clinic
Ruchir Agrawal, MD, is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American College of Allergy, Asthma and Immunology, and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Vijay Sammeta, MD, Medical Information Services, Adventis Pharmaceutical
Disclosure: Nothing to disclose.

Isabelle Thomas, MD, Associate Professor, Department of Dermatology, University of Medicine and Dentistry of New Jersey, New Jersey Medical School; Chief of Dermatology Service, Veterans Affairs Medical Center of East Orange
Isabelle Thomas, MD is a member of the following medical societies: American Academy of Dermatology and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Kevin P Connelly, DO, Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center
Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.