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 gluteale 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.

Diaper rash.

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The following are characteristic physical findings:

• 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 gluteale 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 gluteale 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 gluteale 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.