Diaper Rash

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.[2] Recent studies confirm that this trend is ongoing.[3, 4, 5] 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.

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.[6, 7] 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.[8]

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.

A study by Ersoy-Evans et al of 63 infants with diaper rash found that those with Candida infection (77.4% of the patients) had a significantly greater median number of previous diaper rash episodes than did those with noncandidal diaper rash.[9]

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 gluteale infantum

Granuloma gluteale infantum is a rare disorder.[10] It is not very well understood, but it probably represents an unusual inflammatory response to long-standing irritation, candidiasis, or fluorinated corticosteroids.

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).

The aforementioned study by Ersoy-Evans et al, of 63 infants with diaper rash, found significantly fewer previous instances of the condition in breastfed babies.[9]

United States statistics

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.[11]

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[12] —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.[13] 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 statistics

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.[14]

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.

Race-, sex-, and age-related demographics

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

No sexual predilection exists.

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.

Most cases completely resolve after a concerted effort by the parents toward diaper hygiene. The time to resolution is typically a few days for uncomplicated irritant dermatitis, intertrigo, and miliaria.

Candidal infections last a few weeks after treatment is begun. A study by Adalat et al showed that oral thrush was present in 5% of children and had a strongly significant association with a current episode of diaper dermatitis.[15]

At least one half of the cases of atopic dermatitis resolve by the third year of life. Granuloma gluteale infantum tends to resolve spontaneously over the course of a few months. Langerhans cell histiocytosis is usually a fatal disease.

Morbidity/mortality

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.

Complications

Because of maceration and abrasion of the skin under the diaper, skin ulceration and secondary infection by C albicans or bacteria are common. Prevalence of a secondary bacterial infection is uncertain, but it is frequent. Multiple organisms, both aerobic and anaerobic, contribute to the development of this condition.

Psoriasis id reaction refers to a psoriaticlike eruption of papules and plaques after the initiation of treatment to a candidal infection. The following are common characteristics:

• Involves the torso and the upper body and usually spares the extremities

• Occurs days after antifungal therapy is started

• Is poorly understood but can be treated with low or intermediate potency steroids

Jacquet dermatitis is a complicated form of the irritant chafing type of diaper rash. The following are typical features:

• It involves the development of erosive ulcerations with elevated margins.

• Some nodular patterns also are described in severe chronic irritant dermatitis.

• Cases remain surprisingly asymptomatic and usually are not secondarily infected.

Psoriasiform napkin dermatitis refers to a clinical presentation that combines features of seborrheic and candidal diaper rashes. Secondary bacterial and yeast infections can occur.

The parents of the patient should be educated about proper diaper hygiene and the need for frequent diaper changes to prevent future episodes.

Parents should be taught how to recognize changes in the rash indicative of a secondary infection and should be advised to seek medical attention in such instances.

For patient education resources, see the Children's Health Center, as well as Diaper Rash, Skin Rashes in Children, and Yeast Infection Diaper Rash.

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.

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.

The primary forms of diaper rash generally can be diagnosed clinically. Laboratory studies have few indications and limited utility. A complete blood cell count may be helpful, especially if a fever is present and a secondary bacterial infection is suspected.

The finding of anemia in association with hepatosplenomegaly and the appropriate rash may suggest a diagnosis of Langerhans cell histiocytosis or congenital syphilis.

When suspecting congenital syphilis, relevant serology should be sent. Dark field microscopic examination for spirochetes from any bullous lesion scrapings can be performed.

Serum zinc level of less than 50 mcg/dL can confirm acrodermatitis enteropathica.

Gram stain or culture of the characteristic bullae of impetigo for S aureus can confirm this diagnosis.

Routine cultures demonstrate polymicrobial infections (eg, streptococci, Enterobacteriaceae, and anaerobes) in nearly one half of cases.

Potassium hydroxide (KOH) scrapings from a fresh papular or pustular lesion may demonstrate pseudohyphae in suspected cases of candidiasis. However, these may be absent in long-standing cases.

Finding mites, ova, or feces on a mineral oil preparation of a burrow scraping can confirm the diagnosis of scabies.

Skin biopsy can be performed to help differentiate granuloma gluteale infantum from granulomatous and neoplastic processes.

Histopathology, granuloma gluteale presents as nonspecific dermal inflammatory infiltrate composed of neutrophils, lymphocytes, histiocytes, plasma cells, occasional giant cells, and eosinophils, sometimes with an increase in the number of capillaries.

Examination of granuloma gluteale using an electron microscope reveals 3 types of giant cells: in the first type, the cells have widely enlarged endoplasmic reticulum; in the second type, they phagocytize erythrocytes; and in the third type, they have vesicles and granules and are similar to histiocytes. The name granuloma gluteale infantum is a misnomer since no granulomas are found in these lesions.

Skin biopsy also is used to confirm the diagnosis of Langerhans cell histiocytosis.

The emergency physician's role in this disease is to make a proper diagnosis, to educate the caregivers, and to treat any acute complications that have occurred due to an untreated rash.

Irritant contact dermatitis, miliaria, and intertrigo often can be treated nonmedically through changes in diapering practices.

The emergency physician should advise the parent to keep the skin in the diaper area as dry as possible. This may entail more frequent diaper changes to limit the amount of time the skin is exposed to urine and feces. Caregivers should change diapers frequently, as often as every 2 hours or sooner if the diaper is wet and/or soiled.[16, 17, 18] Expose the skin under the diaper to open air as much as possible throughout the day.

Types of diapers

Switching to a disposable brand of diapers containing superabsorbent gelling material may also be helpful. Superabsorbent disposable diapers contain an absorbent gelling material (AGM) that wicks away moisture. Studies suggest that these diapers are associated with less-severe diaper rashes. Conventional disposable diapers were not found to be superior to reusable cloth diapers. A Cochrane Review did not find definitive evidence to support or refute the use and type of disposable diapers for prevention of diaper dermatitis.[19]  Tight-fitting diapers should be avoided.

The following newer types of diapers have been devised, which further reduce the incidence of diaper rash:

• A disposable diaper that continuously administers a topical petrolatum formulation to the skin has been shown to reduce the severity of diaper rash significantly compared with a conventional disposable diaper.

• Breathable disposable diapers have been shown to reduce the incidence of candidal infection by 38-50% and to also reduce the survival of Candida colonies by two thirds. The prevalence of diaper rash in this study was inversely related to the breathability of the diaper.

• Another innovation is the insertion of a water impermeable but vapor permeable membrane within diaper layers. This selectively permeable membrane allows the water vapor to escape, but prevents urine leak, and thus keeps the skin dry. In a study, this diaper has been shown to reduce the incidence of severe and mild diaper dermatitis by 39% and 18%, respectively.

Topical agents

The use of barrier creams, such as zinc oxide paste or petroleum jelly, is recommended to minimize urine and fecal contact with the skin.[20] Other useful creams include vitamin A & D ointment and Burow solution.

The principal functional effects of damage to the stratum corneum will be, firstly, an increase in the outward permeation of water, known as transepidermal water loss (TEWL), and secondly, an increase in the inward permeation of a wide variety of potentially harmful molecules and microbes. Barrier preparations work in 2 ways, either by providing a lipid film over the surface of the skin and/or by providing lipids that can penetrate into the stratum corneum, simulating the effects of normal intercellular lipids.

Effective treatment of diaper rash with bufexamac (Parfenac) lipid ointment has been reported in one study. Application of 2% eosin is effective in treating diaper area dermatitis.

Some have claimed that topical application of vitamin A ameliorates diaper dermatitis. In a Cochrane Database Systematic Review, a review studying the use of topical vitamin A for the treatment of napkin dermatitis there was no evidence to support or refute the use of topical vitamin A preparations.[21] For the prevention of napkin dermatitis, no evidence suggested that topical vitamin A alters the development of napkin dermatitis. Further, randomized, controlled trials are required to determine whether topical vitamin A is efficacious in treating or preventing napkin dermatitis.

Topical sucralfate has been reported effective for erosive irritant diaper dermatitis in a patient with chronic diarrhea.

Cornstarch can reduce friction, and talc powders that do not enhance the growth of yeast can provide protection against frictional injury in diaper dermatitis, but it does not form a continuous lipid barrier layer over the skin and obstruct the skin pores. These treatments are not recommended.

Topical cholestyramine ointment may be a safe and efficacious treatment option for perianal irritation due to bile acids and high output stools.

White soft paraffin BP is not really recommended for routine use. It is exceptionally occlusive when compared with other emollients and is, therefore, less than ideal for continuous use, since complete occlusion can prevent the recovery of damaged stratum corneum.

Two clinical trials have demonstrated that an ointment containing dexpanthenol, Bepanthen Ointment (Roche Consumer Health, UK), can help prevent and treat IDD.

Some formulations also contains lanolin, which is one of the most physiological emollient constituents currently available, containing many of the lipid groups present in the human stratum corneum and having the advantage of permitting water exchange.

Oral zinc was found to be helpful in one study.

Parents should be taught how to clean the diaper area. Excessive scrubbing should be avoided. Instead, urine can be rinsed away with warm tap water, and feces can be removed with warm water and mild nonperfumed soap.

A clinically controlled trial was completed by Adam.[6] It compared the use of infant wipes and the traditionally recognized as the golden cleansing practice, water and wash cloth. The result was in favor of the infant wipes because water has a polar nature that limits its ability to remove lipophilic substances from the skin and because water is incapable of any pH buffering action. A similar study was completed by Ehretsmann et al.[22]

Lipases and proteases in feces mix with urine and cause an alkaline surface pH, which has an irritant effect on nonintact skin. Newer formulations of wipes that include pH buffers can help restore the pH balance. Advise parents that wipes should be free of soap, essential oils or other fragrances, and harsh detergents that can irritate the skin.[23]

Cornstarch should not be used due to the irritant effect of its content on skin.

Soap has a high PH, which has a negative impact on the skin, and it contains calcium and magnesium salts, which can leave irritant precipitates on the skin and should be avoided. These should be replaced by syndet synthetic detergents, which are less irritating.

If changing in diapering practice is followed, irritant contact dermatitis, miliaria, and intertrigo should resolve very quickly.

If a mild, irritant, noninfected dermatitis is found, a cream may be all that is needed. The following are recommended:

• A cream containing zinc oxide will be appropriate.

• An ointment is a thicker barrier with petrolatum and offers more protection.

• A severe diaper rash requires aggressive treatment. A paste is the topical agent of choice. Pastes are thicker, contain petrolatum, higher concentrations of zinc oxide, karaya powder in some, moisturizers, and other additives to aid in protection, prevention, healing, and comfort.

• It is suggested with some of these products to cover the paste with a thin layer of petroleum jelly so that the paste does not stick to the diaper or to prevent opposing skin surfaces from sticking together.

For the typical irritant dermatitis or intertrigo, a nonfluorinated, low-potency corticosteroid ointment or cream (ie, 1% hydrocortisone) can be prescribed for no longer than 2 weeks. The following are recommended:

• The ointment or cream should be applied to the affected areas 4 times daily with diaper changes.

• The parent should be advised to avoid fixed combination medications, such as Mycolog II or Lotrisone. The steroids in these compounds are too potent to be safely used in the occlusive diaper environment. Usage can cause skin atrophy, striae, adrenal suppression, and Cushing syndrome.

If candidal infection is suspected, topical ointments or creams, such as nystatin, clotrimazole, miconazole, or ketoconazole can be applied to the rash with every diaper change. The following agents are recommended:

• Combination antifungal-steroid agents, such as Mycolog II or Lotrisone, should not be used because the high steroid concentration in the occlusive diaper area might cause Cushing syndrome. A review studied the use of a combination product of miconazole and hydrocortisone preparation and compared it with a combination product of nystatin/benzalkonium chloride/dimethicone/hydrocortisone preparation, both were found to improve the appearance of diaper dermatitis.

• If oral thrush or perianal candidiasis is present or if repeated bouts of candidal dermatitis have occurred, oral nystatin should also be prescribed.

• Ciclopirox was used and studied for the treatment of candidal diaper dermatitis and was found to be safe and effective.[24]

• A 2013 study examined the efficacy and safety of sertaconazole cream (2%) in diaper dermatitis candidiasis and concluded that sertaconazole cream may be considered a new alternative for diaper dermatitis candidiasis treatment.[25]

For mild bacterial infections, a topical antibiotic ointment (ie, bacitracin) should be prescribed. The following should be considered:

• More severe infections caused by gram-positive organisms and anaerobes can be treated with a broad-spectrum oral antibiotic (ie, amoxicillin/clavulanate, 40-mg amoxicillin component/kg/d for 7-10 d).

• Impetigo can be treated with dicloxacillin 12.5-25 mg/kg/d or erythromycin 50 mg/kg/d for 7-10 d.

• Congenital syphilis can be treated with 1 dose of IM penicillin G 50,000 U/kg.

In the case of granuloma gluteale infantum, recovery seems to be slow (several months), but complete. The following measures are recommended:

• Low potency topical steroids may accelerate resolution in some patients.

• Management of this disease is beyond the scope of emergency care.

• Referral to a dermatologist for management and long-term follow-up care is recommended.

Table. Skin Care Ingredients Found in Diaper Rash Creams, Ointments, and Pastes (Open Table in a new window)

Most diaper rashes cared for by emergency physicians do not require consultation.

If a systemic disease such as Langerhans cell histiocytosis, acrodermatitis enteropathica, or HIV is suspected, consultation with a pediatrician or an infectious disease specialist and consideration for admission is appropriate.

Medical treatment of diaper rash primarily involves topical corticosteroids to reduce the inflammatory response in irritated areas of skin and antifungal or antibiotic agents to treat secondary infections.

Class Summary

Suppresses inflammation and itching.

Hydrocortisone topical (Cortizone, Westcort, Dermacort)

Adrenocorticosteroid derivative suitable for application to skin or external mucous membranes. Considered lowest potency, but safest topical steroid. It has mineralocorticoid and glucocorticoid effects resulting in anti-inflammatory activity.

Class Summary

For use in candidal diaper dermatitis. Binds to sterols in fungal cell membrane allowing for leakage of cellular contents. Oral antifungals are indicated if coexisting thrush is found.

Nystatin (Mycostatin, Nilstat)

Fungicidal and fungistatic antibiotic obtained from Streptomyces noursei. Effective against various yeasts and yeastlike fungi. Changes permeability of fungal cell membrane after binding to cell membrane sterols, causing cellular contents to leak. Drug is not significantly absorbed from the GI tract.

Clotrimazole topical (Lotrimin, Mycelex)

Broad-spectrum antifungal agent that binds to phospholipids in the fungal cell membrane altering cell wall permeability resulting in a loss of essential intracellular elements.

Miconazole topical (Monistat)

Damages fungal cell wall membrane by inhibiting biosynthesis of ergosterol. Membrane permeability is increased causing nutrients to leak out, resulting in fungal cell death.

Lotion is preferred in intertriginous areas. If cream is used, apply sparingly to avoid maceration effects.

Ketoconazole topical (Nizoral)

Imidazole broad-spectrum antifungal agent. Inhibits synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death.

Class Summary

Used in treating mild bacterial superimposed infections.

Bacitracin (Baciguent)

Prevents transfer of mucopeptides into growing cell wall, inhibiting bacterial growth.

Class Summary

Used in treating more aggressive bacterial superimposed infections.

Amoxicillin and clavulanate (Augmentin)

Drug combination treats bacteria resistant to beta-lactam antibiotics.

Indicated for skin and skin structure infections caused by beta-lactamase-producing strains of Staphylococcus aureus. For children > 3 months, base dosing protocol on amoxicillin content; because of different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250-mg chewable tab (250/62.5), do not use 250-mg tab until child weighs >40 kg.

Further inpatient care

The following should be admitted to a pediatric ward for further workup:

• Febrile neonates

• Toxic-appearing patients

• Children with a severe recalcitrant rash suggestive of immunodeficiency

Further outpatient care

Arrange for follow-up care with a pediatrician in 1-2 days.

Expose the buttocks to air as much as possible.

Do not use waterproof pants during treatment, as they keep skin wet and subject to rash or infection.

Change diapers frequently.

Superabsorbent diapers are beneficial.[26]