History

Children with a previous medical history of eczema or atopic dermatitis may be more susceptible to diaper dermatitis. Cloth diapers and less frequent changes also increase the risk.^[13]

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.^[14]Low serum zinc level testing should be repeated for laboratory error. Zinc deficiency is easily treated with oral supplements.^[15]

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.^[16]

Physical Examination

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. Chronic granulomatous or erosive-appearing lesions can arise from constant maceration.^{[17, 18]}

Children with diaper dermatitis have marked discomfort from intense inflammation.

Rule out a secondary yeast or bacterial infection, which may occur in the area.

Also consider streptococcal intertrigo.^{[19, 20]}

Complications

Candidal diaper rash leading to confluent diaper area with tomato-red plaques, papules, pustules, and satellite papules Miliaria rubra evident as tiny red papules and papulovesicles at elasticized openings of the diaper

Differential Diagnoses

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Gustin J, Bohman L, Ogle J, Chaudhary T, Li L, Fadayel G, et al. Use of an emollient-containing diaper and pH-buffered wipe regimen restores skin pH and reduces residual enzymatic activity. Pediatr Dermatol. 2020 Jul. 37 (4):626-631. [QxMD MEDLINE Link].
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Higuchi R, Mizukoshi M, Koyama H, et al. Intractable diaper dermatitis as an early sign of biotin deficiency. Acta Paediatr. 1998 Feb. 87(2):228-9. [QxMD MEDLINE Link].
Jordan WE, Lawson KD, Berg RW, et al. Diaper dermatitis: frequency and severity among a general infant population. Pediatr Dermatol. 1986 Jun. 3(3):198-207. [QxMD MEDLINE Link].
Adam R. Skin care of the diaper area. Pediatr Dermatol. 2008 Jul-Aug. 25(4):427-33. [QxMD MEDLINE Link].
O'Connor RJ, Sanchez V, Wang Y, Gibb R, Nofziger DL, Bailey M, et al. Evaluation of the Impact of 2 Disposable Diapers in the "Natural" Diaper Category on Diapered Skin Condition. Clin Pediatr (Phila). 2019 Jun. 58 (7):806-815. [QxMD MEDLINE Link].
Vongsa R, Rodriguez K, Koenig D, Cunningham C. Benefits of Using an Appropriately Formulated Wipe to Clean Diapered Skin of Preterm Infants. Glob Pediatr Health. 2019. 6:2333794X19829186. [QxMD MEDLINE Link].
Sukhneewat C, Chaiyarit J, Techasatian L. Diaper dermatitis: a survey of risk factors in Thai children aged under 24 months. BMC Dermatol. 2019 Jul 2. 19 (1):7. [QxMD MEDLINE Link].
Collipp PJ, Kuo B, Castro-Magana M, et al. Hair zinc, scalp hair quantity, and diaper rash in normal infants. Cutis. 1985 Jan. 35(1):66-70. [QxMD MEDLINE Link].
Benedix F, Hermann U, Brod C, et al. [Transient zinc deficiency in preterm infants]. Hautarzt. 2008 Jul. 59(7):563-6. [QxMD MEDLINE Link].
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Media Gallery

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.

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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 College of Allergy, Asthma and Immunology, American Medical Association, American Academy of Pediatrics

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, Sigma Xi, The Scientific Research Honor Society

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.

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Professor of Pediatrics, Professor of Medicine, Rutgers New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, Royal College of Physicians of Edinburgh, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Kevin P Connelly, DO Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University School of Medicine; 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, American Osteopathic Association

Disclosure: Nothing to disclose.