Diaper Dermatitis (Diaper Rash)

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.[1, 2] Signs and symptoms are restricted in most individuals to the area covered by diapers.[3, 4]

The photograph below depicts a 3-week-old female neonate with diaper rash.

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.

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.)[5]  The bile salts in the stools enhance the activity of fecal enzymes, adding to the effect. pH-balanced wipes and simple washing or rinsing can help restore balance.[6]

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.

The following causes have been noted:

• Overhydration of the skin[7]

• Maceration

• Prolonged contact with urine and feces

• Retained diaper soaps

• Topical preparations

• More than 3 diarrheal stools per day

• Adverse effects of oral antibiotics

• Early sign of biotin deficiency[8]

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.[9]

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

If treated using the ABCDE acronym (air, barrier, cleansing, diaper, and education), the prognosis is excellent for most patients with diaper dermatitis.

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.

Providing education to the parents and/or caregivers of the patient is important in the treatment and further prevention of diaper dermatitis.[10]  Note the following:

• Keep the skin clean and dry.

• Provide diaper education. Frequently change diapers. Use disposable diapers with superabsorbent material. When compared with cloth diapers, disposable diapers provide a lower prevalence and severity of diaper dermatitis.[11]

• Wash genitalia with warm water and mild soap. Wipes may contain sensitizers but can be helpful in some settings.[12]

• Frequently apply a bland protective topical agent after thorough washing.

For patient education resources, see the Skin Conditions & Beauty Center and Children’s Health Center. Also, see the patient education articles Diaper Rash, Contact Dermatitis, and Skin Rashes in Children.

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]

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]

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

Diagnosis of candidal dermatitis can be established by potassium hydroxide (KOH) preparation or culture, but is usually not necessary in patients with diaper dermatitis.

Provide education regarding diaper dermatitis to patient, parents, and/or caregivers (see Patient Education).[21, 22, 23, 24]

Ideally, the first-line therapy for individuals with diaper dermatitis is zinc oxide ointment or various products containing zinc oxide.[25] Zinc oxide is an inexpensive treatment with the following properties:

• Antiseptic and astringent

• Significant role in wound healing

• Low risk for allergic or contact dermatitis

Acetyl tocopherol has been evaluated in the neonatal intensive care unit (NICU) setting and proved to be safe and more effective than the commonly used skin ointments in the topical treatment of exulcerative skin lesions in neonates.[26] Topical 2% magnesium and bentonite have also been used.[27, 28]

Various over-the-counter (OTC) diaper rash medications may confuse parents and/or caregivers. Incidence of allergic contact dermatitis (ACD) due to emollients is increasing; however, toxicity is rare. The safest OTC emollient available for newborns is pure white petrolatum ointment, which acts by trapping water beneath the epidermis. Another safe alternative is Aquaphor ointment, which is composed principally of white petrolatum, mineral oil, and wood wax alcohol. It is more expensive than pure white petrolatum ointment. Petrolatum, zinc oxide, aluminum acetate solution (1-2-3 Paste) is a combination product and is both a skin protectant and has a drying effect on vesicular or wet dermatoses.

If candidiasis is suspected or proven by potassium hydroxide (KOH) preparation or culture, an antifungal agent effective against yeast is indicated. The author has good experience in using hydrocortisone cream (1%) twice daily and antifungal (nystatin cream, powder, or ointment; clotrimazole 1% cream; econazole nitrate cream; miconazole 2% ointment; or amphotericin cream or ointment) cream after every diaper change or at least 4 times per day.[29, 30] If significant inflammation is obvious, hydrocortisone 1% can be used for the first 1-2 days. Avoid higher strength topical steroids including combination including clotrimazole/betamethasone and nystatin/triamcinolone.

Generally, no surgical intervention is needed. However, if a diagnosis other than diaper dermatitis is suspected from the presentation or the lack of response to traditional treatment, a biopsy may be indicated.

In rare incidents of diaper dermatitis, a break in the skin can lead to the inoculation of group A beta hemolytic streptococci (GABHS) or other aerobic and anaerobic organisms, causing necrotizing fascitis (NF). Recognition of this condition is extremely important because disease tends to progress quickly through the fascial plane. Initially, the skin may appear erythematous and edematous, but crepitus, cutaneous ulceration, necrosis, bullae, and abscesses soon develop. Early recognition, empirical treatment with antibiotics, and surgical debridement is essential for lower morbidity and mortality.

A pediatric dermatologist consultation may be indicated for the following:

• Atypical incidents of diaper dermatitis

• Patients who are immunocompromised

• Individuals who present with comorbidities

The diaper area may be left open to air or covered with a topical emollient.

Prevention of diaper dermatitis can be summarized with the acronym ABCDE (air, barrier, cleansing, diaper, and education).

Medical therapy for diaper dermatitis includes the use of protective topical agents, topical anticandidal agents, and, possibly, topical low-potency steroids.

Class Summary

Ideally, first-line therapy for diaper dermatitis is zinc oxide ointment. The safest over-the-counter (OTC) emollient available for newborns is pure white petrolatum ointment. Another safe alternative is Aquaphor ointment, which is principally composed of white petrolatum, mineral oil, and lanolin. It is more expensive than pure white petrolatum ointment. Petrolatum, zinc oxide, aluminum acetate solution (1-2-3 Paste) is a combination product and is both a skin protectant and has a drying effect on vesicular or wet dermatoses.

Petrolatum topical (Aveeno Skin Relief Healing Ointment, Neosporin Lip Health Overnight Renewal Therapy)

Petrolatum traps water beneath the epidermis.

Zinc oxide topical (Aveeno Baby Organic Harvest Diaper Rash Cream, Desitin, Desitin Creamy)

Zinc oxide has antiseptic and astringent properties. It plays a significant role in wound healing with low risk for allergic or contact dermatitis. To remove zinc oxide from the skin, mineral oil is more effective and easier than soap and water.

Class Summary

These agents are indicated for suspected candidiasis or proven candidal infection by potassium hydroxide (KOH) preparation or culture. Commonly used topical antifungal agents are nystatin cream or ointment and econazole nitrate cream.

Nystatin (Mycostatin)

Nystatin is a fungicidal and fungistatic antibiotic obtained from Streptomyces noursei. It is effective against various yeasts and yeastlike fungi. It changes the permeability of fungal cell membranes after binding to cell membrane sterols, causing cellular contents to leak.

Clotrimazole topical (Lotrimin AF)

Clotrimazole topical is effective in cutaneous infections. It interferes with RNA and protein synthesis and metabolism. It disrupts fungal cell wall permeability, causing fungal cell death.

Econazole topical (Ecoza)

Econazole is effective in cutaneous infections. It interferes with RNA and protein synthesis and metabolism. It disrupts fungal cell wall permeability, causing fungal cell death.

Class Summary

Limit potent topical steroid use to a few days and to a small quantity. Avoid combination topical steroid/antifungal cream in the diaper area.

Hydrocortisone, topical (Cortaid, Cortizone, Westcort)

Hydrocortisone topical is an adrenocorticosteroid derivative suitable for application to the skin or external mucous membranes. It has mineralocorticoid and glucocorticoid effects, resulting in anti-inflammatory activity.

For diaper dermatitis, which has the appearance of irritant and candidal dermatitis, the author has good experience using hydrocortisone 1% cream or Desonide 0.05% cream (bid) with nystatin (qid).