Diaper Rash

Diaper Rash: Excerpt from The 5-Minute Pediatric Consult

Kara N. Shah, MD

Diaper Rash - BASICS

Diaper Rash - description

Also known as diaper or napkin rash, diaper dermatitis is a general term that encompasses a spectrum of skin disorders of varying etiologies that share a common distribution. Diaper dermatitis is not necessarily associated with wearing diapers.

• Often the caretaker believes the rash is a result of inadequate cleansing of the skin and, subsequently, attempts to wash the skin more. This causes additional irritation and exacerbates the underlying dermatitis.
• The prolonged use of topical corticosteroids in the diaper area in contraindicated. The side effects of topical steroids, including skin atrophy, are potentiated when used under occlusion as occurs in the diaper area.
• When topical steroids are required, they are best given as a separate prescription that can be stopped at an earlier time (usually when the rash starts to improve) than the antifungal medication. The use of combination products that contain a topical corticosteroid (usually of medium-potency) and an antifungal are not recommended for use in the diaper area.
• Talcum powder can worsen skin irritation and may be aspirated by both baby and caretaker. Its use should be discouraged.
• If a candidal diaper infection is resistant to topical treatment and thrush (monilia infection of the mouth) is present, oral nystatin may be used. An evaluation of the mother for a candidal infection of the nipples should be considered since the mother may transmit the infection to her infant. In severe cases, a short course of oral fluconazole may be necessary.
• Severe cases of diaper rash may be complicated by bacterial infections and may require treatment with topical or systemic antibiotics.

Diaper Rash - general prevention

• Proper skin care with gentle cleansing with a mild nonsoap cleanser should be encouraged.
• The use of superabsorbent diapers may be suggested, along with frequent diaper changes. It is unclear whether there is any difference in the prevalence of diaper dermatitis when disposable versus cloth diapers are used.
• The regular use of barrier creams containing zinc oxide help to protect the skin from external irritants.

Diaper Rash - epidemiology

Diaper Rash - prevalence

• Diaper dermatitis is significantly more common in infants and children who are still in diapers, and generally resolves when diapers are no longer worn.
• It affects 7–35% of the infant population at any given time and is most commonly found in the 9–12-month age group.

Diaper Rash - risk factors

• Concomitant skin disease, such as seborrheic dermatitis
• Acute or chronic conditions associated with increased stooling, diarrhea, or urinary incontinence, such as infectious gastroenteritis and enuresis

Diaper Rash - pathophysiology

Diaper rashes are the result of several different processes, alone and in combination:

• Friction and maceration: Rubbing of wet diapers against exposed skin areas such as the inner surface of the thighs, genitals, buttocks, abdomen that results in an erythematous, shiny rash that spares the intertriginous areas.
• Irritation: Prolonged exposure to irritants such as feces, urine, and skin cleansers can cause skin breakdown that predominantly affects exposed areas under the diaper, sparing intertriginous areas. Occlusion potentiates the effects of irritants.
• Inflammation: Both infectious and noninfectious processes can trigger an acute or chronic inflammatory response in the diaper area.

Diaper Rash - etiology

• Infection
  • Candida albicans: Infection is common during or immediately after use of systemic antibiotics and with any moderate to severe diaper dermatitis. It is often seen in combination with oral Candidal infections (thrush).
  • Group A beta-hemolytic Streptococcus: The most common bacteria associated with diaper dermatitis.
• Inflammation
  • Seborrheic dermatitis: In infants, usually involves the scalp (cradle cap) and face as well as the diaper area and other intertriginous areas. It is presumably related to an inflammatory response to skin colonization with the common skin yeast Pityrosporum ovale.
  • Allergic contact dermatitis: May be caused by exposure to detergents, fragrances, or dyes in diapers or clothing or to the application of topical medications to the diaper area.
  • Granuloma gluteale infantum: Believed to be caused by chronic application of topical steroids to the diaper area, this self-limiting inflammatory dermatitis is rarely seen today.
• Irritant
  • Jacquet’s erosive dermatitis: A severe erosive form of diaper dermatitis that can be confused with herpes simplex infection.

Diaper Rash - DIAGNOSIS

Diaper Rash - signs & symptoms

• Irritant diaper dermatitis and that caused by Group A beta-hemolytic Streptococcus can be painful.
• Rarely, seborrheic dermatitis and psoriatic dermatitis can be mildly pruritic but are generally asymptomatic.

Diaper Rash - history

• A history of acute or chronic diarrhea should suggest a primary irritant dermatitis.
• Antecedent use of oral antibiotics can change the normal bowel and skin flora and may cause diarrhea, which can irritate the skin.
• Use of topical corticosteroids may modify the appearance of the rash, mask superficial infections, or cause skin atrophy. It can also contribute to the development of granuloma gluteale infantum.
• Chemicals, dyes, and fragrances in clothing, lotions, diapers, and detergents can cause irritant or allergic contact dermatitis.
• Frequent bathing can lead to worsening of a pre-existent dermatitis. Parents often think a diaper rash represents poor hygiene, and as a result increase the cleaning of the area around the rash.

Diaper Rash - physical exam

• The location of the rash should be carefully noted:
  • Exposed surfaces: Allergic or irritant contact dermatitis.
  • Intertriginous areas: Seborrheic dermatitis, candidal infection, Group A beta-hemolytic Streptococcus infection
  • Perianal: Group A beta-hemolytic Streptococcus
  • The morphology of the dermatitis is of primary importance:
  • Greasy erythema and scaling suggests seborrheic dermatitis.
  • Well-demarcated, shiny, erosive erythematous perianal patches suggests Group A beta-hemolytic Streptococcus.
  • Erythematous patches with peripheral erythematous papules suggest a candidal infection.
  • Indurated red-brown subcutaneous nodules suggests granuloma gluteale infantum,
• A complete physical examination may reveal other features of the underlying diagnosis.
  • The presence of scalp seborrhea (cradle cap) suggests seborrheic dermatitis.
  • The presence of thrush (oral candidiasis) should raise the possibility of a candidal infection.

Diaper Rash - tests

Diaper Rash - lab

• Rarely helpful
• Candidal infections may be verified by a potassium hydroxide preparation of a skin scraping or by a fungal culture.
• Group A beta-hemolytic Streptococcus infection can be confirmed by a bacterial culture obtained by swabbing the affected area.

Diaper Rash - pathological findings

• Skin biopsy is rarely required.
• Can be helpful in diagnosing psoriasis, Langerhans cell histiocytosis, or a nutritional deficiency. Skin biopsy may be nondiagnostic in the case of allergic or irritant contact dermatitis and seborrheic dermatitis.

Diaper Rash - differencial diagnosis

• Scabies: Pruritic, erythematous papules and nodules may involve the diaper area; often there is a family history of multiple affected family members.
• Psoriasis: May involve the diaper area either exclusively in infants or may occur in the setting of more diffuse presentation. A family history of psoriasis or the presence of psoriasiform plaques elsewhere may suggest the diagnosis.
• Herpes simplex virus: Can present with multiple punched-out erosions in the diaper area, which can be confirmed by specific viral studies such as PCR or DFA. If confirmed, an evaluation for child abuse is mandatory.
• Langerhans cell histiocytosis:Usually presents with multiple reddish-brown crusted papules and/or vesicles and petechiae in conjunction with hepatosplenomegaly. Oral lesions may also be present.
• Nutritional and metabolic disorders: Acrodermatitis enteropathica, which is caused by impaired zinc metabolism (either inherited or acquired), leads to an erosive acrodermatitis involving the face in a perioral and periocular distribution, the diaper area, and the hands and feet. Multiple carboxylase deficiency, essential fatty acid deficiency, and biotinidase deficiency can also present in a similar manner.
• Kawasaki disease: The characteristic diaper rash appears as a scaling, desquamative erythema.
• Child abuse: An unusual history or morphology should suggest the possibility of abuse, especially if the lesions appear geometric or resemble scalds or burns.

Diaper Rash - TREATMENT

Diaper Rash - general measures

• Proper skin care is the primary treatment modality.
• When soiled, the skin should be gently washed with a mild soap or with water alone and patted dry or air dried. Vigorous rubbing of the skin or use of washcloths may cause further irritation and skin breakdown.
• Frequent diaper changes are helpful in minimizing exposure to irritants. The diaper should be kept off and the skin exposed to air as much as possible.
• Routine use of a bland barrier ointment containing zinc oxide with each diaper change is recommended.
• Candidal infections should be treated with topical nystatin cream or a topical antifungal cream such as econazole, ketoconazole, or clotrimazole cream. There is some evidence to suggest that topical clotrimazole may be less efficacious that the use of other topical antifungal agents.
• If the skin is very inflamed or if there is evidence of an allergic contact dermatitis or seborrheic dermatitis, use of a small amount of a low potency topical corticosteroid, such as 1% hydrocortisone cream, for a few days can be helpful.
• Topical application of sucralfate suspension or 10% cholestyramine in petrolatum has been used in severe cases. They function as a physical barrier and may neutralize bile acids and pepsin.

Diaper Rash - prognosis

• Diaper dermatitis usually resolves with the institution of appropriate skin care and the treatment of any underlying cause.
• Irritant diaper dermatitis completely resolves once the child is potty trained and out of diapers.

Diaper Rash - complications

• Generally none, although secondary bacterial or fungal infections may lead to ulceration.
• The chronic use of topical corticosteroids in the diaper area may lead to skin atrophy and striae.

Diaper Rash - patient monitoring

With proper treatment, the rash should improve within 4–7 days. Failure of resolution of rash indicates that another process may be complicating the diaper rash, and further evaluation is warranted.

Diaper Rash - bibliography

1. Alberta L, Sweeney SM, Wiss K. Diaper dye dermatitis. Pediatrics. 2005;116:e450–e452.
2. Akin F, Spraker M, Aly R, et al. Effects of breathable disposable diapers: reduced prevalence of Candida and common diaper dermatitis. Pediatr Dermatol. 2001;18:282–290.
3. Kazaks EL, Lane AT. Diaper dermatitis. Pediatr Clin North Am. 2000;47:909–919.
4. Odio M, Friedlander SF. Diaper dermatitis and advances in diaper technology. Curr Opin Pediatr. 2000;12:342–346.
5. Scheinfeld N. Diaper dermatitis: a review and brief survey of eruptions of the diaper area. Am J Clin Dermatol. 2005;6:273–281.
6. Ward DB, Fleischer AB Jr, Feldman SR, Krowchuk DP. Characterization of diaper dermatitis in the United States. Arch Pediatr Adolesc Med. 2000;154:943–946.

Diaper Rash - CODES

Diaper Rash - icd9

691.0 Diaper rash

Diaper Rash - FAQ

• Q: Should I switch from cloth to disposable diapers (or vice versa)?
• A: This is controversial, although there are some studies that indicate that the superabsorbent disposable diapers may be better for preventing diaper rashes. Cloth diapers used with plastic overpants probably irritate the skin more because they trap moisture against the skin. Frequent changing of diapers is very helpful, along with not wearing diapers at all when practical.
• Q: Is the diaper rash due to not keeping the skin clean enough?
• A: Although the combination of stool and urine may release enzymes that help break down skin integrity, probably more harmful to skin is vigorous and frequent scrubbing with relatively abrasive materials on the macerated, easily damaged skin typically found in the diaper area. This rough cleaning allows introduction of bacteria and yeast into the skin and results in a diaper rash. Parents should be advised to use soft cleaning materials (such as cotton balls) to gently clean stool from the diaper area. It is not usually necessary to clean the skin of urine every time, rather patting the infant dry with a soft cloth and then replacing the diaper is all that is generally required.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Diaper rash

• Back to disease: Diaper rash: Introduction
• Next Book Extract About Diaper rash: Surveys relating to Diaper rash
• More Book Extracts: All Online Books for Diaper rash

More Medical Textbooks Online about Diaper rash

Review other book chapters online related to Diaper rash:

Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

 » Next page: Surveys relating to Diaper rash

Rate This Website

What do you think about the features of this website? Take our user survey and have your say:

Website User Survey

Medical Tools & Articles:

Next articles:

• Surveys relating to Diaper rash
• Ask Question about Diaper rash

Tools & Services:

• Bookmark this page
• Symptom Search
• Symptom Checker
• Medical Dictionary
• Give your feedback

Medical Articles:

• Disease & Treatments Search
• Misdiagnosis Center
• Full list of interesting articles

Forums & Message Boards

• Ask or answer a question at the Boards:
• I cannot get a diagnosis. Please help.
• Tell us your medical story.
• Share your misdiagnosis story.
• What is the best treatment for my condition?
• See all the Boards.

Enter your search terms Submit search form
Search The Web Search wrongdiagnosis.com

Common Health Mistakes

Symptom
Checker

Search Specialists by State and City