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Philippa E. Kellen, MB, BCh(WITS), FFDerm(SA)

Diaper Dermatitis: Differential Diagnosis


and Management
SUMMARY

RESUME

L'erytheme fessier est l'une des dermatoses les


Diaper dermatitis is one of the most
plus
frequentes chez le nourrisson. C'est une
common dermatoses occurring in infancy. It dermatite
oiu nombre de facteurs
is an irritant dermatitis, in which a variety of s'unissent irritative,
pour produire une inflammation de la
factors act in concert to produce
peau en contact avec la couche. Le diagnostic
inflammation of the diapered skin. The
differentiel inclut de nombreuses conditions,
dont certaines courantes et d'autres moins
differential diagnosis includes many
courantes. Le traitement fructueux necessite des
common and some uncommon conditions.
instructions detaillees aux personnes
Successful treatment requires detailed
responsables des soins a l'enfant concernant des
instructions to caregivers regarding simple
mesures hygieniques simples et les pratiques de
hygienic procedures and diapering
changement et d'entretien des couches.
practices. (Can Fam Physician 1990;
36:1569-1572.)
Key words: dermatology, dermatitis, family medicine, pediatrics
-- ----____=__~~~~~
11 -1

1-~~

Dr. Kellen is in private practice in


Saskatoon. She is a Clinical
Assistant Professor in the
Department of Medicine, Division of
Dermatology, at the University of
Saskatchewan. Requests for
reprints to: Dr. P.E. Kellen,
204-514 Queen St. Saskatoon, Sask.
S7K OM5

D IAPER DERMATITIS is an acute


inflammatory dermatosis, which is
a direct consequence of wearing diapers. The term is often loosely applied
to a variety of inflammatory dermatoses
that can occur in the area covered by a
diaper. It is one of the most common
dermatitides in infants, being reported
by up to 75 % of parents, but because it is
often mild and transient, fewer than
10% of cases are referred to physicians
for management.'

Clinical Features
Diaper dermatitis is an inflammatory
dermatosis affecting predominantly the
convex surfaces in closest contact with
wet or soiled diapers. The buttocks,
genitalia, lower abdomen, and upper
thighs are usually the most severely afCAN. FAM. PHYSICIAN Vol. 36: SEPTEMBER 1990

fected, but the distribution depends on further insult. Factors associated with
the position in which the infant is al- the development of diaper dermatitis
lowed to lie. The flexures are spared, are':
particularly in the obese child. In the * age of the infant;
mildest forms there is only erythema, * diet;
but with increasing severity, papules,
vesicles, small erosions, and larger ul- * intestinal carriage of Candida
cers may occur. In chronic forms scal- albicans;
ing is combined with glazed erythema. * the frequency and duration of contact
Scaling may be conspicuous, particular- between the infant's skin and excreta;
ly in the healing stages. Diaper dermati- and
tis may be graded according to severity: * diaper- type used.
* grade 1: slight erythema, perhaps InfantAge
with scaling;
The incidence of moderate dermatitis
* grade 2: moderate to severe erythe- is highest at age nine to 12 months.'
ma, perhaps with scaling; or few pap- There is, however, a strong correlation
ules and some edema (Figure 1);
between the infant's age and rate of dia* grade 3: moderate to severe erythe- per changing; older infants are changed
ma, perhaps with scaling, moderate to less often. Dietary changes may also
severe edema and papules, or early ul- play a significant etiological role in this
age group. Severe diaper dermatitis is
ceration; and
in about 5% of infants at
present
* grade 4: severe erythema, perhaps
with scaling, or severe edema, papules, all ages.'
and ulceration.
Diet
Infants partially or wholly breast-fed,
Causes
or those with a history of breast-feeding,
The causes of diaper dermatitis are are reported to have a lower incidence of
multiplicative rather than additive; im- moderate or severe dermatitis. This difpaired infant skin is more susceptible to ference has variously been attributed to
1569

lower stool pH, differences in intestinal


microflora, and components of feces
and urine in breast-fed infants.'
Intestinal Carriage of Candida Albicans
Candida albicans has been isolated
from the skin and feces of infants with
and without diaper dermatitis. A higher
frequency of carriage is associated with
infants with active dermatitis, and there
is a direct correlation between the severity of diaper dermatitis and the presence
of fecal Candida. The organism is usually viewed as a secondary invader of already damaged skin, but it has been suggested that C. albicans has a primary role
in severe diaper dermatitis. Recent studies have demonstrated an increased recovery of C. albicans from the rectum
and skin of patients receiving systemic
antibiotic therapy.2 This has been associated with an increased risk for developing diaper dermatitis in these patients.
Contact Between Skin and Excreta
The incidence of moderate and severe dermatitis increases when the number of bowel movements per day increases. The incidence and severity is
inversely proportional to the number of
diaper changes; it seldom occurs when
diapers are changed more than eight
times daily.

Diaper Type
Recent advances in understanding
the role of urine, feces, and fecal enzymes in diaper dermatitis have led to
improvements in the manufacturing of
disposable diapers. Clinical data have
suggested that disposable diapers containing absorbent gelling material
(AGM) provide a better skin environment and are associated with less diaper
dermatitis than other diaper types.3

Pathogenesis

be a result of the buffering capacity of


AGM in addition to capture of urine in
the diaper core away from fecal material, thereby reducing the potential for a
pH rise from ammonia production.

Differential Diagnosis
The differential diagnosis of diaper
dermatitis includes several conditions,
which may be associated with or complicated by diaper dermatitis (Table 14).
Seborrheic Dermatitis
Seborrheic dermatitis usually has its
onset during the first month of life and is
characterized by erythema and greasy
scaling. The eruption commonly begins
in the scalp and classically also involves
the flexures more or less symmetrically,
the eyebrows, and the retroauricular regions. Although the skin lesions tend to
resolve spontaneously by age three
months, these infants are reportedly
more susceptible to the development of
diaper dermatitis.'

Increased skin hydration occurs in infants wearing diapers. This hydration


produces higher coefficients of friction,
greater potential for abrasion damage,
more transepidermal penetration, and
increased microbial counts in the skin.
These factors are associated with skin
damage and a greater potential for skin
irritation.
Skin pH has been shown to play an
important role in the development of diaper dermatitis. The production of ammonia from the breakdown of urinary Atopic Eczema
urea by bacterial urease in feces leads to
Atopic eczema usually appears when
increased pH in the diapered area. In- the infant is between three to 12 months
creasing pH to 6 or 7 can increase fecal of age with extremely pruritic, erytheprotease and lipase activities. These fe- matous, papulovesicular lesions. The
cal enzymes damage skin directly and lesions most frequently start on the face,
also increase the susceptibility of the particularly the cheeks and forehead,
skin to other irritants in the dia- and may also be present elsewhere: for
area.
pered
example, on the forearms, cubital andFigure 1
Greater skin pH stability popliteal fossae, and legs. Often the diaGrade 2 Diaper Dermatitis with Severe
has been demonstrated in in- per area is relatively spared, a beneficial
Erythema but Mild
Scaling and Edema
fants wearing AGM-contain- effect of occlusion. The condition often
.M
ing disposable diapers.3 This has a chronic fluctuating course. There
stability is thought to is frequently a family history of atopy.
Figure 2
Candidiasis Showing Irregular Margins with Scaling, Papules,
..II-,~7

Figure provided courtesy of Dr. A. Moreland


1570

Reprinted with permission from Focus on Dermatology 2(1)


"Common problems of pediatric dermatitis" by Dr. Bernice
Krafchik.
CAN. FAM. PHYSICIAN Vol. 36: SEPTEMBER 1990

Candidiasis
Candidiasis can appear at any age.
The lesions tend to extend from the perianal area and are sharply and irregularly marginated red patches that have a
raised scaling edge. Satellite pustules or
papules are a diagnostic feature of this
condition (Figure 2). Oral lesions can
be present.
Miliaria

Intertrigo
Intertrigo is a frictional dermatitis
characterized by flexural, sharply marginated erythema limited to sites of
skin-on-skin contact. Involved sites include genitocrural flexures, natal cleft,
folds of the neck, and axillae.
Perianal Dermatitis
Perianal dermatitis of the newborn
usually presents within the first few
days of life with perianal erythema,
which may extend up to 4 cm or more
from the anal margin. In more severe
forms the skin may be edematous and
superficially eroded. The condition often resolves spontaneously within the
first two to three months of life.

Miliaria most commonly occurs in


the first few weeks of life, but may occur
at any stage throughout infancy. The lesions usually develop rapidly as symmetrical crops of minute papules or papulovesicles, which may present anywhere but are most frequent around the
sides of the neck, upper chest, groins, Infantile Psoriasis
Infantile psoriasis usually appears at
and axillae. The lesions usually subside
within two to three days, but recurrent about two months of age with sharply
crops may continue to develop indefi- marginated, red, scaly plaques typically
nitely if predisposing conditions contin- involving the diaper area or the scalp
ue. Miliaria in areas already inflamed initially. Smaller scattered psoriasiform
(e.g., diaper dermatitis) can be pustular plaques may develop on the trunk,
and need to be distinguished from the around the ears or neck, and on the
axillae.
satellite pustules of candidiasis.

Table 1
Differential Diagnosis of Diaper Dermatitis
Sites
Disorder
Age of Onset
Seborrheic
dermatitis

Under 3 months

Genitocrural flexures

Atopic

Rarely under 2 months


Usually 3 to 12 months

Anywhere

eczema

Candidiasis Any age

Irritant Contact Dermatitis


Irritant contact dermatitis excluding
diaper dermatitis is not uncommon in
infancy. Initially it presents with erythema and edema confined to the area in
contact with the irritant. If contact with
the irritant continues, the dermatitis
may spread beyond the area of contact
and may generalize. The reaction may
become increasingly severe, with vesiculation and even bulla formation. Exudation and crusting may be noted during the active stages and scaling in the
more chronic forms or during the resolution phase. Irritants include detergents, fabric softeners, and alcohol-containing cleansing wipes and solutions.
Other conditions that occur less often
with dermatitis in the diaper area include impetigo, herpes simplex, syphilis, acrodermatitis enteropathica, histiocytosis X syndromes, and the bullous
diseases of childhood.

Management
Diaper dermatitis can be treated and
recurrences can be prevented only after
careful assessment of contributing factors. The hygienic procedures followed

Clinical Features
Erythema and
greasy scaling
Erythema, papules,
vesicles

Extends from
perianal area

Sharply, irregularly
marginated red patches,

Other Signs
Greasy scaling of scalp;
Other flexures may be
involved
Lesions elsewhere:
cheeks, forehead,
forearms, cubital and
popliteal fossae
Pruritus
Oral lesions

raised scaling edge,


satellite pustules or papules

Erythematous papules

Lesions elsewhere:
e.g., neck, chest
Limited to areas of
skin-on-skin contact

lntertrigo

Any age

Variable: groins or
buttocks
Any flexure or fold

Perianal
dermatitis
Infantile

From 0 to 4 weeks

Perianal

Erythema

None

2 weeks to 8 months
(usually 2 months)

Convex areas,
but may be flexures
Any area; initially
area of contact
with irritant

Sharply marginated
red scaly plaques
Erythema and vesicles

Scalp and truncal

Miliaria

psoriasis
Contact
dermatitis
(irritant)

Any age

Any age

vesicles

Erythema only

lesions

Other sites in contact


with irritant may be
involved; distinguish from

atopic eczema

Source: Adapted from reference 4.


CAN. FAM. PHYSICIAN Vol. 36: SEPTEMBER 1990

1571

izoral*

(ketoconazole 2%)

shampoo

TOPICAL ANTIFUNGAL AGENT


ACTIONS
In vitro studies suggest that the antifungal properties of NIZORAL
(ketoconazole) may be related to its ability to impair the synthesis
of ergosterol, a component of fungal and yeast cell membranes.
Without the availability of this essential sterol, there are morphological alterations of the fungal and yeast cell membranes manifested
as abnormal membranous inclusions between the cell wall and the
plasma membrane. The inhibition of ergosterol synthesis has been
attributed to interference with the reactions involved in the removal
of the 14-o-methyl group of the precursor of ergosterol, lanosterol.
Except for its specific pharmacologic effect, i.e., a sporocidal or fungicidal activity, ketoconazole when formulated in a 2% shampoo is
not expected to exert any other pharmacodynamic effect when
applied topically on the skin or hair.
INDICATIONS
NIZORAL (ketoconazole) 2% shampoo is indicated for the topical
treatment and prophylaxis of pityriasis capitis infections (dandruff)
in which the yeast Pityrosporum is involved.
CONTRAINDICATIONS
NIZORAL (ketoconazole) 2% shampoo is contraindicated in persons
who have shown hypersensitivity to the active or excipient ingredients of this formulation.
WARNINGS
Irritation may occur when NIZORAL shampoo is used immediately
after prolonged treatment with topical corticosteroids. Therefore,
it is recommended to wait for about 2 weeks after treatment with
topical corticosteroids before using NIZORAL shampoo.
PRECAUTIONS
If a reaction suggesting sensitivity or chemical irritation should occur,
use of NIZORAL shampoo should be discontinued.
NIZORAL shampoo does not produce detectable blood levels after
topical application. However due to the teratogenic nature of the
active ingredient, ketoconazole, the use of NIZORAL shampoo is
not recommended in pregnant or nursing women.
ADVERSE REACTIONS
NIZORAL (ketoconazole) 2% shampoo causes minimal skin and
scalp irritation. During clinical trials, 11 (2.1 %) of 532 patients treated
with active shampoo reported side effects: Dry, brittle hair (4), greasy
hair (2), hair loss (1), irritation (1), exfoliative dermatitis (1), tiny
pustules on scalp (1) and dryness and itching of forehead and
cheeks (1).
SYMPTOMS AND TREATMENT OF OVERDOSAGE
Oral ingestion is usually followed by nausea and vomiting due to
the detergent. In the event of accidental overdosage, induce vomiting
or consider gastric lavage with sodium bicarbonate, with general
supportive measures as required. It has been reported that ketoconazole cannot be removed by hemodialysis.
DOSAGE AND ADMINISTRATION
NIZORAL shampoo should be applied to the wet scalp, worked into
a lather and left on for 3-5 minutes before rinsing with water. As
with other shampoos, care should be taken to keep the shampoo
out of the eyes and off the eyelids.
Treatment: Twice weekly for 4 weeks.
Prophylaxis: Once every one or two weeks.
DOSAGE FORM
Availability: NIZORAL (ketoconazole) 2% shampoo is supplied in
HDPE flasks with 100 mL shampoo containing 20 mg ketoconazole
per gram.
Storage: NIZORAL 2% shampoo should be stored at room temperature.
Product Monograph available on request.
REFERENCES: 1. Degreef H, Rosenberg EW.: Seborrhoeic dermatitis
and dandruff: a place for antifungals. Proceedings of a satellite symposium to the Second International Skin Therapy Symposium,
Antwerp, Belgium, May 5, 1988. Data on file at Janssen
Pharmaceutica Inc. 2. Degreef H, Jacobs PH, Rosenberg EW, et al
(eds).: Ketoconazole in seborrhoeic dermatitis and dandruff. A
Review. Data on file at Janssen Pharmaceutica Inc. 3. Green CA et
al.: Treatment of seborrhoeic dermatitis with ketoconazole: II.
Response of seborrhoeic dermatitis of the face, scalp and trunk to
topical ketoconazole. Br J Dermatol 1987; 116:217-221.
4. Faergemann J.: Activity of triazole derivatives against
Pityrosporum orbiculare in vitroand in vivo. Annals of the New York
Academy of Sciences 1988; 544:348-353. 5. Smith EB.:
Ketoconazole Shampoo, Seminars in Dermatology1987; 6(1):66-67.
6 Thulliez M.: In: "Janssen in touch with the skin." Abstract of
Satellite Symposium to the 17th World Congress of Dermatology,
Berlin, 1987, 47. 7. Tanew A.: A randomized study with ketoconazole
shampoo 2% or Selsun (selenium sulphide 2.5%) in the treatment
of seborrhoeic dermatitis and/or dandruff. Clinical Research Report
R41 400/172, November 1987. Data on file at Janssen Pharmaceutica Inc. 8. Schrooten P, De Doncker P.: 2% ketoconazole
shampoo in seborrhoeic dermatitis and dandruff, Abstract of the
International Society for Human and Animal Mycology, Barcelona;
In: Revista Iberica de Micologia 1988; 5(1):62. 9. Shuster S,
Blatchford, N.: Seborrhoeic dermatitis and dandruff: Afungal disease.
A Symposium, Royal Society of Medicine, London, December1987.
Data on file at Janssen Pharmaceutica Inc. 10. Jacobs PH.:
Seborrhoeic Dermatitis: Causes and Management. CUTIS March
1988; 41 :182-186. 11. Nizoral shampoo product monograph.

ESJANSSEN

19EMBERl

Mississauga, Ont. *Trademark JANSSEN 1990

and diapering practices are particularly


important to evaluate.
Hygienic Procedures
It is important that the diapers be
changed frequently and as soon as possible after the passage of stool. The skin
should be gently but thoroughly
cleansed with warm water after each diaper change and then gently patted dry
with a soft, smooth, cotton cloth. Keeping the diaper area clean, dry, and exposed to air promotes resolution of the
inflammation. It is advisable that the infant be left without a diaper for 0.5 to
one hour several times a day, as this
practice promotes rapid healing. If the
dermatitis is extensive and severe,
sitz-baths may provide soothing comfort while cleansing the skin. Alternatively, Burow's solution (1:20 aluminium acetate) on a clean cloth or gauze
may be applied four times a day for 15 to
20 minutes before changing the diaper.5
Diapering Practices
The use of disposable diapers containing AGM has been reported to be associated with a lower incidence and severity of diaper dermatitis.6 If cloth diapers are used, parents should be advised
to thoroughly clean and rinse them in order to remove laundry residues, which
may act as irritants, particularly to already compromised skin.
Topical Therapy
Creams and ointments, such as zinc
and castor oil, Zincofax, A & D ointment, Lassar's Paste, or soft paraffin
ointment, may be applied to protect the
skin and maintain subsequent control
once the inflammation has subsided.
The skin should be completely dry before ointments are applied.
Nonfluorinated low-potency topical
steroids (e.g., hydrocortisone) may be
used to control inflammatory changes
unresponsive to the above measures or
to control secondary eczematization.
Careful control of steroid use is required, as continued use may increase
the incidence of candidiasis in addition
to causing skin atrophy, muscle wasting,
and systemic effects. The use of fluorinated steroids is more likely to result in
these problems and may also be associated with the development of granuloma gluteale infantum.
Antibiotics
Topical or systemic antibiotics may
be indicated in severe cases where secondary bacterial infection can be demonstrated. A swab for culture and sensi-

tivity should be taken before commencing antibiotic therapy. It is important to


remember that oral antibiotic therapy
has been associated with an increased
recovery of C. albicans from the rectum
and skin, and antibiotic therapy can,
therefore, increase the risk of candidiasis in these patients.
If candidiasis (primary or secondary)
is suspected, nystatin suspension orally,
in addition to a topical antifungal preparation, is indicated for two to three weeks
to reduce gut carriage of C. albicans.

Conclusion
Diaper dermatitis can be frustrating
for parents and physicians from whom
parents seek advice. Most often, however, it will respond to simple measures
if detailed instructions are given and are
carefully followed. For those patients
with severe dermatitis, regular follow
up with encouragement, reinforcement,
and adjustment of therapy as indicated
is important. Cases resistant to therapy,
or those with atypical features, warrant
referral in order to exclude rare, but potentially serious, disorders. a

Acknowledgements
I thank Dr. R.I. Kellen and Dr. R.
Spooner for manuscript advice and Ms.
W. Erickson for secretarial assistance.

References
1. Jordan WE, Lawson KD, Berg RW, Franxman JJ, Marrer AM. Diaper dermatitis: frequency & severity among a general infant population.
Pediatr Dermatol 1986;

3(3):198-207.
2. Honig RJ, Gribetz B, Leyden JJ, McGinley
KJ, Burke LA. Amoxicillin and diaper dermatitis. JAMAcadDermatol 1988; 19(2):275-9.
3. Cambell RL, Seymour JL, Stone LC, Milligan, LC. Clinical studies with disposable diapers containing absorbent gelling materials:
evaluation of effects on infant skin condition. J
Am Acad Dermatol 1987; 17(6):978-87.
4. Rook AW, Wilkinson DS, Ebling FJG.
Textbook of dermatology. 3rd ed. Oxford:
Blackwell Scientific Publications, 1979:202.
5. Gaunder BN, Plummer E. Diaper rash:
managing and controlling a common problem
in infants and toddlers. J Pediatr Health Care
1987; 1(1):26-34.
6. Austin AP, Milligan MC, Pennington K,
Tweito DH. A survey of factors associated
with diaper dermatitis in thirty-six pediatric
practices. J Pediatr Health Care 1988;

2(6):295-9.

CAN. FAM. PHYSICIAN Vol. 36: SEPTEMBER 1990