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known as infantile pyramidal protrusion, infantile
perineal protrusion (IPP) is a benign condition that
occurs almost exclusively in female prepubertal girls.
It appears as a pyramidal, soft-tissue, tongue-like,
smooth, or velvety pink protrusion. It is usually
located in the midline just anterior to the anus. IPP is
usually asymptomatic, but painful defecation has been
reported. It occurs in three settings: constitutional,
functional (after constipation, diarrhea, or other irritant
exposure), or associated with lichen sclerosus et
atrophicus. Often, IPP is misdiagnosed as condyloma
acuminatum, hemorrhoids, or as a sign of trauma.
Conservative management is indicated. Spontaneous
resolution as well as resolution following high-fiber
diet to relieve constipation has been noted.35,36
DIAPER DERMATITIS. Diaper dermatitis, like hand dermatitis, denotes a group of region-
specific dermatoses. Diaper dermatitis is one of the most common dermatologic conditions in
infants and children, noted in approximately 1 million pediatric outpatient visits each year.45
With the advent of superabsorbent disposable diapers in the last decade, severe forms of
diaper dermatitis have diminished in incidence. Irritant and candidal diaper dermatitis comprises
the vast majority of diaper dermatitides in diaper-wearing individuals of all ages.
The etiology of diaper dermatitis is multifactorial. The initiating factor is prolonged and
increased wetness to the skin. This leads to increased frictional damage,
decreased barrier function, and increased reactivity to irritants. Other interrelated etiologic
factors include contact with urine and feces, fecal proteolytic and lipolytic
digestive enzymes, increased skin pH, and superinfection
with Candida and, less commonly, bacteria.46

Irritant Diaper Dermatitis. By far the most common

type of diaper dermatitis is irritant diaper dermatitis.
This dermatitis occurs in any person who wears
diapers, regardless of age. Irritant diaper dermatitis
appears as erythematous, moist, and sometimes scaly
patches on the convexities of the genitalia and buttocks,
beginning in areas in closest contact with the
diaper. Shallow erosions are sometimes present on the
convex surfaces. It can be asymptomatic or tender.
Candida Diaper Dermatitis. (See Chapter
189). Candida diaper dermatitis is the second most
common type of diaper dermatitis and presents with
bright red erythematous, moist papules, patches,
and plaques that tend to involve body folds as well
as convex surfaces. Satellite lesions are very characteristic.
Oral thrush can be associated. Candida from
intestinal flora frequently contaminates any type of
diaper dermatitis present for greater than 3 days, and
Candida levels increase with the clinical severity of
the dermatitis.47
Miliaria Rubra (Heat Rash). (See Chapter
84.) Miliaria rubra tends to occur at sites where plastic
components of the diaper cause occlusion of eccrine
ducts of the skin. It is also seen in the folds of the neck
and upper torso, and is particularly common when
there is a rapid shift to warm weather, and the child is
Pseudoverrucous Papules and Nodules.
Pseudoverrucous papules and nodules occur in the
diaper and perianal areas in patients of any age with
exposure to prolonged wetness. Children who wear
diapers due to chronic urinary incontinence are prone
to this type of dermatitis for example.
Infantile Granular Parakeratosis. Infantile
granular parakeratosis represents an idiopathic form
of retention keratosis in diaper-wearing infants. There
are two clinical patterns: bilateral linear plaques in the
inguinal folds and erythematous geometric plaques
underlying pressure points from the diaper. A thick,
flake-like scale is present in both forms and is characteristic.
Therapeutic responsiveness to topical agents
is ambiguous; however, spontaneous clearance after
months to 1 year appears to be the rule.48
Jacquet Erosive Dermatitis. Jacquet erosive
dermatitis is an uncommon, severe diaper dermatitis
that can occur at any age. It is characterized by welldemarcated,
punched-out ulcers, or erosions with elevated
borders. Prolonged contact with urine and feces
under occlusion leads to this condition.49 It is seen less
commonly since the advent of superabsorbent disposable
Granuloma Gluteale Infantum. Granuloma
gluteale infantum is an uncommon condition characterized
by reddish purplish nodules of different sizes
(0.53.0 cm) occurring on the convexities of the diaper
area in 2- to 9-month-old infants. It arises within preexisting
diaper dermatitis. Biopsy shows dense dermal
infiltrates of lymphocytes, plasma cells, neutrophils,
and eosinophils, but no true granulomas. It appears to
be an unusual reaction to the usual irritant factors, candidal
infection, and, in some cases, topical steroid use
in the diaper region.49 Treatment consists of avoidance
of irritants, use of barrier pastes, and avoidance of topical
steroids. Resolution occurs over several months.
Dermatoses Not Etiologically Related to
Diaper Wearing. Seborrheic dermatitis, atopic
dermatitis, psoriasis (Fig. 107-14), bullous impetigo,
acrodermatitis enteropathica, scabies, hand-foot-andmouth
disease, herpes simplex infections, and Langerhans
cell histiocytosis are conditions that occur in the
diaper region but are not primarily due to the wearing
of diapers and should be considered in the differential
diagnosis. Skin biopsy is indicated to rule out Langerhans
cell histiocytosis (see Chapter 147) if nonhealing
erosions or petechiae are seen in the diaper area
(Fig. 107-15).
Treatment of Diaper Dermatitis. The treatment
of diaper dermatitis is outlined in Table 107-8.50
Irritant diaper dermatitis and Candida diaper dermatitis
(or a combination of both) comprise the vast
majority of diaper rashes. Candida is more likely to
complicate diaper rash if present for more than 3 days.
Education of parents and primary care physicians
should include instructions regarding the use of
topical steroids in the diaper area. Because of greatly
increased percutaneous absorption of steroids from
moisture and occlusion from diapers, topical steroid
use in this anatomic region should be limited to
a short course (37 days) of hydrocortisone (1% or
2.5%) ointment. This is effective in nearly all cases
when a topical steroid is needed. Similarly, use of
the combination products containing steroids, such
as nystatin plus triamcinolone, and clotrimazole plus
betamethasone dipropionate, should be avoided
due to increased risks of steroid atrophy and
hypothalamicpituitary axis suppression when used
in the diaper area.
Last, parents will be reassured by the fact that even
the most problematic diaper dermatitis will resolve
when toilet training is achieved, and diapers are not