Diaper Rash: Practice Essentials

10/11/21 21:17 https://emedicine.medscape.
com/article/801222-print

emedicine.medscape.com
Diaper Rash
Updated: Aug 25, 2021
Author: Rania Dib, MD; Chief Editor: Kirsten A Bechtel, MD
Overview
Practice Essentials
Diaper rash, or diaper dermatitis, is a general term describing any of a number of inflammatory skin conditions that can occur in the diaper area.[1] (See the
image below.) These disorders can be conceptually divided into 3 categories:
Rashes that are directly or indirectly caused by the wearing of diapers: This category includes dermatoses, such as irritant contact
dermatitis, miliaria, intertrigo, candidal diaper dermatitis, and granuloma gluteale infantum.
Rashes that appear elsewhere but can be exaggerated in the groin area due to the irritating effects of wearing a diaper: This category includes atopic
dermatitis, seborrheic dermatitis, and psoriasis.
Rashes that appear in the diaper area irrespective of diaper use: This category includes rashes associated with bullous impetigo; Langerhans cell
histiocytosis (Letterer-Siwe disease, a rare and potentially fatal disorder of the reticuloendothelial system); acrodermatitis enteropathica (zinc
deficiency); congenital syphilis; scabies; and HIV.
Diaper rash.
Allergic contact dermatitis is exceedingly rare in the infant and is not discussed here. The focus of this article is on the pathophysiology, diagnosis, and treatment
of the rashes in the first category. By definition, these are truly diaper rashes because they present as a rash in the diaper area and can be cured by a change in
diapering practices. The dermatoses within the other 2 categories do not typically appear as a diaper rash alone, and they do not necessarily respond to
diapering modifications. These more generalized diseases are mentioned in terms of helping the emergency physician make the correct diagnosis. However,
details about their etiology and management are beyond the scope of this article.
Pathophysiology
The precise etiology of most diaper rashes is not clearly defined. They likely result from a combination of factors that includes wetness, friction, urine and feces,
and the presence of microorganisms. Anatomically, this skin region features numerous folds and creases, which present a problem with regard to both efficient
cleansing and control of the microenvironment.
The main irritants in this situation are fecal proteases and lipases, whose activity is increased greatly by elevated pH. An acidic skin surface is also essential for
the maintenance of the normal microflora, which provides innate antimicrobial protection against invasion by pathogenic bacteria and yeasts. Fecal lipase and
protease activity is also greatly increased by acceleration of gastrointestinal transit; this is the reason for the high incidence of irritant diaper dermatitis observed
in babies who have had diarrhea in the previous 48 hours.
The wearing of diapers causes a significant increase in skin wetness and pH. Prolonged wetness leads to maceration (softening) of the stratum corneum, the
outer, protective layer of the skin, which is associated with extensive disruption of intercellular lipid lamellae. A series of diaper studies conducted mainly in the
late 1980s found a significant decrease in skin hydration following the introduction of diapers with a superabsorbent core.[2] Recent studies confirm that this
trend is ongoing.[3, 4, 5] Weakening of its physical integrity makes the stratum corneum more susceptible to damage by (1) friction from the surface of the diaper
and (2) local irritants.
The cycle of diaper rash is shown in the illustration below.
https://emedicine.medscape.com/article/801222-print 1/17
10/11/21 21:17 https://emedicine.medscape.com/article/801222-print
Diaper rash pathophysiology scheme.
At full term, the skin of infants is an effective barrier to disease and is equal to adult skin with regard to permeability. Some studies reported infant's
transepidermal water loss to be lower than that of adult skin. However, dampness, lack of air exposure, acidic or irritant exposures, and increases in skin friction
begin to break down the skin barrier.
The normal pH of the skin is between 4.5 and 5.5. When urea from the urine and stool mix, urease breaks down the urine, decreasing the hydrogen ion
concentration (increasing pH). Elevated pH levels increase the hydration of the skin and make the skin more permeable.
Previously, ammonia was believed to be the primary cause of diaper dermatitis. Recent studies have disproved this, showing that when ammonia or urine is
placed on the skin for 24-48 hours, no apparent skin damage occurs.
A series of studies has shown that the pH of cleansing products can change the microbiological spectrum of the skin.[6, 7] High soap pH values encourage
propionibacterial growth on skin, whereas syndets (ie, synthetic detergents) with a pH of 5.5 did not cause changes in the microflora. A study looked to explain
the relationship between skin barrier function in 4-day-old infants and the occurrence of diaper dermatitis during the first month of life. The study concluded that
early neonatal skin pH may predict the risk of diaper dermatitis during the first month of life. These results may be useful in devising strategies to prevent diaper
dermatitis.[8]
Miliaria
Obstruction of eccrine sweat glands when the stratum corneum becomes excessively hydrated and edematous is believed to cause miliaria.
Intertrigo
Intertrigo occurs when wet skin, which is more fragile and has a higher coefficient of friction, becomes damaged from maceration and chafing.
Contact dermatitis
Irritant contact dermatitis is most likely made up of some combination of intertrigo and miliaria. In addition, it has been shown to result from the irritating effects of
mixing urine with feces. Urine in the presence of fecal urease becomes more alkaline due to the production of ammonia. This alkaline urine causes activation of
fecal lipases, ureases, and proteases. These, in turn, irritate the skin directly and increase its permeability to other low molecular weight irritants.
Candidal diaper dermatitis
Once the skin is compromised, secondary infection by Candida albicans is common. Between 40% and 75% of diaper rashes that last for more than 3 days are
colonized with C albicans. Candida has a fecal origin and is not an organism normally found on perineal skin. Amoxicillin was found to increase the colonization
by Candida and worsens the diaper dermatitis.
A study by Ersoy-Evans et al of 63 infants with diaper rash found that those with Candida infection (77.4% of the patients) had a significantly greater median
number of previous diaper rash episodes than did those with noncandidal diaper rash.[9]
Bacterial diaper dermatitis

Bacteria may play a role in diaper dermatitis through reduction of fecal pH and the resultant activation of enzymes. Additionally, fecal microorganisms probably
contribute to secondary infections when they occur. This is particularly evident with bullous impetigo in the diaper area, which causes bullae that are flaccid but
sometimes tense due to Staphylococcus aureus infection, or a cellulitis due to cutaneous streptococci, or even a folliculitis due to S aureus infection.
Polymicrobial growth is documented in at least half of diaper rash cultures. Staphylococcus species are the most commonly grown organisms, followed by
Streptococcus species and organisms from the family Enterobacteriaceae. Nearly 50% of isolates also contain anaerobes.
Granuloma gluteale infantum
Granuloma gluteale infantum is a rare disorder.[10] It is not very well understood, but it probably represents an unusual inflammatory response to long-standing
irritation, candidiasis, or fluorinated corticosteroids.
Etiology
A precise etiology of common diaper rashes has not been determined. Rashes have been associated with the following:
Infrequent diaper changes
Improper cleansing and drying of the diaper area
Failure to apply topical preparations to protect the skin
Diarrhea
Candida is a common cause of secondary infection. Other possible sources of secondary infection include species of Staphylococcus, Streptococcus, and
enteric anaerobes (Bacteroides and Peptostreptococcus species).
The aforementioned study by Ersoy-Evans et al, of 63 infants with diaper rash, found significantly fewer previous instances of the condition in breastfed babies.
[9]
Epidemiology
United States statistics
Diaper rash is the most common dermatitis found in infancy. Prevalence has been variably reported from 4-35% in the first 2 years of life. Incidence triples in
babies with diarrhea. It is not unusual for every child to have at least 1 episode of diaper rash by the time he or she is toilet-trained.[11]
Because fewer than 10% of all diaper rashes are reported by the family, the actual incidence of this condition is likely underestimated if office visits are used as
the screening site.
The incidence is lower among breastfed infants[12] —perhaps due to the less acidic nature of their urine and stool.
Babies wearing superabsorbent disposable diapers with a central gelling material have fewer episodes of diaper dermatitis compared with their counterparts
wearing cloth diapers. However, keep in mind, that superabsorbent diapers contain dyes that were suspected to cause allergic contact dermatitis (ACD). One
study reviewed the effect on the skin of dye-free diapers as compared with dye-containing diapers.[13] A patch testing result with dye similar to that in diapers
was positive in 2 out of 4 patients. This study also reported improvement with dye-free diapers for all of the patients. This would support the hypotheses that
these children had allergic contact dermatitis attributable to the various dyes in the diapers. The patterns of eruption and the responses to dye-free diapers
support a diagnosis of allergic contact dermatitis. Colors are added to diapers primarily for aesthetic purposes or absorbency potential.
International statistics
Few investigations have been reported regarding prevalence outside of the United States. However, one study performed in Italy showed a prevalence of 15.2%,
and a peak incidence of 19.4% in those aged 3-6 months.[14]
One large British study reported diaper dermatitis in 25% of children aged 1 month.
A Nigerian study conducted in 1995-1996 identified diaper dermatitis in 7% of children.
A study in Kuwait noted that diaper dermatitis occurs in 4% of pediatric dermatology cases.
These studies do not distinguish between common or generic diaper dermatitis and secondary diaper dermatitis.
Race-, sex-, and age-related demographics
Atopic dermatitis and related diaper dermatitis are more common among African American patients.
No sexual predilection exists.
Diaper rashes can start in the neonatal period as soon as the child begins to wear diapers. The incidence peaks in those aged 7-12 months, then decreases with
age. Diaper rash stops being a problem once the child is toilet trained, usually around age 2 years.
Prognosis
Most cases completely resolve after a concerted effort by the parents toward diaper hygiene. The time to resolution is typically a few days for uncomplicated
irritant dermatitis, intertrigo, and miliaria.
Candidal infections last a few weeks after treatment is begun. A study by Adalat et al showed that oral thrush was present in 5% of children and had a strongly
significant association with a current episode of diaper dermatitis.[15]
At least one half of the cases of atopic dermatitis resolve by the third year of life. Granuloma gluteale infantum tends to resolve spontaneously over the course of
a few months. Langerhans cell histiocytosis is usually a fatal disease.
Morbidity/mortality
This disease is not usually life threatening; however, it may cause significant distress for parents. Morbidity for the child mostly is in the form of pain and itching in
the affected areas. In one report, diaper rash accounted for nearly 20% of pediatric office visits.
Complications
Because of maceration and abrasion of the skin under the diaper, skin ulceration and secondary infection by C albicans or bacteria are common. Prevalence of a
secondary bacterial infection is uncertain, but it is frequent. Multiple organisms, both aerobic and anaerobic, contribute to the development of this condition.
Psoriasis id reaction refers to a psoriaticlike eruption of papules and plaques after the initiation of treatment to a candidal infection. The following are common
characteristics:
Involves the torso and the upper body and usually spares the extremities
Occurs days after antifungal therapy is started
Is poorly understood but can be treated with low or intermediate potency steroids
Jacquet dermatitis is a complicated form of the irritant chafing type of diaper rash. The following are typical features:
It involves the development of erosive ulcerations with elevated margins.
Some nodular patterns also are described in severe chronic irritant dermatitis.
Cases remain surprisingly asymptomatic and usually are not secondarily infected.
Psoriasiform napkin dermatitis refers to a clinical presentation that combines features of seborrheic and candidal diaper rashes. Secondary bacterial and yeast
infections can occur.
Patient Education
The parents of the patient should be educated about proper diaper hygiene and the need for frequent diaper changes to prevent future episodes.
Parents should be taught how to recognize changes in the rash indicative of a secondary infection and should be advised to seek medical attention in such
instances.
For patient education resources, see the Children's Health Center, as well as Diaper Rash, Skin Rashes in Children, and Yeast Infection Diaper Rash.
Presentation
History
One study review performed in the United Kingdom reported that irritant diaper dermatitis does not usually develop immediately after birth; onset is generally
between 3 weeks and 2 years of age, with prevalence highest between 9 and 12 months. This study showed that one fifth of all pediatric dermatology visits for
children up to the age of 5 years were to treat diaper dermatitis.
Diagnosis of diaper dermatitis is based largely on the physical examination. A careful history, however, could elicit clues that aid in narrowing the differential
diagnosis.
Important points to obtain on history include the following:
Onset, duration, and change in the nature of the rash
Presence of rashes outside the diaper area
Associated scratching or crying
Contact with infants with a similar rash
Recent illness, diarrhea, or antibiotic use
Assessment of current diapering practices (eg, change frequency, type of diapers used, creams or ointments applied, methods used to clean the diaper
area)
Irritant contact dermatitis, miliaria (heat rash), and intertrigo
Usually follows a bout of diarrhea
Exacerbated by scrubbing and the use of commercial wipes or strong detergents
Lasts less than 3 days after more diligent diaper changing practices are initiated
Asymptomatic (except for miliaria)
Candidal diaper dermatitis
Lasts even after more diligent diaper changing practices are started
Should be suspected in all rashes lasting more than 3 d (Candida is isolated in 45-75% of such cases)
Painful - Parents often report severe crying during diaper changes or with urination and defecation.
May follow recent antibiotic use
Secondary bacterial infection
Fever
Pustular drainage
Lymphangitis
Rash lasts months
Resistant to treatments with barrier creams, antifungal agents, and topical steroids
Asymptomatic
Atopic dermatitis
Family or personal history of allergic rhinitis, hay fever, or asthma is common.
Pruritic
Associated with current or previous flares of rash on the face and extensor limb surfaces in infants
Seborrheic dermatitis
Usually occurs in infants aged 2 weeks to 3 months
Consists of an eruption of an oily, scaly, crusted dermatitis of the scalp (cradle cap), face, retroauricular regions, axilla, and presternal areas
Asymptomatic
Any child with widespread seborrheic dermatitis, diarrhea, and failure to thrive should be evaluated for Leiner disease, a functional defect of the C5
component of complement.
Psoriasis
A family history of psoriasis can be a clue.
Not responsive to barrier creams, antifungal agents, and standard topical steroids
Involved areas include the scalp and nails
Impetigo
Common in the first 6 months of life
Usually occurs during the warmer summer months
Langerhans cell histiocytosis
Severe hemorrhagic diaper dermatitis unresponsive to any treatment
Other involved areas include the scalp and retroauricular areas
Diarrhea
Acrodermatitis enteropathica
Associated with diarrhea, hair loss, and erosive perioral dermatitis
Patient may have a predisposition for malabsorption (ie, cystic fibrosis) or malnutrition
Scabies
Acute onset
Pruritic
History of close contacts with recent onset of a similar erythematous serpiginous eruption
Concurrent rash may be found in web spaces of hands or feet
Human immunodeficiency virus
History of HIV exposure or risk factors
Associated cytomegalovirus or herpes infection
Physical Examination
The pertinent physical examination focuses on the skin in the diaper area. Findings vary depending on which subset of diaper rash is most prominent.
Diaper rash.
The following are characteristic physical findings:
Irritant contact dermatitis
Mild forms consist of shiny erythema with or without scale.
Margins are not always evident.
Moderate cases have areas of papules, vesicles, and small superficial erosions.
It can progress to well-demarcated ulcerated nodules that measure a centimeter or more in diameter.
It is found on the prominent parts of the buttocks, medial thighs, mons pubis, and scrotum.
Skin folds are spared or involved last.
Tidemark dermatitis refers to the bandlike form of erythema of irritated diaper margins.
Diaper dermatitis can cause an id (autoeczematous) reaction with reaction outside the diaper area.
Intertrigo
Occurs in skin creases where skin surfaces are in apposition
Characterized by slight to severe erythema in the inguinal area, intergluteal area, or folds of the thighs
Pustules or erosions are not present.
Miliaria
Consists of multiple discrete, pruritic, erythematous papulovesicles, and sterile vesiculopustules.
Similar lesions on the face, neck, and axilla may be present.
Candidal dermatitis
Distinctive clusters of erythematous papules and pustules are present, which later coalesce into a beefy red confluent rash with sharp borders.
Satellite lesions frequently are found beyond these borders.
Skin folds commonly are involved.
White scales may be observed occasionally.
The oropharynx should be inspected for the white plaques of thrush.
Secondary bacterial infection
Edema
Erythema
Tenderness
Purulent discharge
Red streaking
Uncommon disorder
Painless reddish-brown to purplish nodules are observed.
These granulomatous nodules can have large, raised erosions with rolled margins and a purple, almost Kaposi sarcoma–like color.
Nodules range in size from 0.5-4 cm.
Limited to prominent areas of the groin, such as the thighs, abdomen, and genitalia.
Axilla and neck involvement has been reported.
Jacquet diaper dermatitis (dermatitis syphiloids posterosiva) is a term used to describe a severe noduloerosive lesion with an umbilicated or
craterlike presentation in the diaper area. It is probably closely related to granuloma gluteale and is a variant of diaper dermatitis.
Atopic dermatitis
Acute lesions appear as poorly demarcated, erythematous, scaly, weepy, and crusted.
Chronic lesions are poorly defined, thickened, hyperpigmented, and often excoriated.
Lichenification can occur with chronic disease.
Distribution rarely involves the diaper area. It is more commonly observed on the face and extensor limb surfaces in children of diaper-wearing
age.
Seborrheic dermatitis
Well-demarcated erythematous patches or plaques with an occasional greasy yellow scale.
When found in the groin area, the skin creases show more severe involvement.
Skin folds are not spared.
There are no satellite lesions.
Oily, scaly, crusted lesions also can be found in areas with a predominance of sebaceous glands (eg, scalp, face, retroauricular regions, axilla,
presternal area).
Psoriasis
Bright, red, well-defined plaques
Unlike typical psoriatic lesions elsewhere, silvery scales usually are not present in the diaper area due to the dampness of the area.
Inguinal folds typically are involved.
Involvement outside the diaper area is most common (>90% of cases) and may appear as retroauricular erythema or as nail dystrophy or pitting.
Impetigo
Vesicles, pustules, bullae, or crusts are commonly found in the periumbilical area.
In the diaper area, bullae are not usually intact.
They actually present as superficial erosions with a thin peripheral rim of bullous tissue.
Langerhans cell histiocytosis
Discrete, yellow-brown scaly or erythematous papules, purpuric papules, petechiae, deep ulcerations, and skin atrophy are present.
Hemorrhagic features are typical.
Usually involves skin folds
May have associated anemia, lymphadenopathy, and hepatosplenomegaly
May have associated involvement of the CNS, lungs, bones, and bone marrow
Acrodermatitis enteropathica
Typically involves the perioral, perineal, and acral areas
Erythematous, well-demarcated, scaly plaques and erosions
Alopecia and growth failure
Irritability
Congenital syphilis
Symmetric desquamation of palms and soles can be found.
Papulosquamous, reddish-brown lesions are observed in the diaper area. Rarely, these can be erosive or bullous.
Associated with anemia, hepatosplenomegaly, jaundice, and osseous lesions
Scabies
Papules, vesicles, burrows, nodules, and excoriations are found.
The generalized distribution has a predilection for the palms, soles, face, scalp, and genitalia.
Human immunodeficiency virus
When this presents as a diaper rash, severe erosions and ulcerations are often present.
Distribution to the perineal area, especially the gluteal cleft, may be observed.
Perianal pseudoverrucous papules
This condition is characterized by 2-8 shiny, smooth, red, moist, flat-topped, round lesions with acanthosis or psoriasiform spongiotic dermatitis.
Whereas granuloma gluteale can be confused with Kaposi sarcoma, perianal pseudoverrucous papules are most commonly confused with genital
warts.
Perianal pseudoverrucous papules and nodules can occur in the context of Hirschsprung disease.
DDx
Differential Diagnoses
Allergic Contact Dermatitis
Atopic Dermatitis in Emergency Medicine
Candidiasis in Emergency Medicine
Genital Warts
Impetigo
Kawasaki Disease
Psoriasis
Rapid HIV Testing
Scabies
Syphilis
Tinea in Emergency Medicine
Tuberculosis (TB)
Workup

Workup
Laboratory Studies
The primary forms of diaper rash generally can be diagnosed clinically. Laboratory studies have few indications and limited utility. A complete blood cell count
may be helpful, especially if a fever is present and a secondary bacterial infection is suspected.
The finding of anemia in association with hepatosplenomegaly and the appropriate rash may suggest a diagnosis of Langerhans cell histiocytosis or congenital
syphilis.
When suspecting congenital syphilis, relevant serology should be sent. Dark field microscopic examination for spirochetes from any bullous lesion scrapings can
be performed.
Serum zinc level of less than 50 mcg/dL can confirm acrodermatitis enteropathica.
Gram stain or culture of the characteristic bullae of impetigo for S aureus can confirm this diagnosis.
Routine cultures demonstrate polymicrobial infections (eg, streptococci, Enterobacteriaceae, and anaerobes) in nearly one half of cases.
Other Tests
Potassium hydroxide (KOH) scrapings from a fresh papular or pustular lesion may demonstrate pseudohyphae in suspected cases of candidiasis. However,
these may be absent in long-standing cases.
Finding mites, ova, or feces on a mineral oil preparation of a burrow scraping can confirm the diagnosis of scabies.
Procedures
Skin biopsy can be performed to help differentiate granuloma gluteale infantum from granulomatous and neoplastic processes.
Histopathology, granuloma gluteale presents as nonspecific dermal inflammatory infiltrate composed of neutrophils, lymphocytes, histiocytes, plasma cells,
occasional giant cells, and eosinophils, sometimes with an increase in the number of capillaries.
Examination of granuloma gluteale using an electron microscope reveals 3 types of giant cells: in the first type, the cells have widely enlarged endoplasmic
reticulum; in the second type, they phagocytize erythrocytes; and in the third type, they have vesicles and granules and are similar to histiocytes. The name
granuloma gluteale infantum is a misnomer since no granulomas are found in these lesions.
Skin biopsy also is used to confirm the diagnosis of Langerhans cell histiocytosis.
Treatment
Emergency Department Care

The emergency physician's role in this disease is to make a proper diagnosis, to educate the caregivers, and to treat any acute complications that have occurred
due to an untreated rash.
Irritant contact dermatitis, miliaria, and intertrigo often can be treated nonmedically through changes in diapering practices.
The emergency physician should advise the parent to keep the skin in the diaper area as dry as possible. This may entail more frequent diaper changes to limit
the amount of time the skin is exposed to urine and feces. Caregivers should change diapers frequently, as often as every 2 hours or sooner if the diaper is wet
and/or soiled.[16, 17, 18] Expose the skin under the diaper to open air as much as possible throughout the day.
Types of diapers
Switching to a disposable brand of diapers containing superabsorbent gelling material may also be helpful. Superabsorbent disposable diapers contain an
absorbent gelling material (AGM) that wicks away moisture. Studies suggest that these diapers are associated with less-severe diaper rashes. Conventional
disposable diapers were not found to be superior to reusable cloth diapers. A Cochrane Review did not find definitive evidence to support or refute the use and
type of disposable diapers for prevention of diaper dermatitis.[19] Tight-fitting diapers should be avoided.
The following newer types of diapers have been devised, which further reduce the incidence of diaper rash:
A disposable diaper that continuously administers a topical petrolatum formulation to the skin has been shown to reduce the severity of diaper rash
significantly compared with a conventional disposable diaper.
Breathable disposable diapers have been shown to reduce the incidence of candidal infection by 38-50% and to also reduce the survival of Candida
colonies by two thirds. The prevalence of diaper rash in this study was inversely related to the breathability of the diaper.
Another innovation is the insertion of a water impermeable but vapor permeable membrane within diaper layers. This selectively permeable membrane
allows the water vapor to escape, but prevents urine leak, and thus keeps the skin dry. In a study, this diaper has been shown to reduce the incidence of
severe and mild diaper dermatitis by 39% and 18%, respectively.
Topical agents
The use of barrier creams, such as zinc oxide paste or petroleum jelly, is recommended to minimize urine and fecal contact with the skin.[20] Other useful
creams include vitamin A & D ointment and Burow solution.
The principal functional effects of damage to the stratum corneum will be, firstly, an increase in the outward permeation of water, known as transepidermal water
loss (TEWL), and secondly, an increase in the inward permeation of a wide variety of potentially harmful molecules and microbes. Barrier preparations work in 2
ways, either by providing a lipid film over the surface of the skin and/or by providing lipids that can penetrate into the stratum corneum, simulating the effects of
normal intercellular lipids.
Effective treatment of diaper rash with bufexamac (Parfenac) lipid ointment has been reported in one study. Application of 2% eosin is effective in treating diaper
area dermatitis.
Some have claimed that topical application of vitamin A ameliorates diaper dermatitis. In a Cochrane Database Systematic Review, a review studying the use of
topical vitamin A for the treatment of napkin dermatitis there was no evidence to support or refute the use of topical vitamin A preparations.[21] For the
prevention of napkin dermatitis, no evidence suggested that topical vitamin A alters the development of napkin dermatitis. Further, randomized, controlled trials
are required to determine whether topical vitamin A is efficacious in treating or preventing napkin dermatitis.
Topical sucralfate has been reported effective for erosive irritant diaper dermatitis in a patient with chronic diarrhea.
Cornstarch can reduce friction, and talc powders that do not enhance the growth of yeast can provide protection against frictional injury in diaper dermatitis, but it
does not form a continuous lipid barrier layer over the skin and obstruct the skin pores. These treatments are not recommended.
Topical cholestyramine ointment may be a safe and efficacious treatment option for perianal irritation due to bile acids and high output stools.
White soft paraffin BP is not really recommended for routine use. It is exceptionally occlusive when compared with other emollients and is, therefore, less than
ideal for continuous use, since complete occlusion can prevent the recovery of damaged stratum corneum.
Two clinical trials have demonstrated that an ointment containing dexpanthenol, Bepanthen Ointment (Roche Consumer Health, UK), can help prevent and treat
IDD.
Some formulations also contains lanolin, which is one of the most physiological emollient constituents currently available, containing many of the lipid groups
present in the human stratum corneum and having the advantage of permitting water exchange.
Oral zinc was found to be helpful in one study.
Parents should be taught how to clean the diaper area. Excessive scrubbing should be avoided. Instead, urine can be rinsed away with warm tap water, and
feces can be removed with warm water and mild nonperfumed soap.
A clinically controlled trial was completed by Adam.[6] It compared the use of infant wipes and the traditionally recognized as the golden cleansing practice, water
and wash cloth. The result was in favor of the infant wipes because water has a polar nature that limits its ability to remove lipophilic substances from the skin
and because water is incapable of any pH buffering action. A similar study was completed by Ehretsmann et al.[22]
Lipases and proteases in feces mix with urine and cause an alkaline surface pH, which has an irritant effect on nonintact skin. Newer formulations of wipes that
include pH buffers can help restore the pH balance. Advise parents that wipes should be free of soap, essential oils or other fragrances, and harsh detergents
that can irritate the skin.[23]
Cornstarch should not be used due to the irritant effect of its content on skin.
Soap has a high PH, which has a negative impact on the skin, and it contains calcium and magnesium salts, which can leave irritant precipitates on the skin and
should be avoided. These should be replaced by syndet synthetic detergents, which are less irritating.
If changing in diapering practice is followed, irritant contact dermatitis, miliaria, and intertrigo should resolve very quickly.
If a mild, irritant, noninfected dermatitis is found, a cream may be all that is needed. The following are recommended:
A cream containing zinc oxide will be appropriate.
An ointment is a thicker barrier with petrolatum and offers more protection.
A severe diaper rash requires aggressive treatment. A paste is the topical agent of choice. Pastes are thicker, contain petrolatum, higher concentrations of
zinc oxide, karaya powder in some, moisturizers, and other additives to aid in protection, prevention, healing, and comfort.
It is suggested with some of these products to cover the paste with a thin layer of petroleum jelly so that the paste does not stick to the diaper or to
prevent opposing skin surfaces from sticking together.
For the typical irritant dermatitis or intertrigo, a nonfluorinated, low-potency corticosteroid ointment or cream (ie, 1% hydrocortisone) can be prescribed for no
longer than 2 weeks. The following are recommended:
The ointment or cream should be applied to the affected areas 4 times daily with diaper changes.
The parent should be advised to avoid fixed combination medications, such as Mycolog II or Lotrisone. The steroids in these compounds are too potent to
be safely used in the occlusive diaper environment. Usage can cause skin atrophy, striae, adrenal suppression, and Cushing syndrome.
If candidal infection is suspected, topical ointments or creams, such as nystatin, clotrimazole, miconazole, or ketoconazole can be applied to the rash with every
diaper change. The following agents are recommended:
Combination antifungal-steroid agents, such as Mycolog II or Lotrisone, should not be used because the high steroid concentration in the occlusive diaper
area might cause Cushing syndrome. A review studied the use of a combination product of miconazole and hydrocortisone preparation and compared it
with a combination product of nystatin/benzalkonium chloride/dimethicone/hydrocortisone preparation, both were found to improve the appearance of
diaper dermatitis.
If oral thrush or perianal candidiasis is present or if repeated bouts of candidal dermatitis have occurred, oral nystatin should also be prescribed.
Ciclopirox was used and studied for the treatment of candidal diaper dermatitis and was found to be safe and effective.[24]
A 2013 study examined the efficacy and safety of sertaconazole cream (2%) in diaper dermatitis candidiasis and concluded that sertaconazole cream
may be considered a new alternative for diaper dermatitis candidiasis treatment.[25]
For mild bacterial infections, a topical antibiotic ointment (ie, bacitracin) should be prescribed. The following should be considered:
More severe infections caused by gram-positive organisms and anaerobes can be treated with a broad-spectrum oral antibiotic (ie,
amoxicillin/clavulanate, 40-mg amoxicillin component/kg/d for 7-10 d).
Impetigo can be treated with dicloxacillin 12.5-25 mg/kg/d or erythromycin 50 mg/kg/d for 7-10 d.
Congenital syphilis can be treated with 1 dose of IM penicillin G 50,000 U/kg.
In the case of granuloma gluteale infantum, recovery seems to be slow (several months), but complete. The following measures are recommended:
Low potency topical steroids may accelerate resolution in some patients.
Management of this disease is beyond the scope of emergency care.
Referral to a dermatologist for management and long-term follow-up care is recommended.
Table. Skin Care Ingredients Found in Diaper Rash Creams, Ointments, and Pastes (Open Table in a new window)
Several products are available for the care, management, and maintenance of skin integrity. The following are examples of ingredients frequently found in
skin care products.
Petrolatum Skin protectant, water repellant, a barrier
Zinc oxide Skin protectant, soothes irritated skin
Dimethicone Skin protectant
Vitamins A and D Skin conditioner
Karaya Viscosity modifier and absorbs moisture
Emollient, softens and soothes irritated skin, a lubricant

Mineral oil, lanolin, glycerin
Humectant, hygroscopic (brings water to the surface of the skin producing a moisturizing effect)
Vitamin E acetate Skin conditioner
Isopropyl palmitate Skin conditioner
Purified water Diluent
Chloroxylenol (PCMX) Antimicrobial, kills or inhibits bacteria
Isopropyl alcohol Antimicrobial
Miconazole nitrate Antifungal
Carboxymethylcellulose sodium Viscosity modifier
Methyl glucose dioleate Emulsifier, added to water-oil preparations to prevent the oil from separating from the water
Stearate acid Emulsifier
Butylparaben Preservative, prevents breakdown of product and destroys or prevents growth of bacteria
Methylparaben Preservative
Triethanolamine pH adjuster (normal pH of skin is 4.5-5.5)
Aminomethyl propanol pH adjuster
Cetyl alcohol Emollient and thickening agent
Adapted from Pediatr Nurs. 2004 Nov-Dec; 30(6): 467-70.[16]
Consultations
Most diaper rashes cared for by emergency physicians do not require consultation.
If a systemic disease such as Langerhans cell histiocytosis, acrodermatitis enteropathica, or HIV is suspected, consultation with a pediatrician or an infectious
disease specialist and consideration for admission is appropriate.
Medication
Medication Summary
Medical treatment of diaper rash primarily involves topical corticosteroids to reduce the inflammatory response in irritated areas of skin and antifungal or
antibiotic agents to treat secondary infections.
Corticosteroid, topical
Class Summary
Suppresses inflammation and itching.
Hydrocortisone topical (Cortizone, Westcort, Dermacort)

Adrenocorticosteroid derivative suitable for application to skin or external mucous membranes. Considered lowest potency, but safest topical steroid. It has
mineralocorticoid and glucocorticoid effects resulting in anti-inflammatory activity.
Antifungal agents
Class Summary
For use in candidal diaper dermatitis. Binds to sterols in fungal cell membrane allowing for leakage of cellular contents. Oral antifungals are indicated if coexisting
thrush is found.
Nystatin (Mycostatin, Nilstat)

Fungicidal and fungistatic antibiotic obtained from Streptomyces noursei. Effective against various yeasts and yeastlike fungi. Changes permeability of fungal cell
membrane after binding to cell membrane sterols, causing cellular contents to leak. Drug is not significantly absorbed from the GI tract.
Clotrimazole topical (Lotrimin, Mycelex)

Broad-spectrum antifungal agent that binds to phospholipids in the fungal cell membrane altering cell wall permeability resulting in a loss of essential intracellular
elements.
Miconazole topical (Monistat)

Damages fungal cell wall membrane by inhibiting biosynthesis of ergosterol. Membrane permeability is increased causing nutrients to leak out, resulting in fungal
cell death.
Lotion is preferred in intertriginous areas. If cream is used, apply sparingly to avoid maceration effects.
Ketoconazole topical (Nizoral)

Imidazole broad-spectrum antifungal agent. Inhibits synthesis of ergosterol, causing cellular components to leak, resulting in fungal cell death.
Antibiotics, topical
Class Summary
Used in treating mild bacterial superimposed infections.
Bacitracin (Baciguent)
Prevents transfer of mucopeptides into growing cell wall, inhibiting bacterial growth.
Antibiotics, oral
Class Summary
Used in treating more aggressive bacterial superimposed infections.
Amoxicillin and clavulanate (Augmentin)

Drug combination treats bacteria resistant to beta-lactam antibiotics.
Indicated for skin and skin structure infections caused by beta-lactamase-producing strains of Staphylococcus aureus. For children > 3 months, base dosing
protocol on amoxicillin content; because of different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250-mg chewable tab (250/62.5), do not use
250-mg tab until child weighs >40 kg.
Follow-up
Further Inpatient and Outpatient Care

Further inpatient care
The following should be admitted to a pediatric ward for further workup:
Febrile neonates
Toxic-appearing patients
Children with a severe recalcitrant rash suggestive of immunodeficiency
Further outpatient care
Arrange for follow-up care with a pediatrician in 1-2 days.
Deterrence/Prevention
Expose the buttocks to air as much as possible.
Do not use waterproof pants during treatment, as they keep skin wet and subject to rash or infection.
Change diapers frequently.
Superabsorbent diapers are beneficial.[26]
Questions & Answers

Overview
What is diaper rash?
What causes diaper rash?
What plays a role in the pathophysiology of diaper rash?
What is the pathophysiology of diaper rash?
What causes miliaria associated with diaper rash?
What causes intertrigo associated with diaper rash?
What causes irritant contact dermatitis associated with diaper rash?
What causes Candida infection in diaper rash?
What is the role of bacteria in diaper rash?
What is the role of granuloma gluteale infantum in diaper rash?
How common is diaper rash in the US?
What is the international prevalence of diaper rash?
What is the mortality and morbidity associated with diaper rash?
What are the race-related demographics of diaper rash?
What are the age-related demographics of diaper rash?
Presentation
What is the typical history of the onset of diaper rash?
What information should be obtained in the history for diaper rash?
What is the clinical history of irritant contact dermatitis, miliaria (heat rash), and intertrigo in diaper rash?
What is the clinical history of candidal diaper rash?
What is the clinical history of secondary bacterial infection in diaper rash?
What is the clinical history of granuloma gluteale infantum?
What is the clinical history of atopic diaper rash?
What is the clinical history of seborrheic diaper rash?
What is the clinical history of psoriasis in diaper rash?
What is the clinical history of impetigo in diaper rash?
What is the clinical history of Langerhans cell histiocytosis in diaper rash?
What is the clinical history of acrodermatitis enteropathica in diaper rash?
What is the clinical history of scabies in diaper rash?
What is the clinical history of HIV in diaper rash?
What are the physical findings of irritant contact dermatitis in diaper rash?
What are the physical findings of intertrigo in diaper rash?
What are the physical findings of miliaria in diaper rash?
What are the physical findings of candidal dermatitis in diaper rash?
What are the physical findings of secondary bacterial infection in diaper rash?
What are the physical findings of granuloma gluteale infantum in diaper rash?
What are the physical findings of atopic dermatitis in diaper rash?
What are the physical findings of seborrheic dermatitis in diaper rash?
What are the physical findings of psoriasis in diaper rash?
What are the physical findings of impetigo in diaper rash?
What are the physical findings of Langerhans cell histiocytosis in diaper rash?
What are the physical findings of acrodermatitis enteropathica in diaper rash?
What are the physical findings of congenital syphilis in diaper rash?
What are the physical findings of scabies in diaper rash?
What are the physical findings of HIV in diaper rash?
What are the physical findings of perianal pseudoverrucous papules in diaper rash?
What causes diaper rash?
What causes secondary infections in diaper rash?
DDX
What are the differential diagnoses for Diaper Rash?
Workup
Which lab studies are indicated in the workup of diaper rash?
What other tests are indicated in the workup of diaper rash?
Which procedures are indicated in the workup of diaper rash?
Treatment
What is involved in emergency department care of diaper rash?
What new types of diapers have been developed to reduce the incidence of diaper rash?
How do barrier creams and ointments help diaper rash?
How effective is bufexamac (Parfenac) lipid ointment for the treatment of diaper rash?
Is topical vitamin A an effective treatment for diaper rash?
Is powder or cornstarch an effective treatment for diaper rash?
Is topical cholestyramine ointment an effective treatment for diaper rash?
Is white soft paraffin BP effective for the treatment of diaper rash?
Which ointments have been demonstrated to help prevent and treat diaper rash?
Are wipes or wash cloths better for cleaning the diaper area?
Should cornstarch be used on the diaper area?
Is soap a good cleanser for diaper rash?
What can help resolve irritant contact dermatitis, miliaria, and intertrigo in diaper rash?
How is mild, irritant, noninfected dermatitis in diaper rash treated?
How is typical irritant dermatitis or intertrigo in diaper rash treated?
How is candidal infection in diaper rash treated?
How is mild bacterial infections in diaper rash treated?
How is granuloma gluteale infantum in diaper rash treated?
When is specialist consultation indicated in the treatment of diaper rash?
Medications
What is the medical treatment of diaper rash?
Which medications in the drug class Antibiotics, oral are used in the treatment of Diaper Rash?
Which medications in the drug class Antibiotics, topical are used in the treatment of Diaper Rash?
Which medications in the drug class Antifungal agents are used in the treatment of Diaper Rash?
Which medications in the drug class Corticosteroid, topical are used in the treatment of Diaper Rash?
Follow-up
What is the follow-up care for diaper rash?
How can diaper rash be prevented?
What are the potential complications of diaper rash?
What is the prognosis of diaper rash?
What is involved in patient education for diaper rash?
When should a patient with diaper rash be admitted to the hospital?
Contributor Information and Disclosures
Author
Rania Dib, MD Pediatric Senior Specialist, Procare Riaya Hospital, Al Khobar, Saudia Arabia
Disclosure: Nothing to disclose.
Coauthor(s)
Amin Antoine Kazzi, MD Professor of Clinical Emergency Medicine, Department of Emergency Medicine, American University of Beirut, Lebanon

Amin Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine

Specialty Editor Board
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board,
Mercy St Vincent Medical Center, Toledo, Ohio

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics,
Society for Academic Emergency Medicine

Chief Editor
Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free
Coalition for Kids, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Additional Contributors
Jerry R Balentine, DO, FACEP, FACOEP Vice President, Medical Affairs and Global Health, New York Institute of Technology; Professor of Emergency
Medicine, New York Institute of Technology College of Osteopathic Medicine

Jerry R Balentine, DO, FACEP, FACOEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of
Medicine, American College of Osteopathic Emergency Physicians, American Association for Physician Leadership, American Osteopathic Association

References
1. Fölster-Holst R. Differential diagnoses of diaper dermatitis. Pediatr Dermatol. 2018 Mar. 35 Suppl 1:s10-s18. [Medline].
2. Davis JA, Leyden JJ, Grove GL, Raynor WJ. Comparison of disposable diapers with fluff absorbent and fluff plus absorbent polymers: effects on skin hydration, skin
pH, and diaper dermatitis. Pediatr Dermatol. 1989 Jun. 6(2):102-8. [Medline].
3. Prasad HR, Srivastava P, Verma KK. Diapers and skin care: merits and demerits. Indian J Pediatr. 2004 Oct. 71(10):907-8. [Medline].
4. Prasad HR, Srivastava P, Verma KK. Diaper dermatitis--an overview. Indian J Pediatr. 2003 Aug. 70(8):635-7. [Medline].
5. Wilson PA, Dallas MJ. Diaper performance: maintenance of healthy skin. Pediatr Dermatol. 1990 Sep. 7(3):179-84. [Medline].
6. Adam R. Skin care of the diaper area. Pediatr Dermatol. 2008 Jul-Aug. 25(4):427-33. [Medline].
7. Korting HC, Braun-Falco O. The effect of detergents on skin pH and its consequences. Clin Dermatol. 1996 Jan-Feb. 14(1):23-7. [Medline].
8. Yonezawa K, Haruna M, Shiraishi M, Matsuzaki M, Sanada H. Relationship between skin barrier function in early neonates and diaper dermatitis during the first month
of life: a prospective observational study. Pediatr Dermatol. 2014 Nov-Dec. 31 (6):692-7. [Medline].
9. Ersoy-Evans S, Akinci H, Dogan S, Atakan N. Diaper Dermatitis: A Review of 63 Children. Pediatr Dermatol. 2016 May. 33 (3):332-6. [Medline].
10. Walsh SS, Robson WJ. Granuloma gluteale infantum: an unusual complication of napkin dermatitis. Arch Emerg Med. 1988 Jun. 5(2):113-5. [Medline].
11. Cohen B. Differential Diagnosis of Diaper Dermatitis. Clin Pediatr (Phila). 2017 May. 56 (5_suppl):16S-22S. [Medline].
12. Ersoy-Evans S, Akıncı H, Doğan S, Atakan N. Diaper Dermatitis: A Review of 63 Children. Pediatr Dermatol. 2016 May. 33 (3):332-6. [Medline].
13. Alberta L, Sweeney SM, Wiss K. Diaper dye dermatitis. Pediatrics. 2005 Sep. 116(3):e450-2. [Medline].
14. Longhi F, Carlucci G, Bellucci R, di Girolamo R, Palumbo G, Amerio P. Diaper dermatitis: a study of contributing factors. Contact Dermatitis. 1992 Apr. 26(4):248-52.
[Medline].
15. Adalat S, Wall D, Goodyear H. Diaper dermatitis-frequency and contributory factors in hospital attending children. Pediatr Dermatol. 2007 Sep-Oct. 24(5):483-8.
[Medline].
16. Borkowski S. Diaper rash care and management. Pediatr Nurs. 2004 Nov-Dec. 30(6):467-70. [Medline].
17. Atherton DJ. A review of the pathophysiology, prevention and treatment of irritant diaper dermatitis. Curr Med Res Opin. 2004 May. 20(5):645-9. [Medline].
18. Nield LS, Kamat D. Prevention, diagnosis, and management of diaper dermatitis. Clin Pediatr (Phila). 2007 Jul. 46(6):480-6. [Medline].
19. Baer EL, Davies MW, Easterbrook KJ. Disposable nappies for preventing napkin dermatitis in infants. Cochrane Database Syst Rev. 2006 Jul 19. CD004262. [Medline].
20. Blume-Peytavi U, Hauser M, Lünnemann L, Stamatas GN, Kottner J, Garcia Bartels N. Prevention of diaper dermatitis in infants--a literature review. Pediatr Dermatol.
2014 Jul-Aug. 31 (4):413-29. [Medline].
21. Davies MW, Dore AJ, Perissinotto KL. Topical vitamin A, or its derivatives, for treating and preventing napkin dermatitis in infants. Cochrane Database Syst Rev. 2005
Oct 19. CD004300. [Medline].
22. Ehretsmann C, Schaefer P, Adam R. Cutaneous tolerance of baby wipes by infants with atopic dermatitis, and comparison of the mildness of baby wipe and water in
infant skin. J Eur Acad Dermatol Venereol. 2001 Sep. 15 Suppl 1:16-21. [Medline].
23. Benitez Ojeda AB, Mendez MD. Diaper Dermatitis. 2021 Jan. [Medline]. [Full Text].
24. Gallup E, Plott T. A multicenter, open-label study to assess the safety and efficacy of ciclopirox topical suspension 0.77% in the treatment of diaper dermatitis due to
Candida albicans. J Drugs Dermatol. 2005 Jan-Feb. 4(1):29-34. [Medline].
25. Bonifaz A, Tirado-Sánchez A, Graniel MJ, Mena C, Valencia A, Ponce-Olivera RM. The efficacy and safety of sertaconazole cream (2 %) in diaper dermatitis
candidiasis. Mycopathologia. 2013 Apr. 175(3-4):249-54. [Medline]. [Full Text].
26. Blume-Peytavi U, Kanti V. Prevention and treatment of diaper dermatitis. Pediatr Dermatol. 2018 Mar. 35 Suppl 1:s19-s23. [Medline].

Diaper Rash: Practice Essentials

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Diaper Rash: Practice Essentials

Uploaded by

Copyright:

Available Formats

10/11/21 21:17 https://emedicine.medscape.

The cycle of diaper rash is shown in the illustration below.

Diaper rash pathophysiology scheme.

Candidal diaper dermatitis

Bacterial diaper dermatitis

Granuloma gluteale infantum

A Nigerian study conducted in 1995-1996 identified diaper dermatitis in 7% of children.

Race-, sex-, and age-related demographics

No sexual predilection exists.

It involves the development of erosive ulcerations with elevated margins.

Important points to obtain on history include the following:

Onset, duration, and change in the nature of the rash

Presence of rashes outside the diaper area

Associated scratching or crying

Contact with infants with a similar rash

Recent illness, diarrhea, or antibiotic use

Irritant contact dermatitis, miliaria (heat rash), and intertrigo

Usually follows a bout of diarrhea

Exacerbated by scrubbing and the use of commercial wipes or strong detergents

Asymptomatic (except for miliaria)

Candidal diaper dermatitis

May follow recent antibiotic use

Secondary bacterial infection

Granuloma gluteale infantum

Family or personal history of allergic rhinitis, hay fever, or asthma is common.

Usually occurs in infants aged 2 weeks to 3 months

A family history of psoriasis can be a clue.

Involved areas include the scalp and nails

Common in the first 6 months of life

Usually occurs during the warmer summer months

Langerhans cell histiocytosis

Severe hemorrhagic diaper dermatitis unresponsive to any treatment

Other involved areas include the scalp and retroauricular areas

Associated with diarrhea, hair loss, and erosive perioral dermatitis

Concurrent rash may be found in web spaces of hands or feet

Human immunodeficiency virus

History of HIV exposure or risk factors

Associated cytomegalovirus or herpes infection

The following are characteristic physical findings:

Irritant contact dermatitis

Mild forms consist of shiny erythema with or without scale.

Margins are not always evident.

Skin folds are spared or involved last.

Occurs in skin creases where skin surfaces are in apposition

Pustules or erosions are not present.

Consists of multiple discrete, pruritic, erythematous papulovesicles, and sterile vesiculopustules.

Similar lesions on the face, neck, and axilla may be present.

Satellite lesions frequently are found beyond these borders.

Skin folds commonly are involved.

White scales may be observed occasionally.

The oropharynx should be inspected for the white plaques of thrush.

Secondary bacterial infection

Granuloma gluteale infantum

Painless reddish-brown to purplish nodules are observed.

Nodules range in size from 0.5-4 cm.

Axilla and neck involvement has been reported.

Lichenification can occur with chronic disease.

Well-demarcated erythematous patches or plaques with an occasional greasy yellow scale.

Skin folds are not spared.

There are no satellite lesions.

Bright, red, well-defined plaques

Inguinal folds typically are involved.

In the diaper area, bullae are not usually intact.