What is diaper rash?

Diaper rash is a generalized term indicating any skin irritation (regardless of cause) that develops in the diaper-covered region. Synonyms include diaper dermatitis (dermatitis = inflammation of the skin), napkin (or "nappy") dermatitis and ammonia dermatitis. While there are a several broad categories of causes of diaper rash, contact irritation is the most common culprit. While diaper rash is generally thought to affect infants and toddlers, any individual wearing a diaper (for example, an incontinent adult) is a candidate to develop this dermatitis.

Is diaper rash a sign of neglectful care?

No, not at all. Parents often incorrectly feel that the rash is a visual representation of poor caretaking skills. However, parents need to understand that the basic causes for this common kind of skin irritation are still under active debate in the field of dermatology and that neglectful parenting is not among the possible factors. In the United States, diaper dermatitis represents about 10%-20% of all skin disorders managed by a general pediatrician. While the rash may develop as early as the first week of life, the most frequent time period is between 9 and 12 months of age. Studies have indicated that, at any point in time, between 7%-35% of children in this age range are experiencing such a skin rash.

What causes diaper rash?

There are several categories of causes for this dermatitis. First and foremost is "irritant" or "contact" dermatitis. Skin involvement may vary from mild redness (similar in character to a sunburn) to erosion of the top layers of skin. A characteristic differential point of contract diaper dermatitis from other causes of diaper rash is that it rarely involves the skin fold regions -- therefore, it spares areas not in contact with urine/stool. Skin infections compose the next most common category of diaper rash. Bacteria (Staph and Strep) and yeast/fungal (Candida) are common causes of diaper rash. Generally both of these types of infections tend to result from a disruption of skin integrity and overwhelming the natural defense mechanisms of skin in this diaper region. Staph and Strep bacterial infections are commonly termed impetigo. Classic descriptions of impetigo include small (1-2 mm) tiny blisters (vesicles) and pustules that tend to easily rupture leaving multiple erosions in a sea of generalized skin irritation. Candida diaper dermatitis also has several distinguishing patterns. The rash is characterized by zones of bright red skin with a series of discrete 2-4 mm "satellite" lesions at the borders of the confluent irritated skin. In contrast to contact dermatitis, Candida is generally only found in the skin folds creases and often around the anal region. Infectious causes of diaper dermatitis can generally be diagnosed by visual inspection alone. If confusion exists, laboratory studies of swabs of the involved areas may be obtained. Allergic reactions are a less common cause of diaper rash. Commonly proposed allergens are fragrances and components of the diaper and wipes. These regions often have well-defined zones of redness with superficial vesicles and erosions. If the diagnosis of allergic skin reaction is suspect, skin-patch testing may be done to identify the offending agent. This is rarely necessary. There are very rare causes of diaper rash. Unusual infections, metabolic and nutritional deficiency states, and immunodeficiency states and malignancies can all be implicated. Unfortunately, child abuse (hot-water immersion, extreme neglect to infant hygiene) can also present as diaper rash. Less often, allergic reactions to the fragrances or other components found in disposable diapers or wipes can cause diaper rash.

What treatments are recommended for diaper rash?

The best treatment for diaper rash is avoidance of the precipitating agents which led to the contact irritation and to regions becoming secondarily infected by skin bacteria or yeast. Frequent diaper changes limit stool and urine exposure to the area and remain the foundation for prevention and management of diaper dermatitis. Should a rash develop, simple cleansing with water and soft cloths tends to be less irritating to the injured skin than disposable wipes. Frequent application of one of the many diaper-area ointments containing either petroleum jelly (Vaseline) or zinc oxide (Desitin) provides an effective barrier against skin irritants and lessen friction to irritated skin. If the diaper rash is especially irritated by the rubbing necessary for proper hygiene, then using a non-sticky cream or ointment (such as Vaseline) as a barrier may be an important consideration. If sticky stool hinders hygiene, it may be more easily removed after application of mineral oil to the area. Most pediatricians find no benefit to using cornstarch or talcum power. The risk of possible aspiration of these

powders underscores their general lack of significant efficacy. High-concentration baking soda or boric-acid baths are to be avoided due to possibility of toxicity associated with an increased rate of absorption due to skin breakdown. Weather and/or carpet permitting, open-air exposure of the irritated skin is also extremely effective in helping clear up diaper rash. Many children have a therapeutic response to merely sitting in a warm-water bath twice daily for 15-20 minutes per session. The value of additional agents (including baking soda) is debatable. Should these measures not provide a solid response within two to three days, the possibility of a secondary bacterial or yeast infection must be considered. The diaper region should be examined by a pediatrician unless the parent is confident in correctly making these diagnoses. Several topical antibiotic ointments are available for therapy in these situations.

How about not using disposable diapers?

Parents often wonder if switching from disposable to cloth diapers will lessen the likelihood of contact type diaper rash. In fact, the opposite seems to be true. The absorbent gel material found in most of today's disposable diapers draws moisture away from the skin area, thus helping to promote a healthy diaper area.

How should an allergic rash be treated?

For an allergic reaction to the fragrances or other components found in disposable diapers or wipes, eliminating the offending agents by using either simple water cleansing of the skin and a switch to another brand of disposable diapers or using cloth diapers instead is usually therapeutic.

How about using cortisone cream?

A minimally concentrated hydrocortisone cream may be recommended in certain cases. However, the excessive usage of minimally concentrated hydrocortisone cream and the use of increased potency hydrocortisone preparations are notorious for causing secondary side effects. They should only be used under the guidance of a pediatrician or another physician who is fully familiar with their application to infants.

How about using Neosporin?

This ointment (and others containing the topical antibiotic neomycin) should be avoided since neomycin is a very common allergen promoting an allergic skin reaction. Instead of helping the situation, such a medication may complicate and confuse the situation.

Diaper Rash At A Glance

Diaper rash is very common in babies and is not a sign of parental neglect. Diaper rash is most commonly a kind of contact dermatitis. Diaper rash may become secondarily infected by bacteria or yeast normally present on the skin. In this case, topical antibiotic ointments provide a rapid and effective therapy. Avoidance of skin irritants by frequent diaper changing provides the number-one preventative measure. Effective treatments include frequent diaper changes, application of topical barriers (for example, petroleum jelly), and rarely topical antibiotic/antifungal ointments, or low-potency hydrocortisone cream. High-potency steroid creams, powders, and concentrated baking-soda/boric-acid baths and neomycin-containing ointments are to be avoided.

Featured: Diaper Rash Main Article

A diaper rash is a skin irritation that develops in the diaper-covered region. Most diaper rashes are caused by bacterial or yeast infections, though some may be caused by contact dermatitis or allergic reactions to the diapers and wipes. Cleansing with water

application of petroleum jelly or zinc oxide and frequent diaper changes is the best treatment for a diaper rash.
and soft cloths, followed by

Pathophysiology

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. 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 gluteal 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.

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. he 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.[1] Recent studies confirm that this trend is ongoing.[2, 3, 4] 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.

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.[5, 6] 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.

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.

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 gluteal infantum

Granuloma gluteal infantum is a rare disorder.[7] It is not very well understood, but it probably represents an unusual inflammatory response to long-standing irritation, candidiasis, or fluorinated corticosteroids.

Frequency

United States
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. 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 infantsperhaps 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.[8] 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
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.[9] 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.

Mortality/Morbidity

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.

Race
Atopic dermatitis and related diaper dermatitis are more common among African American patients.

Sex
No sexual predilection exists.

Age

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.