Clinical Pediatrics

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Prevention, Diagnosis, and Management of Diaper Dermatitis

Linda S. Nield and Deepak Kamat
CLIN PEDIATR 2007 46: 480
DOI: 10.1177/0009922806292409

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Commentaries
Prevention, Diagnosis, and Management
of Diaper Dermatitis
Linda S. Nield, MD,1 Deepak Kamat, MD, PhD2
Introduction
D
iaper dermatitis, considered the most com-
mon skin disorder of infancy in the United
States, accounts for more than 1 million
clinic visits per year. Care is sought mainly at the
office of the pediatrician or family practitioner.1
Severe diaper dermatitis occurs in less than 10% of
affected infants,2 which probably accounts for the
small number of referrals made to a dermatologist
for this common condition. Therefore, the primary
care physician has to become the diaper rash pre-
vention and cure expert. Many effective preventive
measures and treatments of diaper rash have been
studied to various degrees and are reviewed here
along with our recommendations for proper diaper-
ing hygiene.
Etiology
Irritant Contact Dermatitis
Diaper rash is most likely due to irritant contact der-
matitis, a non-immunologic reaction triggered by
irritants present in the area covered by the diaper.
Jacquet erosive dermatitis refers to severe irritant
contact dermatitis.3 The key irritants are moisture
(urine and feces) and fecal enzymes (urease, pro-
teases, lipases). The occluded skin of the diaper area
is macerated by prolonged contact with these key
irritants, which are increased in quantity in certain
conditions (incontinence, urinary tract infections,
gastroenteritis, short gut syndrome). The increased
From the 1West Virginia University School of Medicine,
Morgantown, West Virginia; 2Children’s Hospital of Michigan,
Detroit, Michigan.
Address correspondence to: Deepak Kamat, MD, PhD, Professor
of Pediatrics, Vice Chair of Education, Director Institute of
Medical Education, Children’s Hospital of Michigan, 3901,
Beaubien Blvd, Detroit, MI 48201; tel: 313-966-2810; fax:
313-966-5236; email: dkamat@med.wayne.edu.
480
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Clinical Pediatrics
Volume 46 Number 6
July 2007 480-486
© 2007 Sage Publications
10.1177/0009922806292409
http://clp.sagepub.com
hosted at
http://online.sagepub.com
pH of the skin that is associated with diaper wearing
further activates the destructive enzymes. A child is
at greatest risk of developing an irritant contact dia-
per rash in the first 2 years of life most likely
because during these early childhood years, more
time is spent in a diaper, less objection is raised by
the child when soiling occurs and more frequent uri-
nations and defecations occur daily. Any aged indi-
vidual who requires the use of diapers on a long-term
basis will develop some skin irritation at some point
in time. The majority of newborns display mild dia-
per dermatitis by 1 week of age with increasing
severity by age 3 weeks.4
Other irritants that promote skin breakdown in
the perineum include glue used in diaper manufac-
turing 5 and friction produced by the diapers them-
selves or by the caregiver’s application of baby care
products.4 A contact dermatitis due to chemical
exposure of the buttock region after ingestion of a
senna-containing laxative has also been reported.6
Infections
Candida albicans may be isolated in up to 80% of
infants with perineal skin irritation that persists for
3 or more days.7 Children with diaper dermatitis are
more likely to be colonized with yeast in the peri-
anal, inguinal, and oral regions compared to unaf-
fected children.8 The exact role that gastrointestinal
colonization with C albicans has on the development
or recurrence of diaper dermatitis is unknown.9
Conditions that are known to increase the likelihood
of secondary yeast infection include antibiotic admin-
istration, immunodeficiencies, and diabetes mellitus.
Bacteria such as Staphylococcus aureus or group
A streptococci can cause eruptions in the diaper
area. S aureus colonization is more likely in children
with atopic dermatitis and in children with diaper
rash versus those without diaper rash.8 Other bacte-
ria that can lead to inflammation of the vagina and
surrounding tissues (vulvovaginitis) include Shigella,
Escherichia coli, and Yersinia enterocolitica.

Table 1. Systemic Etiologies of Persistent Diaper Dermatitis
Etiology
Acrodermatitis enteropathica
Child abuse/neglect
Dermatologic disorders
–allergic contact dermatitis
–seborrhea
–psoriasis
–granuloma gluteale infantum
–infantile granular parakeratosis
Langerhans cell histiocytosis
Metabolic disorders
–cystic fibrosis
–maple syrup urine disease
–organic aciduria
–methylmalonic acidemia
Nutritional deficiencies
–biotin, essential fatty acid, protein
Additional infectious agents that can lead to irri-
tation, inflammation or eruptions in the diaper area
include viruses (coxsackie, herpes simplex, human
immunodeficiency viruses), parasites (pinworms, sca-
bies), and other fungi (tinea).
Other Dermatologic Disorders
Other dermatologic disorders that affect the diaper
area include allergic contact dermatitis, seborrheic
dermatitis, psoriasis, granuloma gluteale infantum,
lichen sclerosis, and infantile granular parakerato-
sis.10 The diaper area is usually spared in atopic der-
matitis, but if diaper rash develops, secondary
S aureus infection should be suspected. Although less
common than irritant contact dermatitis, allergic
contact dermatitis deserves special mention because
many components of diapers have been implicated
as skin sensitizers. Allergic contact dermatitis involves
an immunologic response which produces rash within
12 to 24 hours after re-exposure to the offending
antigen.11 Components of the diaper that have been
implicated as potential antigens include dyes, fra-
grances, rubber, glue, and other chemicals used in the
manufacturing process.11 Preservatives found in some
toilet tissues may also be important skin sensitizers.12
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Diaper Dermatitis / Nield and Kamat 481
Features
–Low serum zinc level
–Failure to thrive, diarrhea and red, moist erosions of the distal extremities and
perioral/perianal areas
–Poor hygiene accompanying diaper rash
–Any suspicious skin findings
–Fractures in a non-ambulating child
–Generalized skin findings characteristic of the particular diagnosis
–Nail abnormalities
–Scaly papules in diaper area, scalp, face, axilla
–“Birbeck granule” on skin biopsy
–Failure to thrive, developmental delay
–Rash similar to acrodermatitis enteropathica
–Characteristics specific to underlying diagnosis
–Failure to thrive
–Rash similar to acrodermatitis enteropathica
–Alopecia
Unusual Etiologies
Persistent diaper dermatitis, despite aggressive
treatment, is suspicious for underlying systemic ill-
ness (Table 1). Nutritional deficiencies of protein,
biotin, and zinc can cause dermatitis along with
essential fatty acid deficiency, acrodermatitis
enteropathica (zinc deficiency), cystic fibrosis, urea
cycle defects, congenital or acquired immunodefi-
ciencies, and child neglect/abuse. A persistent dia-
per rash may rarely be indicative of Langerhans cell
histiocytosis (LCH).
Clinical Presentation
Irritant contact dermatitis begins as acute erythema
on the convex skin surfaces of the pubic area and
buttocks with sparing of the skin folds, reflecting the
areas of the body in most contact with the diaper. An
intensely erythematous rash that affects the groin
creases and perianal skin accompanied by papules
and pustules (satellite lesions) is indicative of a yeast
infection; involvement of the mouth (thrush), neck,
and/or axillae is common. It may be difficult to clin-
ically differentiate allergic contact dermatitis from
irritant contact dermatitis which also begins as
482 Clinical Pediatrics / Vol. 46, No. 6, July 2007
acute erythema, which progresses to a papular
eczematous eruption.11
S aureus infection presents as bullous impetigo,
characterized by scattered vesicles, bullae and denuded
areas of skin, while group A streptococcus presents
as an erythematous patch perianally. The enteric
bacteria can cause dysuria, vaginal itching, and vul-
var inflammation. Coxsackie virus causes erythema-
tous papules on the buttocks, palms and soles and
ulcers in the posterior pharynx. Crops of painful
vesicles in the vulva and perianal area characterize
herpes. Pruritus is a typical symptom of pinworms
and scabies. The appearance of scabies infestation
can be variable and should be considered when a
child has a diffuse papular eruption that can also
affect the head and neck in infants. The character-
istic curvilinear lesions of scabies may not be easily
identifiable.
Recalcitrant skin breakdown or unusual erup-
tions in the diaper area, especially if accompanied
by systemic symptoms should alert the clinician to
the possibility of an underlying systemic disorder.
Worrisome signs and symptoms include failure to
thrive, extensive skin involvement (especially peri-
orally), gastrointestinal disturbances, and neurologic
deficits. The rash associated with acrodermatitis
enteropathica is characterized by red, moist erosions
of the distal extremities and perioral and perianal
areas. Similar dermatologic features can occur in
metabolic disorders (maple syrup urine disease,
organic aciduria, methylmalonic acidemia), cystic
fibrosis, and nutritional deficiencies (kwashiorkor,
essential fatty acid and biotinidase deficiencies).13
Recurrent infections may signify an underlying
immunodeficiency, and bruising and consistently
poor dental and body hygiene may signify abuse and
neglect. A persistent scaly dermatitis characterizes
LCH, which is not easily diagnosed based upon phys-
ical examination alone, especially since many pedia-
tricians have limited experience with this disease.
Evaluation
Acute Case
The diagnosis of irritant contact dermatitis can typ-
ically be made quite easily by quick examination of
the diaper area that reveals the characteristic
appearance in the perineum. The history (lasting 3
or more days) and clinical presentation are usually
all that is necessary to diagnose a secondary yeast
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infection. Although a potassium hydroxide slide prepa-
ration of skin scrapings is not routinely done to diag-
nose a candidal infection, the prescribing information
of the only and newly approved compounded oint-
ment (Vusion, Barrier Therapeutics, Princeton, NJ;
0.25% miconazole nitrate/15% zinc oxide/white petro-
leum) specifically for candidal diaper dermatitis
states that this medication is indicated in cases of
candidiasis documented via microscopic discovery of
pseudohyphae and/or budding yeast in immunocom-
petent patients aged 4 weeks or older.14 In cases of
suspected herpes, a Tzanck smear and/or culture
specimen should be obtained, especially in cases of
suspected abuse.
Recalcitrant Case
If the diaper rash does not resolve or improve after
2 to 3 weeks of treatment, noncompliance with the
suggested management should be suspected and the
history reviewed. Although most cases of yeast der-
matitis resolve by 10 days of topical antifungal
administration, Munz and colleagues9 report that
approximately half of their subjects required treat-
ment as long as 3 weeks duration before complete
clinical resolution. Inquiries about recent or fre-
quent antibiotic usage and the presence of frequent
urination, diarrhea, and thrush should be made. A
family history of immunodeficiencies or skin disor-
ders should also be noted.
If assured that compliance is adequate, the cli-
nician should next consider the possibility of a sec-
ondary bacterial infection, which can be empirically
treated with topical mupirocin. Whether or not it is
cost effective and useful to obtain cultures of the
affected area prior to the empiric treatment is
unknown, but cultures should be considered if topi-
cal antibiotics are unhelpful or exacerbate the situa-
tion. Recurrent or unresolving yeast infections may
rarely indicate chronic mucocutaneous syndrome or
another congenital or acquired immune disorder.
Although the perineum is the essential area to
examine in any case, a thorough head-to-toe assess-
ment should be performed in cases of recalcitrant
diaper dermatitis. In order to uncover evidence of an
underlying systemic illness, growth parameters
should be plotted, and a thorough neurologic, der-
matologic, and oropharyngeal examination should
be performed.
Consideration of further evaluation is necessary
if the diaper rash persists beyond 1 month, despite

Table 2. Prevention of Irritant Diaper Dermatitis
Use super-absorbent disposable diapers
Keep the diaper area dry via frequent diaper changes or
inspection for soiling at least every 2 hours and even more
frequently in children with diarrhea and newborns
To eliminate the irritants at each diaper change, cleanse the
diaper area with water plus cotton cloth or commercial “baby
wipes” that have minimal additives; avoid excess friction and
detergents
If prone to develop diaper rash, empirically apply a topical
barrier that contains water impermeable ingredient (such
as zinc oxide) and minimal other ingredients
Allow for daily diaper-free time and avoid the use of plastic
underpants that fit over the diaper area
aggressive treatment for irritant, bacterial and yeast
dermatitis. If other worrisome signs, symptoms or
physical examination findings (ie, facial involve-
ment, neurologic abnormalities, and growth delay)
are present, the workup should begin before the one
month time frame. The time frame of 1 month has
been chosen to allow for adequate time for antifun-
gal and antibacterial treatments to prove their effec-
tiveness. Chosen on a case-by-case basis, a general
illness laboratory screen may include complete
blood cell count, liver enzymes, renal function tests,
serum zinc level, biotin and biotinidase activity,
blood ammonia and amino acids, and urine organic
acids. Any abnormal results from this initial screen
will dictate further evaluation.
To definitively diagnose LCH (by the presence
of cytoplasmic tennis racket-shaped Birbeck gran-
ules in the affected skin cells) and many of the
other potential dermatologic conditions, a biopsy is
needed, which requires referral to a dermatologist.
Based upon biopsy results, the primary care pedia-
trician may then consult or refer the patient to the
appropriate subspecialist (ie, hematology-oncology
for LCH).
Prevention
Irritant contact diaper dermatitis is a very preventa-
ble condition, and parents of newborns should be
educated about proper diapering hygiene (Table 2)
right from the start. Practicing meticulous diaper
hygiene measures and choosing appropriate skin
cleansing and skin care products will prevent the
majority of diaper rashes in the otherwise healthy
child. Routine handwashing by the caregiver before
and after each diaper change is essential to prevent
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Diaper Dermatitis / Nield and Kamat 483
the spread of infection. Parents should be advised
that ideally, the diaper should be removed as soon as
soiling has occurred and the urine and fecal matter
washed away immediately. The diaper area should
be gently pat dry and the child allowed some diaper-
free time. Because that is not always possible or
practical, the diaper should be inspected for soiling
or changed at least every 2 hours or even more fre-
quently for children with diarrhea or during the
newborn period. Healthy newborns are able to toler-
ate such frequent changes, but the caregiver must
be mindful that aggressive handling of premature
infants may lead to physiologic instability, so gentle
manipulation must be used when cleaning these tiny
infants.15 Cleansing the diaper area with warm water
and a cotton cloth or commercial “baby wipes” is
essential to eliminate the irritants. Harsh soaps and
detergents should not be used in the diaper area
because they will remove the natural lipids from
the skin that serve as a protective barrier; a non-
detergent cleanser should be used instead. Most
commercial “baby wipes” are well tolerated by most
children,16,17 but reactions can occur secondary to
fragrances, detergents, alcohol, or preservatives con-
tained within the product.18
The advances that have been made in the man-
ufacturing of disposable diapers have greatly
improved their quality and their efficacy at prevent-
ing skin breakdown. In comparison to cloth diapers,
disposable diapers cause less diaper rash and are less
likely associated with the development of Jacquet’s
erosive dermatitis.19-21 Superabsorbent diapers that
contain an absorbent gelling material that extracts
moisture from the wet area are helpful in preventing
skin maceration.22 Other improvements include the
creation of a disposable diaper that is capable of
continuously administering a petroleum-containing
emollient to the skin23 and the development of a
“breathable” cover. 2 which keeps the skin drier and
cooler. Any products that further occlude the skin of
the perineum, such as plastic underpants placed
over the diaper, should be avoided.
In general, empiric application of a barrier cream,
ointment, or paste is unnecessary, unless a child is
prone to frequent diaper rashes. The caregiver of a
child with atopic dermatitis must be vigilant in general
when caring for the child’s skin which requires the
daily liberal application of emollients. When a topical
preparation is used, one that has limited number of
ingredients should be used so that the perineum is
exposed to fewer potential sensitizers or irritants. The
most common water impermeable substances available
484 Clinical Pediatrics / Vol. 46, No. 6, July 2007
Table 3. Treatment of Diaper Dermatitis
Step-up the Prevention Measures
• Reinforce good diapering hygiene practices (Table 1) at
first sign of skin breakdown
Apply a Mechanical Barrier
• Choose a barrier with minimal ingredients to avoid poten-
tial irritants or sensitizers
• Use a paste if diarrhea is occurring
Prescribe a Topical Antifungal
• If rash persists > 3 days
• Treat breast-feeding mother if infected and cleanse associ-
ated objects
• Oral nystatin is reasonable adjunct if thrush is present;
other uses of oral antifungals in the routine treatment of
diaper dermatitis is not supported in the literature
• Never use antifungal-corticosteroid combination products
in the diaper area
Prescribe a Topical Corticosteroid Judiciously
• Apply smallest quantity needed twice daily for 3 days and
no longer than 2 weeks of the lowest potency medications;
only use in moderate to severe case for symptom relief
• Warn parents of serious side effects: adrenal suppression,
Cushing syndrome, skin atrophy, and striae
Consider Other Interventions
• Antibiotics: topical mupirocin is a reasonable addition if
rash progresses or fails to improve despite above measures;
oral antibiotics may be necessary in atopic child
• Referral to specialist: consider after 4 weeks of failed
treatment or sooner if worrisome signs and symptoms are
present
in commercial products are zinc oxide, petroleum, and
dimethicone. Various skin conditioning and soothing
substances are also included in many products; vita-
mins, lanolin, mineral oil, wax, and olive oil are some
examples of exact unknown efficacy. 24,25
Although talcum powder and cornstarch may
reduce friction, absorb moisture and eliminate chaf-
ing in the diaper area, these products are not rou-
tinely recommended because of the infant’s risk of
aspirating air-borne particles. Severe pneumonitis
following inhalation of cornstarch powder26 and talc
during diapering has been reported.
Treatment
Step-up the Prevention Measures
At the first sign of any skin erythema or breakdown,
more attention must be given to the care of the skin
in the diaper area (Table 3) to prevent further dam-
age, to help heal the affected skin, and to prevent re-
occurrence. The prevention measures must be
reinforced (Table 2).
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Apply Mechanical Barrier
The routine application of a water-impermeable
cream or ointment with each diaper change should
be instituted to create a continuous barrier layer on
the skin. If the child is suffering from diarrhea, a
paste containing the water-impermeable substance
should be used because pastes are most efficacious
at protecting the underlying skin from moisture.
Other products, not routinely used in general prac-
tice, are available for the treatment of severe irritant
dermatitis. Topical 4% sucralfate in aqueous cream
acts as a mechanical barrier on ulcerative skin
lesions.27 Over-the-counter liquid antacids have also
been recommended for use in the eroded diaper
area, applied 4 times daily, allowed to dry, and then
covered with another barrier preparation.21
Prescribe a Topical Antifungal
If a diaper rash continues to progress after
72 hours despite diligent care, a concomitant fungal
infection should be suspected. Superficial fungal
infections can be treated with topical nystatin,
miconazole, clotrimazole, and ciclopirox, to name a
few, and nystatin is the typical first choice because
of its efficacy and low cost.28 The previously men-
tioned newly approved miconazole/zinc oxide/white
petroleum ointment is the only prescription product
approved specifically for candidal diaper dermatitis in
the United States. Mupirocin, an excellent anti-
staphylococcal agent, is also an effective topical anti-
fungal medication.29,30 Parents need to be vigilant with
the application of the antifungal medication, which
may take 10 days to 3 weeks for complete cure.9
Although recommended by some experts,31 oral
antifungal medications probably have a limited role
in the treatment of candidal diaper dermatitis, and
the pediatric literature is lacking in studies that sup-
port the use of oral anti-fungal agents. One such
study by Munz and colleagues reported that topical
nystatin alone is as effective as combined oral and
topical nystatin in the mycological and clinical cure
of candidal diaper rash.9 Frielander recommends the
use of oral fluconazole at the dose of 3 mg/kg per
day as a pulse dose weekly x 2 or for a short course
of 5 to 7 days in severe cases of yeast dermatitis only
after other causes of diaper rash have been considered
and ruled out.31 The routine use of oral fluconzole
for diaper dermatitis is also not supported in the
pediatric literature, as this drug has limited approved
indications in the United States.28,32

When children have both thrush and diaper rash,
oral nystatin is a reasonable adjunct. In the case of the
breast-fed infant, the mother should also be treated. A
topical antifungal (such as nystatin) can be applied to
the mother’s breast after each feeding and continued
until a few days beyond assurance of eradication of
Candida.33 Any objects that come in contact with
mother and baby should be cleansed thoroughly,
including pacifiers, plastic nipples, teething toys,
breast pump equipment, and bras. To prevent the
passing back and forth of the yeast, prolonged dual
treatment of mother and infant should be encouraged.
Prescribe a Topical
Corticosteroid Judiciously
The application of low potency corticosteroids (class 6
or 7 only) in the diaper area to reduce inflammation
and discomfort should be used very judiciously and
only in moderate to severe cases. Low strength hydro-
cortisone (1%) and desonide are appropriate choices.
A minimal amount of medication should be applied
once or twice daily for 3 days initially and no longer
than 2 weeks. Caregivers have to be warned emphati-
cally about the adverse effects of prolonged and exces-
sive use of topical steroids in the occluded diaper area.
Occlusion will increase systemic absorption of these
active medications. The development of Cushingoid
features and drug-induced adrenal suppression are
major complications that will occur if the steroid is
applied inappropriately.34,35 Dermal atrophy and striae
are other potential adverse effects, along with the
development of granuloma gluteale infantum.
Although topical corticosteroids will alleviate the
inflammatory symptoms of allergic contact dermatitis,
Alberta and colleagues emphasize that avoidance of
the allergen is the key to prevent progression and
recurrence of this dermatitis.11 Dye-free or cloth dia-
pers would be a wise choice when allergic contact der-
matitis is suspected or proven via patch testing.
The use of antifungal-corticosteroid combina-
tion products (such as clotrimazole-betamethasone
dipropionate) in the diaper area should be absolutely
avoided. These products contain high potency, fluori-
nated, halogenated corticosteroids that are contraindi-
cated for use in the occluded diaper area. A physician
should never prescribe these combination products for
the treatment of diaper rash. Despite this strict warn-
ing, a recent survey revealed that many pediatricians
continue to use the antifungal-corticosteroid combi-
nation products for diaper dermatitis, regardless of
their knowledge of the agent’s potency.36
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Diaper Dermatitis / Nield and Kamat 485
Consider Other Interventions
An empiric 1-week trial of topical mupirocin (which
provides good antibacterial and antifungal coverage)
would be a reasonable addition to the treatment reg-
imen when progression or failure of improvement of
the rash is occurring despite adherence to the previ-
ously stated measures. An obvious secondary bacte-
rial infection in a child with atopic dermatitis has
the potential of becoming widespread and may
require systemic treatment that offers adequate S
aureus coverage.
The literature is lacking in studies that support
the use of the immuno-modulators, tacrolimus and
pimecrolimus, for the treatment of diaper dermati-
tis. These medications are only approved for use as
the second-line treatment of atopic dermatitis in
children older than 2 years of age.37
A pediatric dermatologist should be consulted
for recalcitrant cases to establish definitive diagno-
sis and treatment. On a case-by-case basis, it may be
decided to try other empiric treatments as described
above or to stop all medications and fragranced or
dyed products for 1 to 2 more weeks in lieu of a
biopsy, but then proceeding with a biopsy if the fur-
ther empiric interventions fail and the general ill-
ness screen in unhelpful. Frequent unexplained
recurrences also may require a biopsy for definitive
diagnosis. Patch testing should be considered if an
allergic contact dermatitis is suspected.11
If an underlying dermatologic or systemic disor-
der is diagnosed, the treatment must be tailored to
the specific diagnosis in order to allow for ultimate
skin healing. The pediatrician is responsible for
referring the patient to the appropriate specialist
and coordinating the multi-disciplined care.
References
1. Ward DB, Fleischer AB, Feldman SR, Krowchuk DP.
Characterization of diaper dermatitis in the United
States. Arch Pediatr Adolesc Med. 2000;154:943-946.
2. Akin F, Spraker M, Aly R, Leyden J, Raynor W, Landin
W. Effects of breathable disposable diapers: reduced
prevalence of Candida and common diaper dermatitis.
Pediatr Dermatol. 2001;18(4):282.
3. Halbert AR, Chan JJ. Anogenital and buttock ulceration
in infancy. Aust J Dermatol. 2002;45:1-8.
4. Visscher MO, Chatterjee R, Munson KA, Bare DE,
Hoath SB. Development of diaper rash in the newborn.
Pediatr Dermatol. 2000;17(1):52.
5. Larralde M, Raspa ML, Silvia H, Lamas F. Diaper dermati-
tis: a new clinical feature. Pediatr Dermatol. 2001;18(2):167.
486 Clinical Pediatrics / Vol. 46, No. 6, July 2007
6. Leventhal JM, Griffin D, Duncan KO, Starling S,
Christian CW. Laxative induced dermatitis of the but-
tocks incorrectly suspected to be abusive burns. Pediatrics.
2001;107(1):178-179.
7. Gupta AK, Skinner AR. Management of diaper dermati-
tis. Int J Dermatol. 2004;43:830-834.
8. Ferrazzini G, Kaiser RR, Cheng SKH, et al. Microbiological
aspects of diaper dermatitis. Dermatology. 2003;206:
136-141.
9. Munz D, Powell KR, Pai CH. Treatment of candidal dia-
per dermatitis: a double-blind placebo-controlled com-
parison of topical nystatin with topical plus oral nystatin.
J Pediatr. 1982;101(6):1022-1025.
10. Chang MW, Kaufmann JM, Orlow SJ, Cohen DE,
Mobini N, Kamino H. Infantile granular parakeratosis;
recognition of two clinical patterns. J Am Acad Dermatol.
2004;50(5Suppl):S114-7.
11. Alberta L, Sweeney SM, Wiss K. Diaper dye dermatitis.
Pediatrics. 2005;116(3):e450-e452.
12. Jackson JM, Fowler JF. Methyldibromoglutaronitrile (Euxyl
K400): a new and important sensitizer in the United
States? J Am Acad Dermatol. 1998;38(6 Pt. 1):934-937.
13. Sidbury R. Chapter 661: Nutritional Dermatoses. In:
Behrman RE, Kliegman RM, Jenson HB, eds. Nelson
Textbook of Pediatrics, 17th ed. Philadelphia: Saunders;
2004:2249.
14. Barrier Therapeutics. Introducting Vusion. Complete
prescribing information. Accessed on March 29, 2006.
Available at: http://www.vusionointment.com/.
15. Yung-Weng W, Ying-Ju C. A preliminary study of bottom
care effects on premature infants’ heart rate and oxygen
saturation. J Nurs Res. 2004;12(2):161-168.
16. Ehretsmann C, Schaefer p, Adam R. Cutaneous toler-
ance 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;
15(Suppl 1):16-20.
17. Odio M, Streicher-Scott J, Hansen R. Disposable baby
wipes: efficacy and skin mildness. Dermatol Nurs.
2001;13(2):107-121.
18. Guin JD, Kincannon J, Church FL. Baby-wipe dermati-
tis: preservative-induced hand eczema in parents and
persons using moist towelettes. Am J Contact Dermatol.
2001;12(4):189-92.
19. Jordan WE, Lawson KD, Berg RW, et al. Diaper der-
matitis: frequency and severity among a general infant
population. Pediatr Dermatol. 1986;3:198-207.
20. Dorko E, Viragova S, Pilipcinec E, Tkacikova L. Candida—
agent of the diaper dermatitis? Folia Microbial. 2003;
48(3):385-388.
21. Fiorillo L. Therapy of pediatric genital diseases. Dermatol
Ther. 2004;17:117-128.
22. Lane AT, Rehder PA, Helm K. Evaluations of diapers
containing absorbent gelling material with conventional
Downloaded from cpj.sagepub.com at CARLETON UNIV on June 15, 2014
disposable diapers in newborn infants. Am J Dis Child.
1990;144:315-318.
23. Odio MR, O’Connor RJ, Sarbaugh F, Baldwin S.
Continuous topical administration of a petroleum for-
mulation by a novel disposable diaper. 2. Effect on skin
condition. Dermatology. 2000;200(3):238-243.
24. Davies M, Dore A, Perissinotto K. Topical vitamin A, or
its derivatives, for treating and preventing napkin der-
matitis in infants. Cochrane Database Syst Rev. 2005;
19(4):CD004300.
25. Al-Waili NS. Clinical and mycological benefits of topi-
cal application of honey, olive oil and beeswax in dia-
per dermatitis. Clin Microbiol Infect. 2005;11(2):
160-163.
26. Silver P, Sagy M, Rubin L. Respiratory failure from corn
starch aspiration: a hazard of diaper changing. Pediatr
Emerg Care. 1996;12(2):108-110.
27. Markham T, Kennedy F, Collins P. Topical sucralfate for
erosive irritant diaper dermatitis. Arch Dermatol. 2000;
136:1199-1200.
28. American Academy of Pediatrics. Candidiasis. In:
Pickering LK, ed. Red Book: 2003 Report of the Committee
on Infectious Diseases. 26th ed. Elk Grove Village, Ill:
American Academy of Pediatrics; 2003:229-231.
29. de Wet PM, Rode H, van Dyk A, Millar AJW. Perianal
candidosis—a comparative study with mupirocin and
nystatin. Int J Dermatol. 1999;38:618-622.
30. Nicholas RO, Berry V, Hunter PA, Kelly JA. The anti-
fungal activity of mupirocin. J Antimicrob Chemother.
1999;43:579-582.
31. Friedlander SE. Contact dermatitis. Pediatr Rev.
1998;19(5):166-171.
32. Gupta AK, Cooper EA, Montero-Gei F. The use of flu-
conazole to treat superficial fungal infections in chil-
dren. Dermatol Clin. 2003;21(3):537-542.
33. Powers NG, Slusser W. Breastfeeding update. 2: clin-
ical lactation management. Pediatr Rev. 1997;18(5):
147-161.
34. Ermis B, Ors R, Tastekin A, Ozkan B. Cushing’s syn-
drome secondary to topical corticosteroid abuse. Clin
Endocrinol. 2003;58:795-797.
35. Siklar Z, Bostanci I, Atli O, Dallar Y. An infantile
Cushing Syndrome due to misuse of topical steroid.
Pediatr Dermatol. 2004;21(5):561-563.
36. Railan D, Wilson JK, Feldman SR, Fleischer AB. Pedia-
tricians who prescribe clotrimazole-betamethasone dipro-
pionate (Lotrisone) often utilize it in inappropriate settings
regardless of their knowledge of the drug’s potency.
Dermatol Online J. 2002;8(2):3.
37. U. S. Food and Drug Administration. FDA Public Health
Advisory: Elidel (pimecrolimus) cream and Protopic
(tacrolimus) ointment. Date created: March 10, 2005.
Date accessed: December 22, 2005. Available at: http://
www.fda.gov/cder/drug/advisory/elidel_protopic.htm.