Diaper dermatitis

Published on 18/03/2015 by admin

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Diaper dermatitis

Pamela Chayavichitsilp and Lawrence F. Eichenfield

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Diaper (napkin) dermatitis is a form of irritant contact dermatitis which presents as erythema and mild scaling on the convex surfaces of the inner upper thigh, lower abdomen, and buttock areas, classically sparing the inguinal folds where the skin is not in contact with irritants. It can present as early as 3 weeks of age or as late as 2 years. Many other dermatoses can affect the diaper area and may need to be excluded.

Management strategy

Diaper dermatitis is triggered by irritants present in the area covered by the diaper, which acts as an occlusive surface. Moisture from urine and feces increases the friction coefficient of the skin, causing frictional damage. Skin integrity is further compromised by the increased pH from urine and fecal enzymes and the physical erosive effects of these activated enzymes. The reduction in skin barrier function and increase in pH contribute to the increased susceptibility to infections with microorganisms such as Candida albicans, which further increases the severity of diaper dermatitis. Therefore, management should aim at preventing over-hydration and frictional damage in the diaper area.

Frequent diaper changes, particularly after defecation, reduce moisture and prevent the build-up of irritants. This is therefore one of the most important steps in the management of diaper dermatitis. Disposable diapers containing superabsorbent gelling materials and breathable backsheets are preferred to those without. Cloth diapers should be avoided, as they have been shown to be associated with an increased incidence of diaper dermatitis compared to disposable diapers.

The skin in the area may be cleaned with water alone or with mild soap. Baby wipes should not contain fragrance or alcohol. Rubbing of the area can cause damage to the skin and should be avoided.

A barrier cream may be applied at every diaper change. This can provide a barrier between the skin and irritants in order to reduce friction and contact with stool and urine.

A low-potency topical steroid such as hydrocortisone 1% ointment can be used in more severe cases of diaper dermatitis, but must be used sparingly to avoid skin atrophy and systemic absorption. High-potency steroids should be avoided in diaper dermatitis, including the use of compound formulations containing potent steroids and antimicrobial agents.

Topical antifungal preparations are recommended for use in proven or suspected cases of C. albicans infection.

Specific investigations

Diaper dermatitis: a review and update.

Ravanfar P, Wallace JS, Pace NC. Curr Opin Pediatr 2012; 24: 427–79.

This excellent review article discusses common causes of diaper dermatitis and similarly presenting conditions. The authors divided the differential diagnoses of diaper dermatitis into two categories: non-infectious and infectious. Non-infectious causes include irritant and allergic contact dermatitis, psoriasis, zinc deficiency, lichen sclerosus, miliaria rubra, and Langerhans cell histiocytosis. Infectious causes include fungal (most commonly C. albicans), bacterial (group A beta-hemolytic Streptococcus and Staphylococcus spp.), viral (herpes simplex, molluscum and enterovirus which can cause hand, foot and mouth disease) and scabies. In addition, complications of untreated diaper dermatitis including Jacquet erosive diaper dermatitis, peri-anal pseudoverrucous papules and granuloma gluteale infantum should also be considered. In recalcitrant cases, clinical findings can provide clues that lead to the diagnoses discussed above.

First-line therapy

image Water-repellant barrier cream A
image Frequent changing of diapers B
image Superabsorbent disposable diapers A

Diaper dermatitis and advances in diaper technology.

Odio M, Friedlander SF. Curr Opin Pediatr 2000; 12: 342–6.

This article discusses advances in diaper technology. Absorbent gelling materials (AGM) have been proved to reduce skin overhydration and reduce the frequency and severity of diaper dermatitis compared to cellulose-only disposable diapers. In a study with nearly 4000 children, a temporal association between the introduction of AGM and a reduction in the incidence of severe diaper dermatitis was found. Polymeric covers or films, commonly known as breathable backsheets, allow moisture vapor to flow out of the diaper and significantly reduce over-hydration in the area. The inner lining of diapers designed to deliver a petrolatum-based formulation to the skin continuously during use has been shown to be associated with a statistically significant and sustained reduction in the severity of diaper dermatitis.

Second-line therapy

image 1% Hydrocortisone ointment D
image Topical antifungal agent (including miconazole, clotrimazole, nystatin, ketoconazole) A

Third-line therapy

image Continuous administration of petrolatum and zinc oxide by disposable diaper A
image Oral antifungal agent E

[/level-membership-for-dermatology-category][not-level-membership-for-dermatology-category]

Diaper dermatitis

Pamela Chayavichitsilp and Lawrence F. Eichenfield

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Diaper (napkin) dermatitis is a form of irritant contact dermatitis which presents as erythema and mild scaling on the convex surfaces of the inner upper thigh, lower abdomen, and buttock areas, classically sparing the inguinal folds where the skin is not in contact with irritants. It can present as early as 3 weeks of age or as late as 2 years. Many other dermatoses can affect the diaper area and may need to be excluded.

Management strategy

Diaper dermatitis is triggered by irritants present in the area covered by the diaper, which acts as an occlusive surface. Moisture from urine and feces increases the friction coefficient of the skin, causing frictional damage. Skin integrity is further compromised by the increased pH from urine and fecal enzymes and the physical erosive effects of these activated enzymes. The reduction in skin barrier function and increase in pH contribute to the increased susceptibility to infections with microorganisms such as Candida albicans, which further increases the severity of diaper dermatitis. Therefore, management should aim at preventing over-hydration and frictional damage in the diaper area.

Frequent diaper changes, particularly after defecation, reduce moisture and prevent the build-up of irritants. This is therefore one of the most important steps in the management of diaper dermatitis. Disposable diapers containing superabsorbent gelling materials and breathable backsheets are preferred to those without. Cloth diapers should be avoided, as they have been shown to be associated with an increased incidence of diaper dermatitis compared to disposable diapers.

The skin in the area may be cleaned with water alone or with mild soap. Baby wipes should not contain fragrance or alcohol. Rubbing of the area can cause damage to the skin and should be avoided.

A barrier cream may be applied at every diaper change. This can provide a barrier between the skin and irritants in order to reduce friction and contact with stool and urine.

A low-potency topical steroid such as hydrocortisone 1% ointment can be used in more severe cases of diaper dermatitis, but must be used sparingly to avoid skin atrophy and systemic absorption. High-potency steroids should be avoided in diaper dermatitis, including the use of compound formulations containing potent steroids and antimicrobial agents.

Topical antifungal preparations are recommended for use in proven or suspected cases of C. albicans infection.

Specific investigations