Published on 18/03/2015 by admin
Filed under Dermatology
Last modified 22/04/2025
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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
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.
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.
Inquiry about recent antibiotic usage
In selected cases:
KOH preparation, fungal and bacterial cultures
Serum zinc and biotin levels
Skin biopsy
Patch testing
Honig PJ, Gribetz B, Leyden JJ, McGinley KJ, Burke LA. J Am Acad Dermatol 1988; 19: 275–9.
Skin cultures for C. albicans were done in 57 infants with otitis media before and after amoxicillin therapy in sites including the mouth, nose, rectum, perineum, inguinal folds, and buttocks. A twofold increase in C. albicans was detected after 10 days of antibiotic therapy. Infants who later developed diaper dermatitis had a significant increase in the number of C. albicans compared to those who did not.
Smith WJ, Jacob SE. Pediatr Dermatol 2009; 26: 369–70.
This article stresses the role of allergic contact dermatitis as an important cause of diaper dermatitis. Allergens to consider include many chemicals added to diapers as well as preservatives in baby wipes. For example, sorbitan sesquioleate, fragrances and disperse dye have been increasingly reported to cause contact dermatitis in the diaper area. Cyclohexlthiopthalimide and mercatobenzothiazole which are rubber additives tend to cause ‘lucky Luke’ dermatitis, a pattern that resembles a cowboy’s holster due to elastic bands coming into contact with the skin. The authors suggested patch testing in diaper dermatitis that fails to improve despite treatment.
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.
Nield LS, Kamat D. Clin Pediatr (Philadelphia) 2007; 46: 480–6.
This is an excellent review article that discusses differential diagnoses, prevention and management strategies of diaper dermatitis in a stepwise, tabular format. The key prevention strategy is to keep the area dry. This can be accomplished by using superabsorbent disposable diapers, frequent diaper changes, eliminating irritants (e.g., avoiding baby wipes that contain fragrance and alcohol), using a water-impermeable topical barrier, and allowing for daily diaper-free time.
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.
Hoeger PH, Stark S, Jost G. J Eur Acad Dermatol Venereol 2010; 24: 1094–8.
This double-blinded, multicenter, randomized, controlled trial compared the efficacy and safety of two antifungal pastes (1% clotrimazole versus nystatin with 20% zinc oxide) for the treatment of diaper dermatitis complicated by Candida infection. Results showed clotrimazole to be superior to nystatin in symptom reduction. Both clotrimazole and nystatin had microbiological cure rate of 100% and both were safe and well-tolerated.
Eichenfield LF, Bogen ML. J Drugs Dermatol 2007; 6: 522–6.
Twenty-four infants with moderate to severe diaper dermatitis were evaluated for relative safety from systemic absorption of topical miconazole. Nineteen received 0.25% miconazole nitrate ointment and five received 2% miconazole nitrate cream for 7 days. The results showed blood concentrations in the 0.25% miconazole nitrate treatment group to be minimal (undetectable in 83% and minimal in 17%), thereby demonstrating its safety as a treatment for diaper dermatitis.
Spraker MK, Gisoldi EM, Siegfied EC, Fling JA, de Espinosa ZD, Quiring JN, et al. Cutis 2006; 77: 113–20.
This double-blinded, vehicle-controlled, parallel-group study compared the efficacy and safety of 0.25% miconazole nitrate in a zinc oxide/petrolatum base ointment versus zinc oxide/petrolatum vehicle control for the treatment of diaper dermatitis complicated by candidiasis in 330 patients. Results showed miconazole nitrate ointment to be well tolerated and significantly more effective than vehicle control in the treatment of diaper dermatitis complicated by Candida infection.
Railan D, Wilson JK, Feldman SR, Fleischer AB. Dermatol Online J 2002; 8: 3.
This article stresses the importance of refraining from the use of high-potency topical corticosteroid in diaper dermatitis as it can cause skin atrophy and systemic absorption. Combined topical corticosteroid and antibiotic products, such as clotrimazole–betamethasone dipropionate, often contain high-potency corticosteroids and should therefore be avoided in the diaper area.
Baldwin S, Odio MR, Haines SL, O’Connor RJ, Englehart JS, Lane AT. J Eur Acad Dermatol Venereol 2001; 1: 5–11.
This is a double-blind, randomized controlled clinical trial comparing regular diapers to diapers designed to continuously deliver zinc oxide and petrolatum in 268 infants over a 4 week period. Results showed that the ointment formulation was effectively transferred to the skin and a significant reduction in skin erythema and rash was observed in the treatment group compared to controls.
Friedlander SF. Pediatr Rev 1998; 19: 166–71.
Some diaper dermatitis can continue despite first- and second-line therapies. In these recalcitrant cases oral mycostatin may be beneficial. In addition, an evaluation of the mother for infections of the nipples or genital tract should be considered, as continuous re-inoculation of the infant is possible. If positive, a short course of oral fluconazole (5 to 7 days) can help eradicate the infection.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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Water-repellant barrier cream
Frequent changing of diapers
Superabsorbent disposable diapers
1% Hydrocortisone ointment
Topical antifungal agent (including miconazole, clotrimazole, nystatin, ketoconazole)
Continuous administration of petrolatum and zinc oxide by disposable diaper
Oral antifungal agent
