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Diaper dermatitis
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 encompasses a broad set of conditions, although the most common form is irritant contact dermatitis (ICD). ICD usually presents as erythema and mild scaling on the convex surfaces of the inner upper thigh, lower abdomen, and buttock, classically sparing the inguinal folds where the skin is not in contact with irritants. It may present as early as a few days after birth to as late as several years of age. Diaper use in older disabled and geriatric patients may be identical in pathogenesis and physical findings. Many other dermatoses such as psoriasis, seborrheic dermatitis, allergic contact dermatitis, acrodermatitis enteropathica, infections ( Candida , Staphylococcus , and Streptococcus ), and Langerhans cell histiocytosis can affect the diaper area and need to be excluded. Prevalence and severity of infant and toddler diaper dermatitis varies greatly internationally, influenced by age of toilet-training, regional diaper care habits, frequency of diaper changes, time spent overnight without diaper changes, and prophylactic use of topical products.
Management Strategy
ICD is triggered by irritants present in the area covered by the diaper, which acts as an occlusive surface. Moisture from urine and feces causes damage from friction, increased pH from urine and fecal enzymes, and physical erosion. Skin barrier dysfunction and increase in pH contribute to the increased susceptibility to infections with microorganisms such as C. albicans . Management is aimed at preventing overhydration and frictional damage, and addressing inflammation or infection.
Prevention
Frequent diaper changes, particularly after defecation, reducing moisture, and minimizing irritants are important steps in managing diaper dermatitis. Disposable diapers containing superabsorbent gelling materials and breathable backsheets are preferred. The evolving diaper technology, including mesh-like apertures, variable topsheet construction, and use of ‘natural’ or ‘organic’ materials, has prompted development of ‘enhanced’ disposable diapers, which can be associated with a lower incidence of diaper dermatitis. Cloth diapers are associated with an increased incidence of irritant diaper dermatitis compared with disposable diapers.
The skin in an area of active diaper dermatitis may be cleaned with water alone, with mild soap, or with commercial wipes. Optimally, wipes should not contain fragrance, isothiazolinones, iodopropynyl butylcarbamate, or alcohol. Rubbing of the area can cause damage to the skin and should be avoided.
A barrier cream such as zinc oxide cream maybe 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 should 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.
Diaper dermatitis: clinical characteristics and differential diagnosis
Coughlin CC, Eichenfield LF, Frieden IJ. Pediatr Dermatol 2014; 31(Suppl 1): 19–24.
This article characterizes three subgroups: skin conditions caused by the presence of the diaper, eruptions exacerbated by the diaper, and rashes present regardless of the presence of the diaper. Those caused by the presence of the diaper include irritant diaper dermatitis and its different presentations, as well as allergic contact dermatitis. The conditions exacerbated by the diaper include infectious causes (yeast and bacteria), seborrheic dermatitis, and psoriasis. The third group includes infantile hemangiomas, Langerhans cell histiocytosis, zinc deficiency, Kawasaki disease, and Coxsackie virus.
Potential allergens in disposable diaper wipes, topical diaper preparations and disposable diapers: under-recognized etiology of pediatric perineal dermatitis
Yu J, Treat J, Chaney K, Brod B. Dermatitis 2016; 27: 110–8.
Botanical extracts, which include members of the Compositae family, were the top potential allergens in both diaper wipes and topical preparations. Others identified include tocopherol, fragrances, propylene glycol, parabens, iodopropynyl butylcarbamate, and lanolin.
The role of allergic contact dermatitis in diaper dermatitis
Smith WJ, Jacob SE. Pediatr Dermatol 2009; 26: 369–70.
Allergens include the many chemicals added to diapers, as well as preservatives in baby wipes. For example, sorbitan sesquioleate, fragrances, and disperse dye have been reported to cause contact dermatitis in the diaper area. Rubber additives, cyclohexylthiophthalimide and mercaptobenzothiazole, tend to cause ‘lucky Luke’ dermatitis, a pattern that resembles a cowboy’s holster due to elastic bands coming into contact with the skin. Patch testing is recommended in diaper dermatitis that fails to improve despite treatment.
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