We have previously mentioned my disdain for skin ailments, but we cannot avoid them, so it is best to address them directly. We have discussed a general approach to pediatric rashes and have covered some specific ones as well (ex, Atopic Dermatitis, Molluscum, Scalded Skin, Measles, Scabies, Popsicle Panniculitis, Meningococcemia, Intertrigo, and Perianal Strep). Now let us review a commonly encountered pediatric rash: Diaper Dermatitis.

Diaper Dermatitis: Basics

• “Diaper Dermatitis” is the term often applied to any skin eruption in the diaper region, but…
• “Diaper Dermatitis” does not denote a specific etiology of the eruption, of which there are many.
• Diaper Dermatitis is reported to be the cause of ~20% of pediatric dermatology visits.
• Incidence shown to peak between 9 months and 12 months of age, but is also prevalent in the neonatal period.

Diaper Dermatitis: Common Causes

• There are a multitude of etiologies ranging from simple to complex systemic illnesses.
• Some of the ones to keep at the forefront of your mind:
  • Contact Dermatitis
    • A physical irritant leads to the eruption.
    • Current understanding of pathophysiology of contact diaper dermatitis:
      • Occlusive design of the diaper in addition to urine and fecal material leads to increased moisture.
      • Moisture leads to maceration and increased susceptibility to frictional damage.
      • High pH environment leads to increased fecal protease and lipase activity as well as adversely affects normal skin flora.
  • Allergic Dermatitis
    • Diaper Dyes have been found to be a source of sensitization.
    • There are numerous other potential chemicals within modern diapers that may lead to allergic type reaction.
  • Candidal Dermatitis
    • Altered pH adversely affects normal skin flora and promotes other pathogens.
  • Strep or Bacterial Infection
    • Altered pH adversely affects normal skin flora and promotes other pathogens.
  • Atopic Dermatitis
  • Seborrheic Dermatitis
  • Non-Accidental Trauma

Diaper Dermatitis: Basic Management

• The ABCDEs of Diaper Dermatitis Management [Klunk, 2014]
  • Air
    • Take the diaper off!
    • Ok, this is obviously not as easy as said… but, since the origin of the contact irritant is the diaper, removing it removes it from the equation.
  • Barrier
    • First line therapies are typically non-medicated barrier creams.
    • Recommend applying a liberal amount and to not wide it all off.
    • Using simple petroleum product (ex, Vasoline) on top of the cream to prevent the barrier cream from sticking to the diaper.
  • Cleansing
    • Important to keep the area clean, but to use soaps with near-physiology pH levels.
    • Important to avoid scrubbing or over-cleaning.
  • Diaper
    • Important to minimize the trapped moisture.
    • Frequent diaper changes (ie, every 2 hours) can help reduce time spent in a moist environment.
    • May also recommend using diapers that are designed to maintain normal pH and are absorbent.
  • Education
    • So, this is the most important treatment.
    • Spending 5 more minutes describing the causes, your considerations, and the management plan will help set expectations and… hopefully… prevent a return ED visit.
    • Also important point out potentially hazardous therapies to avoid:
      • Powders (ex, Talc, Baby Powder)
      • Sodium Bicarbonate
      • Benzocaine
      • Salicylates
      • High-dose steroids (can become too potent in the occluded diaper region)

Diaper Dermatitis: Other Therapeutic Considerations

• The Basic Management is a good place to start, but occasionally, the cause warrants other therapies or the condition is recalcitrant to the Basics.
• Consider:
  • Is this an infection?
    • Perianal Strep?
    • Candidal infection?
      • As the condition progresses, the hallmarks that can distinguish candidal infection from contact irritation (ex, satellite lesions, involvement in the skin folds) become less obvious.
      • For recalcitrant diaper dermatitis, a trial of anti-fungal is often reasonable.
  • Low Dose Steroid application applicable?
    • Desonide 0.05% ointment
    • Hydrocortisone validate 0.2% ointment
    • Can be combined with other antimicrobial medications if needed.

References