Pathophysiology: Diaper rash affects the areas within the confines of the diaper. Increased wetness in the diaper area makes the skin more susceptible to damage by physical, chemical, and enzymatic mechanisms. Wet skin increases the penetration of irritant substances. Superhydration urease enzyme found in the stratum corneum liberates ammonia from cutaneous bacteria. Urease has a mild irritant effect on nonintact skin. Lipases and proteases in feces mix with urine on nonintact skin and cause alkaline surface pH, adding to the irritation. Feces in breastfed infants have a lower pH and are less susceptible to diaper dermatitis. The bile salts in the stools enhance the activity of fecal enzymes, adding to the effect.

Candida albicans has been identified as another contributing factor to diaper dermatitis, often occurs after 48 to 72 hours of active eruption. Whether it is the cause or the effect is controversial; however, C albicans was isolated from the perineal area in as many as 92% of children with diaper dermatitis. Other microbial agents have been isolated less frequently, perhaps more as a result of secondary infections.

Mortality/Morbidity:

• With the exception of an individual who is immunocompromised, no mortality is associated with diaper rash when correctly diagnosed. However, a rash incorrectly diagnosed as diaper dermatitis certainly may lead to significant morbidity and mortality if associated with a serious illness.

• Morbidity associated with diaper dermatitis is discomfort and the possibility of secondary bacterial or candidal infection, which may be more severe in an individual who is immunocompromised.

Race: No difference is based on race.

Sex: No difference is based on sex.

Age:

• Diaper dermatitis commonly affects infants, with peak incidence occurring when the individual is aged 9-12 months. One study determined that at any given time, diaper dermatitis is prevalent in 7-35% of the infant population.

• However, diaper dermatitis can affect persons of any age group who wear diapers, in particular the elderly.

History:

• Children with a previous medical history of atopic dermatitis may be more susceptible to diaper dermatitis.

• Nutritional history also may be an important factor to consider in diaper dermatitis.

• A biotin-poor diet, such as occurs with elemental formula alone, may result in perioral erythema, developmental delay, loss of hair, and hypotony (in addition to diaper dermatitis).

• Lack of zinc-binding ligands in the intestine, such as in the autosomal recessive disorder acrodermatitis enteropathica, may result in a triad of hair loss, dermatitis, and diarrhea. Generally, a decrease in zinc in the diet may be associated with relative alopecia and diaper dermatitis. One study found the lowest levels of zinc in the hair of infants aged 8 months.

• Another factor to consider in a child’s medical history is the immune status; patients who are immunocompromised are more susceptible to infections by C albicans and other bacterial superinfections.

Physical:

• Diaper dermatitis presents as an erythematous scaly diaper area often with papulovesicular or bullous lesions, fissures, and erosions.

• The eruption may be patchy or confluent, affecting the abdomen from the umbilicus down to the thighs and encompassing the genitalia, perineum, and buttocks. Genitocrural folds are spared.

• Children with diaper dermatitis have marked discomfort from intense inflammation.

• Rule out a secondary yeast or bacterial infection, which may occur in the area.

Causes:

• Overhydration of the skin

• Maceration

• Prolonged contact with urine and feces

• Retained diaper soaps

• Topical preparations

• More than 3 diarrheal stools per day

Medical Care:

Medical therapy for diaper dermatitis includes the use of protective topical agents, topical anticandidal agents, and possibly, topical low-potency steroids.
 

Drug Category: Protective topical agents -- Ideally, first-line therapy for diaper dermatitis is zinc oxide ointment. The safest OTC emollient available for newborns is pure white petrolatum ointment. Another safe alternative is Aquaphor ointment (ie, composed principally of white petrolatum, mineral oil, and wood wax alcohol). It is more expensive than pure white petrolatum ointment.

Drug Category: Antifungal agents -- Indicated for suspected candidiasis or proven candidal infection by KOH preparation or culture. Commonly used topical antifungal agents are nystatin cream or ointment and econazole nitrate cream.

Drug Category: Topical steroids -- Limit potent topical steroid use to a few days and to a small quantity. Avoid combination topical steroid/antifungal cream in the diaper area.

Deterrence/Prevention:

• Prevention consists of the ABCDEs: Air, barrier, cleansing, diaper, and education.

Complications:

• Candidal diaper rash leading to confluent diaper area with tomato-red plaques, papules, pustules, and satellite papules

• Miliaria rubra evident as tiny red papules and papulovesicles at elasticized openings of the diaper

Prognosis:

Patient Education:

• Providing education to the parents and/or caregivers of the patient is very important in the treatment and further prevention of diaper dermatitis.

• Keep the skin clean and dry.

• Provide diaper education.

• Frequently change diapers.
• Use disposable diapers with superabsorbent material.
• When compared to cloth diapers, disposable diapers provide a lower prevalence and severity of diaper dermatitis.

• Wash genitalia with warm water and mild soap.

• Frequently apply a bland protective topical agent after thorough washing.