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Diaper dermatitis

Nappy rash ( also called as diaper dermatitis ) is a general definition used to describe a range of inflammatory reactions of the skin in the area covered by the nappy ( Longhi F et al 1992 )

 

How common –Most common dermatological disorder of infancy Incidence varies widely between studies but prevalence and incidence are high varying under the conditions of each country and the most commonly used diaper Estimated overall prevalence ranges from 7 % to 43.8 %
○ Pogacar et al report a prevalence between 7 % and 50 % Seen more commonly in children under 24 months of age and peaks between 9-12 months The highest prevalence in 9-12 age group is believed to be due an ↑↑ in consumption of solid foods Another paper reports that a diaper rash is seen in 20 % of pediatric dermatology consults and diaper dermatitis is present in 25 % of of all children presenting to outpatient departments Merrill et al 2015 report that both sexes are equally affected Daniel B Ward et al report that in their study ( in USA ) all races and Hispanics and non – Hispanics were nearly proportionately diagnosed in outpatient visits A recent phenomena in some societies as China with the adoption of Western diapering practices It should also be noted that this condition is not limited to infancy and can happen in a person of any age who wears diapers

 

What happens –Most cases are of the irritant diaper dermatitis ( IDD ) type ( acute dermatitis ) Most inflammatory reactions are caused by moisture , heat or various enzymes from urine and faeces ( major irritants ) Chaffing dermatitis , irritant contact dermatitis and diaper dermatitis are the 3 most common types of diaper dermatitis Several causes are implicated as
○ Postnatal regional failure of skin to cope with exogenous insults with subsequent compromise of epidermal barrier integrity 
○ friction and maceration causing breach- breach in stratum corneum
○ skin moisture content is increased which encourages growth of microorganisms
○ altered surface pH due to diaper / ammonia
○ use of broad spectrum antibiotics Combination of these factors leads to a breakdown of the stratum corneum which predisposes the skin to opportunistic infection by faecal microbes such as Candida albicans and Staphylococcus aureus Microbial infections- particularly fungi especially C. albicans which are responsible for > 80 % of cases ( most acidophilic yeasts that thrive at skin pH of around 5.5 or 6.0 in 
newborns ) Diaper dermatitis candidiasis ( DDC ) Other species also found but seen less commonly include Candida tropicalis ,Candida parapsilosis and Candida glabrata.

 

Risk factors -Use of diaper ( diaper dependency ) Age ( < 2 as high use of diapers in this age group ) Day care centers Gastrointestinal tract infection ( diarrhoea ) Use of oral antibiotics Type of diaper used Frequency of diaper change ( risk ↑ if diapers are changed fewer than 6/day ) Atopic conditions Jordan et al have reported infant maturity , infant formula feed and the presence and the level of faecal C albicans

 

Breast feeding may play a protective role in moderate to severe DD likely due to significantly lower pH of faeces from exclusively breast fed infants with less enzymatic activity.

 

Presentation –Onset is generally between 3 weeks and 2 yrs of age Dermatitis appears in the region covered by the diaper affecting the gluteal , perineal and inguinal areas ( occasionally part of the genitals ) Rash can be itchy , painful , burning ( may cause discomfort but hard to evaluate as clients very young ) Although rarely causes any long term problems – causes parental distress Can be irritating as oral thrush , particularly during perineal care Parents may report
○ prolonged periods of crying as 1st symptom of pain
○ agitation , changes in sleeping patterns and ↓↓ frequency of urination and defecation Morphology – erythematous, scaly , macerated plaques with oedema accompanied by vesicles and pustules Often relative sparing of skin folds which do not come in direct contact with the diaper Jacquet dermatitis – is a severe form of DD which presents with erosions or plaques and discrete ulceration ( Common Newborn Dermatoses Kate Khorsand et al Avery’s Disease of the Newborn 10th edition 2018 )

 

Diagnosis -Diagnosis is clinical based on appearance of an erythematous eruption that involves the convex surfaces of buttocks and genital area and by excluding other potential causes Undertake a physical examination Enquire about
○ duration
○ frequency of urination and defecation , bathing , diet
○ hygiene practices , cleansing routine
○ interventions tried for e.g use of soaps , cleansers , wipes , OTC creams
○ type of diaper , frequency of change
○ exposure to potential irritants and contagious diseases
○ skin trauma
○ previous skin problems as allergy , infections
○ recent antibiotic use Laboratory diagnosis is rarely required but available options are
○ direct examination with KOH ( 10 % )
○ fungal culture of skin scraping for Candida species
○ yeasts can be identified by biochemical testing ( zymograms ) , molecular testing PCR ) and proteomic testing ( MALDI-TOF )
○ mineral oil slide preparation for scabies.

 

Differentials -Infantile seborrhoeic dermatitis Atopic eczema Candidiasis Eczema herperticum Granuloma gluteale infantum Miliaria rubra ( heat rash ) Intertrigo ( frictional dermatitis -flexural sharply marginated erythema limted to sites of skin to skin contact ) Perianal streptococcal dermatitis Infantile psoriasis Contact irritant dermatitis Lichen sclerosus Scabies Child abuse ( rare ) but should be considered in severe , recalcictrant or atypical diaper dermatitis Kawasaki disease ( rare ) Zinc deficiency ( rare )

 

Skin care measures -avoid rubbing or friction during diaper changes clean gently and , rinse and pat dry ( allow to air dry ) to minimize skin trauma periods of rest without diaper -damaged skin is exposed to air and reduces the contact time of skin with urine , faeces , moisture and other irritants consider using water/ cotton wool or fragrance/alcohol free baby wipes CKS suggests not to use soap , bubble bath lotions , talcum powder or topical antibiotics frequent diaper changing every 1-3 hour change napkin as soon as it is soiled by urine or faeces prevention is the key – render advice on good nappy care.

 

Diapers -should be properly fitting ( use correct size ) high absorbency nappies ( in comparison to non-disposable nappies ) i.e recommend use of superabsorbent disposable diapers try and leave the nappy off for periods.

 

Topical preparations -usually sufficient in mild to moderate cases barrier creams with zinc / oxide and or petrolatum create a lipid film on the skin surface which minimizes urine and faecal contact with skin ( other preparations may include agents as dexpanthenol , Vitamins A,D,E , mineral oils , aloe vera , lanolin , wax ) topical zinc oxide ( used widely ) provides water impermeable barrier that reduces friction and maceration antifungal agents ( for severe cases ) nystatin , clotrimazole , miconazole , ketoconazole & sertaconazole can be used with every diaper change low potency topical corticosteroids like HC and HC acetate are generally safe when used in moderation if localised bacterial infection is present topical mupirocin bd for 5-7 days may be sufficient.

 

Mild cases -parent education OTC barrier preparations -with each nappy change consider written information – find under links

 

Moderate-moderate cases causing infant discomfort use 0.5 % or 1 % HC OD x 7 days until symptoms settle

 

Severe cases –fungal or bacterial infection is usually present NICE recommends use of

○ clotrimazole 1 % cream 2-3/ day- continue for atleast 2 weeks after the affected area has healed
○ econazole 1 % cream bd – continue application until all skin lesions have healed
○ miconazole 2 % cream – bd continue for 10 days after the affected area has healed

Topical nystatin tds & to continue for 3 days after rash clears has been historically used for over 50 yrs
 combination ( with steroid ) to reduce inflammation in more severe cases – this is not supported by NICE as it is felt that dilution of topical steroid in the formulation will not effectively treat severe inflammation
 if bacterial infection has complicated the case prescribe oral antibiotic ( flucloxacillin 1st choice and if allergic use erythromycin or clarithromycin )

 

Treatment failure -compliance understanding what is being used , how often the nappy is being changed an alternative cause.

 

Tests -swab for culture & sensitivity adjust treatment based on swab result BMJ best practice recommends CBC / Zinc levels in severe or persistent disease.

 

Allergic contact dermatitis -from fragrances , preservatives and emulsifiers can develop anywhere where it is applied erythema , vesicles , superficial erosions & oedema often 1-3 week period of sensitization and can persist for another 2-4 weeks after discontinuation.

 

Seborrhoeic dermatitis -seborrhoeic dermatitis normally affects face , ears , neck with erythema , greasy yellow scales which can spread to diaper area -seen during the 1st 6-9 mts of life psoriasis ( ask for family hx ) is uncommon -bright red well demarcated symmetrical plaques -suspect is it persists beyond 1st year of life ( this responds poorly to treatment for DD )

 

Infections -thin walled pustules ( fluid or pus filled ) on a red base -suspect staphylococcal pustulosis bright red patches or plaques with erosions and satellite pustules are characteristic of candidiasis.

 

Referral -Diagnostic uncertainty If symptoms persist for > 14 days with no response to treatment ( BMJ Best Practice) Recurrent , severe unexplained cases ( CKS )

PATIENT INFORMATION

From health navigator New Zealand https://www.healthnavigator.org.nz/health-a-z/n/nappy-rash/

Society of Paediatric Dermatology – printable pdf 2 pages https://pedsderm.net/site/assets/files/1028/spd_diaper_care_color_web.pdf

A good explainer from Pampers https://www.pampers.co.uk/safety-and-commitment/nappies-and-wipes/article/nappy-rash-treatment-and-remedies

 

 

References

  1. Suebsarakam, Porntipa et al. “Diaper Dermatitis: Prevalence and Associated Factors in 2 University Daycare Centers.” Journal of primary care & community health vol. 11 (2020): 2150132719898924. doi:10.1177/2150132719898924
  2. Šikić Pogačar M, Maver U, Marčun Varda N, Mičetić-Turk D. Diagnosis and management of diaper dermatitis in infants with emphasis on skin microbiota in the diaper area. Int J Dermatol. 2018 Mar;57(3):265-275. doi: 10.1111/ijd.13748. Epub 2017 Oct 6. PMID: 28986935.( Abstract )
  3. Blume‐Peytavi, UKanti, VPrevention and treatment of diaper dermatitisPediatr Dermatol201835s19‐ s23https://doi.org/10.1111/pde.13495
  4. Spotlight : tackling nappy rash in infants Julie Van Onselen British Journal of Family Medicine , April 2018 Spotlight: tackling nappy rash in infants (bjfm.co.uk)
  5. Ward DB, Fleischer, AB, Feldman SR, Krowchuk DP. Characterization of Diaper Dermatitis in the United States. Arch Pediatr Adolesc Med. 2000;154(9):943–946. doi:10.1001/archpedi.154.9.943
  6. Nappy rash CKS NHS Nappy rash | Health topics A to Z | CKS | NICE
  7. Lisa Merrill, Prevention, Treatment and Parent Education for Diaper Dermatitis, Nursing for Women’s Health, Volume 19, Issue 4, 2015, Pages 324-337, ISSN 1751-4851,
    https://doi.org/10.1111/1751-486X.12218.( Abstract )
  8. Adalat, S., Wall, D. and Goodyear, H. (2007), Diaper Dermatitis‐Frequency and Contributory Factors in Hospital Attending Children. Pediatric Dermatology, 24: 483-488. https://doi.org/10.1111/j.1525-1470.2007.00499.x
  9. BMJ Best Practice nappy rash Nappy rash – Symptoms, diagnosis and treatment | BMJ Best Practice
  10. Diaper dermatitis Science direct Diaper Dermatitis – an overview | ScienceDirect Topics
  11. Bonifaz, Alexandro et al. “Superficial Mycoses Associated with Diaper Dermatitis.” Mycopathologia vol. 181,9-10 (2016): 671-9. doi:10.1007/s11046-016-0020-9
  12. Cohen B. Differential Diagnosis of Diaper Dermatitis. Clin Pediatr (Phila). 2017 May;56(5_suppl):16S-22S. doi: 10.1177/0009922817706982. PMID: 28420251.

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