Diaper Dermatitis

Question 1

What is the pathophys of Diaper Dermatitis?

Answer 1

▪ A form of contact dermatitis due to disruption
of normal skin barrier
▪ Due to the skin’s contact with moisture, friction, urine and feces

▪ May be irritant, allergic or 2o infected

▪ Peak incidence between 9 to 12 months old, but can occur as early as 7 days old

Question 2

What are the signs/sx’s?

Answer 2

• Irritant:
  – Shiny erythema (on darker skin appears dusky purple), patches in the diaper area
  – Folds of the skin are usually NOT affected
  – Most common type
• Candida Fungal infection
  – presents with beefy red rash, satellite papules and pustules in the area
  – Almost always seen in folds of skin
  – Second most common type

Question 3

What are the risk factors?

Answer 3

• Irritants and friction: Urine and bowel frequency, excessive rubbing and over-cleaning
• Comorbid Conditions: atopic dermatitis or seborrheic dermatitis or psoriasis
• Chemicals: soaps or other products containing boric acid, fragrances, surfactants, volatile alcohols
• Diaper issues: infrequent changes, inadequate rinsing of reusable cloth diapers, using plastic covers over diapers
• Lack of improvement after 7 days of treatment or if it has not healed in 14 days after start of treatment
• Acute start with oozing, vesicles, ulcers or pus present
• Numerous recurrences, especially when there isn’t a rash free time
• Moderate or severe presentation with or without systemic symptoms such as: fever, nausea, vomiting

Question 4

When to refer?

Answer 4

• Rash or lesions elsewhere outside the diaper area
• Complicated secondary infection or another infection present (example UTI)
• Significant behavioral changes
• Signs of abuse or neglect
• Deficient immune system
• Symptoms part of or associated with another disease state that requires further evaluation

Question 5

What are the Goals of Therapy?

Answer 5

1. Relief of symptoms
2. Resolution of dermatitis
3. Prevention of complications and recurrences

Question 6

What are the non-pharm suggestions?

Answer 6

• Use fragrant-free, mild soap or hypoallergic baby wipes for fecal removal
• Dry diaper area by patting gently
• Baby wipes without irritants, fragrance, lanolin, methylisothiazolinone or alcohol. Use a soft cloth or a hypoallergenic wipe after urination or defecation
• Apply barrier product to diaper area, do NOT use powders such as talc and topical cornstarch
• Frequent diaper changes
• Prevention! Remember ABCDE

Question 7

What are the barrier products?

Answer 7

Are two categories:
– Barrier-only: water impermeable
– Barrier-absorptive: water-absorptive

Question 8

What are the water impermeable products?

Answer 8

• Petrolatum
  – No capacity to absorb moisture
  – May cause maceration if applied to overhydrated skin
  – 1 study found no significant difference in preventing diaper dermatitis compared to controls
• Dimethicone or Dimethylpolysiloxane – Silicone base
  – Water-repellent only
  – Soothe by protecting against irritants
• Ceramide based
  – Protectant and may help to promote normalization of skin barrier
  – No capacity to absorb moisture
  – Evidence of effectiveness versus other barrier options lacking

Question 9

What is Zinc Oxide?

Answer 9

• Mild antiseptic and astringent
• Absorption capabilities increases with concentration
  – At lower concentrations (10 to 20%), use for prevention
  – At higher concentrations (up to 40%), effective treatment
• A plain zinc oxide barrier preferred

Question 10

Examples of Barrier Products:

Answer 10

• Aveeno Diaper Rash cream (zinc oxide 13%)
• Desitin Ointment (zinc oxide 37%, cod liver oil)
• Penaten Cream (zinc oxide 18%)
• Vaseline (petroleum jelly)
• Zincofax Ointment (various strengths of zinc oxide)
• Barrier Cream (dimethylpolysiloxane 20%)

Question 11

What are other OTC tx’s?

Answer 11

Antifungal agents
– Clotrimazole (Canesten®) and Miconazole (Micatin®)
* 70 to 90% effectiveness against Candida within 1 week of treatment

– Nystatin (Nyaderm®)
* 70% effectiveness
* Usually requires longer treatment (2 weeks) * May stain fabric

– Apply antifungals first, then barrier cream, once inflammation resolved, discontinue antifungal but continue with barrier cream
* Use for 1 week, if no improvement refer, if improvement may continue for 7 more days

Question 12

Topical Corticosteroids:

Answer 12

• Cautious use of topical hydrocortisone 0.5 to 1% may an option for short periods (MAX 1 to 2 WEEKS)
  – Caution for use in children <2 years old
  – Rarely associated with side effects when used appropriately
• Higher potency not recommended due to risk of absorption and increased risk of side effects
• Used in cases where inflammation is prominent