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Diaper Dermatitis

 

Introduction

Diaper rash usually occurs in two stages: First there is irritation of the skin in the diaper area caused from a combination of the moisture under the diaper from the skin, the urine, and the stool. If the irritation gets bad enough (and any parent will tell you that it doesn't take much), the skin can become contaminated with a yeast called Candida. This is the same yeast which causes oral thrush. Therefore, in trying to control or treat diaper rash, two things must occur: 1. Try to minimize the exposure of the skin to the irritants. This is hard to do especially in infants. Try changing the diaper more often than you are used to. Cloth diaper users tend not to have as many problems with diaper rash mainly because the cloth diapers are not as absorbent as disposables which in turn results in more diaper changes. Also, liberal use of a zinc oxide barrier ointment to protect the skin from urine and stool is very helpful. Dr. Jacobs suggests using a thick zinc oxide ointment like Desitin. Apply this with every diaper change when the skin appears irritated. 2. However, even the most diligent of parents will not be able to keep irritation of the diaper area at bay 100% of the time. And, when infection with yeast occurs, no amount of over-the-counter lotion will make it go away. This type of infection usually looks like a large reddened patch with much smaller "satellite" areas around it. An antifungal medication must be used to kill the yeast. In addition, a steroid cream may occasionally be prescribed. This decreases the irritation of the skin and helps with the healing of the skin. Generally, a yeast diaper rash goes away after about 14 days of antifungal medication. Severe rashes may take longer to treat.

 

Definition and cause

The term diaper dermatitis is synonymous with "diaper rash" and includes all eruptions that occur in the area covered by the diaper. These are conditions caused directly by the wearing of diapers (such as irritant contact dermatitis), those that are aggravated by diapers (such as psoriasis), and those that occur whether diapers are worn or not (such as acrodermatitis enteropathica due to zinc deficiency). Diaper rash is quite common and it represents the end result of several factors. Some of these factors are: A. Chaffing caused by constant contact of the diaper to the skin. B. Constant exposure to moisture. C. Exposure of the skin to irritating chemicals in the urine (such as ammonia) D. The presence of bacteria in stool. Mild diaper rash can be treated at home with over-the- counter remedies. However, when the rash does not respond to these remedies, medical assistance should be sought to determine if a yeast infection has developed. Regarding irritant diaper dermatitis, the etiology of this condition remains unknown, although maceration, occlusion, and possibly candida may all play a role. It has also been shown that bacteria from feces may have a synergistic effect with candida yeast.

 

How it begins

Damage to the epidermis causes loss of the normal barrier function, which leads to increased susceptibility to irritation and infection. Because the perineal area is covered with a continuously wet and warm impervious cover, compounded with continuous friction in the area, is probably directly responsible for some of the changes seen in irritant contact dermatitis. Water, whether from urine, or merely as a result of hydration from occlusion, makes the skin susceptible to friction from movement under the diaper. It would appear that certain infants are more susceptible to irritant contact dermatitis than others. Those with atopic dermatitis fall into this group. Patient with atopic dermatitis are likely to suffer with worse diaper rash.

 

Incidence

The incidence of diaper rash appears to be equal between the sexes, and the condition usually occurs between 3 and 18 months of age, peaking between 6 and 9 months. Please keep in mind that anyone who wears diapers may develop diaper rash. This includes adults, as well. In babies, because of the thinness of skin, the symptoms may be more severe than in adults. The principles explained in this educational handout apply to both babies and adults who wear diapers.

 

Appearance

The parent usually notices redness in color on the convex surfaces of the inner thighs, buttocks, and upper thigh areas. The creases are spared, as is the area over the mons pubis in boys. The eruption may become deeply red a typical glistening or glazed appearance and wrinkled surface.

 

Ways to prevent and treat common diaper rash

Prevention of diaper rash is most ideal. Some preventative measures include:

A. Keep the diaper area open to fresh air. The cooling, drying effects of air evaporation is a natural way to prevent diaper rash and to treat diaper rash once it occurs.

B. Keep the diaper area as dry as possible by changing your baby's diaper frequently.

C. Clean the baby's bottom with warm water or baby wipes, making sure to wipe front to back in girls to prevent bladder infections. Avoid excess use of soaps and perfumed diaper wipes as these can further irritate your baby's skin.

D. Avoid use of corn starch which can be broken down to microorganisms (germs). In fact, cornstarch provides excellent food for candida yeast to grow.

E. At early signs of a developing rash, apply protective ointments such as Zinc Oxide Ointment, Desitin, & A&D ointment. These create a protective barrier.

F. If diaper rash does not respond to these measures within a couple of days, or if it worsens, seek medical assistance, as your baby may have developed a yeast infection which may require a prescription creme or ointment.

 

Once it develops, diaper dermatitis may respond to the use of protective emollients, particularly zinc oxide preparations such as Desitin, which can eliminate the effects of hydration and excessive maceration. Zinc oxide preparations provide protection from urine and feces. Chafing of the diaper area may occur on the convex surfaces and a "tide mark" area of dermatitis may occur at the margin of the diaper. This mark is caused by friction from the diaper and wet skin, and responds well to the use of protective emollients. In addition to protective emollients, a mild non fluorinated corticosteroid such as Acclovate, Hydrocortisone, or Des Owen may alleviate the initial inflammation and should be used at least 3 times per day until improvement is noticed. Cloth diapers may be better because they are more frequently changed. However, in cases where numerous chemicals are used for washing, or when cloth diaper changing is not frequent enough, a specific eruption consisting of well demarcated punched out ulcers or erosions on the labia or penis may occur. This eruption responds well to changes in diapering habits, which usually means changing to diaper service or disposable diapers. The best treatment is leaving the child without any diapers, but this is usually not practical. The ulcers respond well to mild topical steroid preparations, compressing with Burow's 1/40 solution 3 times per day, and using thick protective emollients to act as a protective barrier.

 

Treatment of Candidiasis

Certain infants seem to be particularly prone to monilial (candidal) infection. The clinical picture of candidiasis may take two forms. First, it may present with a diffuse erythematous patch extending over the genitalia. The patch shows peripheral scaling and satellite pustules. The other form seen more frequently is that of small pink papules surrounded by a thin scale. The perineum and perianal areas are either both or separately involved, as are the creases, which help differentiate this candidal eruption from an irritant contact dermatitis. Candida albicans appears to have the ability to invade through the epidermal barrier, possibly by liberating enzymes called keratinases. These enzymes can break up and dissolve the skin, causing damage. For candida diaper dermatitis, the treatment of choice consists of topical antimycotic therapy such as Loprox, Nystatin, clotrimazole, Nizoral, Spectazole, Oxistat, or miconazole three or four times daily. Adding hydrocortisone 2.5% to the above agents, provides an anti-inflammatory effect and promotes more rapid healing. If the lesions are highly inflammatory, cool water compresses may be helpful. Potent corticosteroids can be used for one, two, or three days in severe cases, but should then be avoided in the diaper area as they can rapidly thin the skin in babies. Hydrocortisone 2.5 is fairly safe to use for up to 30 days.

 

 

 

 
Ken Alpern, M.D. Charity Morris, PAC Eleni Litras,
PAC

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Hello, and welcome to our dermatology office. My name is Randy Jacobs, MD, FAAD. Some people are blessed with the most beautiful skin, and it’s all natural. Others have to work at it. Healthy skin is lovely to behold, comfortable to live in, and a pleasure to touch.
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