Philippa E. Kellen, MB, BCh(WITS), FFDerm(SA)

Diaper Dermatitis: Differential Diagnosisand Management

SUMMARYDiaper dermatitis is one of the mostcommon dermatoses occurring in infancy. Itis an irritant dermatitis, in which a variety offactors act in concert to produceinflammation of the diapered skin. Thedifferential diagnosis includes manycommon and some uncommon conditions.Successful treatment requires detailedinstructions to caregivers regarding simplehygienic procedures and diaperingpractices. (Can Fam Physician 1990;36:1569-1572.)

RESUMEL'erytheme fessier est l'une des dermatoses lesplus frequentes chez le nourrisson. C'est unedermatite irritative, oiu nombre de facteurss'unissent pour produire une inflammation de lapeau en contact avec la couche. Le diagnosticdifferentiel inclut de nombreuses conditions,dont certaines courantes et d'autres moinscourantes. Le traitement fructueux necessite desinstructions detaillees aux personnesresponsables des soins a l'enfant concernant desmesures hygieniques simples et les pratiques dechangement et d'entretien des couches.

Key words: dermatology, dermatitis, family medicine, pediatrics____=__~~~~~-1111-~~ -- -----

Dr. Kellen is in private practice inSaskatoon. She is a ClinicalAssistant Professor in theDepartment of Medicine, Division ofDermatology, at the University ofSaskatchewan. Requests forreprints to: Dr. P.E. Kellen,204-514 Queen St. Saskatoon, Sask.S7K OM5

D IAPER DERMATITIS is an acuteinflammatory dermatosis, which is

a direct consequence of wearing dia-pers. The term is often loosely appliedto a variety of inflammatory dermatosesthat can occur in the area covered by adiaper. It is one of the most commondermatitides in infants, being reportedby up to 75% of parents, but because it isoften mild and transient, fewer than10% of cases are referred to physiciansfor management.'

Clinical FeaturesDiaper dermatitis is an inflammatory

dermatosis affecting predominantly theconvex surfaces in closest contact withwet or soiled diapers. The buttocks,genitalia, lower abdomen, and upperthighs are usually the most severely af-

fected, but the distribution depends onthe position in which the infant is al-lowed to lie. The flexures are spared,particularly in the obese child. In themildest forms there is only erythema,but with increasing severity, papules,vesicles, small erosions, and larger ul-cers may occur. In chronic forms scal-ing is combined with glazed erythema.Scaling may be conspicuous, particular-ly in the healing stages. Diaper dermati-tis may be graded according to severity:* grade 1: slight erythema, perhapswith scaling;* grade 2: moderate to severe erythe-ma, perhaps with scaling; or few pap-ules and some edema (Figure 1);* grade 3: moderate to severe erythe-ma, perhaps with scaling, moderate tosevere edema and papules, or early ul-ceration; and* grade 4: severe erythema, perhapswith scaling, or severe edema, papules,and ulceration.

CausesThe causes of diaper dermatitis are

multiplicative rather than additive; im-paired infant skin is more susceptible to

further insult. Factors associated withthe development of diaper dermatitisare':* age of the infant;* diet;* intestinal carriage of Candidaalbicans;* the frequency and duration of contactbetween the infant's skin and excreta;and* diaper- type used.

InfantAgeThe incidence of moderate dermatitis

is highest at age nine to 12 months.'There is, however, a strong correlationbetween the infant's age and rate of dia-per changing; older infants are changedless often. Dietary changes may alsoplay a significant etiological role in thisage group. Severe diaper dermatitis ispresent in about 5% of infants atall ages.'

DietInfants partially or wholly breast-fed,

or those with a history ofbreast-feeding,are reported to have a lower incidence ofmoderate or severe dermatitis. This dif-ference has variously been attributed to

CAN. FAM. PHYSICIAN Vol. 36: SEPTEMBER 1990

m

1569

lower stool pH, differences in intestinalmicroflora, and components of fecesand urine in breast-fed infants.'

Intestinal Carriage ofCandida AlbicansCandida albicans has been isolated

from the skin and feces of infants withand without diaper dermatitis. A higherfrequency of carriage is associated withinfants with active dermatitis, and thereis a direct correlation between the severi-ty of diaper dermatitis and the presenceof fecal Candida. The organism is usual-ly viewed as a secondary invader of al-ready damaged skin, but it has been sug-gested that C. albicans has a primary rolein severe diaper dermatitis. Recent stu-dies have demonstrated an increased re-covery of C. albicans from the rectumand skin of patients receiving systemicantibiotic therapy.2 This has been asso-ciated with an increased risk for devel-oping diaper dermatitis in these patients.

Contact Between Skin and ExcretaThe incidence of moderate and se-

vere dermatitis increases when the num-ber of bowel movements per day in-creases. The incidence and severity isinversely proportional to the number ofdiaper changes; it seldom occurs whendiapers are changed more than eighttimes daily.

Figure 1Grade 2 Diaper Dermatitis with SevereErythema but Mild Scaling and Edema

..II-,~7.M

Diaper TypeRecent advances in understanding

the role of urine, feces, and fecal en-zymes in diaper dermatitis have led toimprovements in the manufacturing ofdisposable diapers. Clinical data havesuggested that disposable diapers con-taining absorbent gelling material(AGM) provide a better skin environ-ment and are associated with less diaperdermatitis than other diaper types.3

PathogenesisIncreased skin hydration occurs in in-

fants wearing diapers. This hydrationproduces higher coefficients of friction,greater potential for abrasion damage,more transepidermal penetration, andincreased microbial counts in the skin.These factors are associated with skindamage and a greater potential for skinirritation.

Skin pH has been shown to play animportant role in the development of di-aper dermatitis. The production of am-monia from the breakdown of urinaryurea by bacterial urease in feces leads toincreased pH in the diapered area. In-creasing pH to 6 or 7 can increase fecalprotease and lipase activities. These fe-cal enzymes damage skin directly andalso increase the susceptibility of theskin to other irritants in the dia-pered area.

Greater skin pH stabilityhas been demonstrated in in-fants wearing AGM-contain-ing disposable diapers.3 Thisstability is thought to

Figure 2

be a result of the buffering capacity ofAGM in addition to capture of urine inthe diaper core away from fecal materi-al, thereby reducing the potential for apH rise from ammonia production.

Differential DiagnosisThe differential diagnosis of diaper

dermatitis includes several conditions,which may be associated with or com-plicated by diaper dermatitis (Table 14).Seborrheic Dermatitis

Seborrheic dermatitis usually has itsonset during the first month of life and ischaracterized by erythema and greasyscaling. The eruption commonly beginsin the scalp and classically also involvesthe flexures more or less symmetrically,the eyebrows, and the retroauricular re-gions. Although the skin lesions tend toresolve spontaneously by age threemonths, these infants are reportedlymore susceptible to the development ofdiaper dermatitis.'

Atopic EczemaAtopic eczema usually appears when

the infant is between three to 12 monthsof age with extremely pruritic, erythe-matous, papulovesicular lesions. Thelesions most frequently start on the face,particularly the cheeks and forehead,and may also be present elsewhere: forexample, on the forearms, cubital and-popliteal fossae, and legs. Often the dia-per area is relatively spared, a beneficialeffect ofocclusion. The condition oftenhas a chronic fluctuating course. Thereis frequently a family history of atopy.

Candidiasis Showing Irregular Margins with Scaling, Papules,

Figure provided courtesy of Dr. A. Moreland1570

Reprinted with permission from Focus on Dermatology 2(1)"Common problems of pediatric dermatitis" by Dr. BerniceKrafchik.

CAN. FAM. PHYSICIAN Vol. 36: SEPTEMBER 1990

Candidiasis

Candidiasis can appear at any age.The lesions tend to extend from the per-ianal area and are sharply and irregular-ly marginated red patches that have araised scaling edge. Satellite pustules orpapules are a diagnostic feature of thiscondition (Figure 2). Oral lesions canbe present.

Miliaria

Miliaria most commonly occurs inthe first few weeks of life, butmay occurat any stage throughout infancy. The le-sions usually develop rapidly as sym-metrical crops of minute papules or pa-pulovesicles, which may present any-where but are most frequent around thesides of the neck, upper chest, groins,and axillae. The lesions usually subsidewithin two to three days, but recurrentcrops may continue to develop indefi-nitely ifpredisposing conditions contin-ue. Miliaria in areas already inflamed(e.g., diaper dermatitis) can be pustularand need to be distinguished from thesatellite pustules of candidiasis.

IntertrigoIntertrigo is a frictional dermatitis

characterized by flexural, sharply mar-ginated erythema limited to sites ofskin-on-skin contact. Involved sites in-clude genitocrural flexures, natal cleft,folds of the neck, and axillae.

Perianal DermatitisPerianal dermatitis of the newborn

usually presents within the first fewdays of life with perianal erythema,which may extend up to 4 cm or morefrom the anal margin. In more severeforms the skin may be edematous andsuperficially eroded. The condition of-ten resolves spontaneously within thefirst two to three months of life.

Infantile PsoriasisInfantile psoriasis usually appears at

about two months of age with sharplymarginated, red, scaly plaques typicallyinvolving the diaper area or the scalpinitially. Smaller scattered psoriasiformplaques may develop on the trunk,around the ears or neck, and on theaxillae.

Irritant Contact DermatitisIrritant contact dermatitis excluding

diaper dermatitis is not uncommon ininfancy. Initially it presents with ery-thema and edema confined to the area incontact with the irritant. If contact withthe irritant continues, the dermatitismay spread beyond the area of contactand may generalize. The reaction maybecome increasingly severe, with vesi-culation and even bulla formation. Ex-udation and crusting may be noted dur-ing the active stages and scaling in themore chronic forms or during the reso-lution phase. Irritants include deter-gents, fabric softeners, and alcohol-con-taining cleansing wipes and solutions.

Other conditions that occur less oftenwith dermatitis in the diaper area in-clude impetigo, herpes simplex, syphi-lis, acrodermatitis enteropathica, histio-cytosis X syndromes, and the bullousdiseases of childhood.

ManagementDiaper dermatitis can be treated and

recurrences can be prevented only aftercareful assessment of contributing fac-tors. The hygienic procedures followed

Table 1Differential Diagnosis of Diaper Dermatitis

Disorder Age of Onset Sites Clinical Features Other SignsSeborrheic Under 3 months Genito- Erythema and Greasy scaling of scalp;dermatitis crural flexures greasy scaling Other flexures may be

involved

Atopic Rarely under 2 months Anywhere Erythema, papules, Lesions elsewhere:eczema Usually 3 to 12 months vesicles cheeks, forehead,

forearms, cubital andpopliteal fossaePruritus

Candidiasis Any age Extends from Sharply, irregularly Oral lesionsperianal area marginated red patches,

raised scaling edge,satellite pustules or papules

Miliaria Any age Variable: groins or Erythematous papules Lesions elsewhere:buttocks ± vesicles e.g., neck, chest

lntertrigo Any age Any flexure or fold Erythema only Limited to areas ofskin-on-skin contact

Perianal From 0 to 4 weeks Perianal Erythema Nonedermatitis

Infantile 2 weeks to 8 months Convex areas, Sharply marginated Scalp and truncalpsoriasis (usually 2 months) but may be flexures red scaly plaques lesions

Contact Any age Any area; initially Erythema and vesicles Other sites in contactdermatitis area of contact with irritant may be(irritant) with irritant involved; distinguish from

atopic eczema

Source: Adapted from reference 4.

CAN. FAM. PHYSICIAN Vol. 36: SEPTEMBER 1990 1571

N izoral*(ketoconazole 2%) shampoo

TOPICAL ANTIFUNGAL AGENTACTIONSIn vitro studies suggest that the antifungal properties of NIZORAL(ketoconazole) may be related to its ability to impair the synthesisof ergosterol, a component of fungal and yeast cell membranes.Without the availability of this essential sterol, there are morpho-logical alterations of the fungal and yeast cell membranes manifestedas abnormal membranous inclusions between the cell wall and theplasma membrane. The inhibition of ergosterol synthesis has beenattributed to interference with the reactions involved in the removalof the 14-o-methyl group of the precursor of ergosterol, lanosterol.Except for its specific pharmacologic effect, i.e., a sporocidal or fungi-cidal activity, ketoconazole when formulated in a 2% shampoo isnot expected to exert any other pharmacodynamic effect whenapplied topically on the skin or hair.INDICATIONSNIZORAL (ketoconazole) 2% shampoo is indicated for the topicaltreatment and prophylaxis of pityriasis capitis infections (dandruff)in which the yeast Pityrosporum is involved.CONTRAINDICATIONSNIZORAL (ketoconazole) 2% shampoo is contraindicated in personswho have shown hypersensitivity to the active or excipient ingre-dients of this formulation.WARNINGSIrritation may occur when NIZORAL shampoo is used immediatelyafter prolonged treatment with topical corticosteroids. Therefore,it is recommended to wait for about 2 weeks after treatment withtopical corticosteroids before using NIZORAL shampoo.PRECAUTIONSIf a reaction suggesting sensitivity or chemical irritation should occur,use of NIZORAL shampoo should be discontinued.NIZORAL shampoo does not produce detectable blood levels aftertopical application. However due to the teratogenic nature of theactive ingredient, ketoconazole, the use of NIZORAL shampoo isnot recommended in pregnant or nursing women.ADVERSE REACTIONSNIZORAL (ketoconazole) 2% shampoo causes minimal skin andscalp irritation. During clinical trials, 11 (2.1 %) of 532 patients treatedwith active shampoo reported side effects: Dry, brittle hair (4), greasyhair (2), hair loss (1), irritation (1), exfoliative dermatitis (1), tinypustules on scalp (1) and dryness and itching of forehead andcheeks (1).SYMPTOMS AND TREATMENT OF OVERDOSAGEOral ingestion is usually followed by nausea and vomiting due tothe detergent. In the event of accidental overdosage, induce vomitingor consider gastric lavage with sodium bicarbonate, with generalsupportive measures as required. It has been reported that keto-conazole cannot be removed by hemodialysis.DOSAGE AND ADMINISTRATIONNIZORAL shampoo should be applied to the wet scalp, worked intoa lather and left on for 3-5 minutes before rinsing with water. Aswith other shampoos, care should be taken to keep the shampooout of the eyes and off the eyelids.Treatment: Twice weekly for 4 weeks.Prophylaxis: Once every one or two weeks.DOSAGE FORMAvailability: NIZORAL (ketoconazole) 2% shampoo is supplied inHDPE flasks with 100 mL shampoo containing 20 mg ketoconazoleper gram.Storage: NIZORAL 2% shampoo should be stored at room tem-perature.Product Monograph available on request.

REFERENCES: 1. Degreef H, Rosenberg EW.: Seborrhoeic dermatitisand dandruff: a place for antifungals. Proceedings of a satellite sym-posium to the Second International Skin Therapy Symposium,Antwerp, Belgium, May 5, 1988. Data on file at JanssenPharmaceutica Inc. 2. Degreef H, Jacobs PH, Rosenberg EW, et al(eds).: Ketoconazole in seborrhoeic dermatitis and dandruff. AReview. Data on file at Janssen Pharmaceutica Inc. 3. Green CA etal.: Treatment of seborrhoeic dermatitis with ketoconazole: II.Response of seborrhoeic dermatitis of the face, scalp and trunk totopical ketoconazole. Br J Dermatol 1987; 116:217-221.4. Faergemann J.: Activity of triazole derivatives againstPityrosporum orbiculare in vitroand in vivo. Annals of the New YorkAcademy of Sciences 1988; 544:348-353. 5. Smith EB.:Ketoconazole Shampoo, Seminars in Dermatology1987; 6(1):66-67.6 Thulliez M.: In: "Janssen in touch with the skin." Abstract ofSatellite Symposium to the 17th World Congress of Dermatology,Berlin, 1987, 47. 7. Tanew A.: A randomized study with ketoconazoleshampoo 2% or Selsun (selenium sulphide 2.5%) in the treatmentof seborrhoeic dermatitis and/or dandruff. Clinical Research ReportR41 400/172, November 1987. Data on file at Janssen Pharma-ceutica Inc. 8. Schrooten P, De Doncker P.: 2% ketoconazoleshampoo in seborrhoeic dermatitis and dandruff, Abstract of theInternational Society for Human and Animal Mycology, Barcelona;In: Revista Iberica de Micologia 1988; 5(1):62. 9. Shuster S,Blatchford, N.: Seborrhoeic dermatitis and dandruff: Afungal disease.A Symposium, Royal Society of Medicine, London, December1987.Data on file at Janssen Pharmaceutica Inc. 10. Jacobs PH.:Seborrhoeic Dermatitis: Causes and Management. CUTIS March1988; 41 :182-186. 11. Nizoral shampoo product monograph.

ESJANSSEN 19EMBERl

Mississauga, Ont. *Trademark ©JANSSEN 1990

and diapering practices are particularlyimportant to evaluate.

Hygienic ProceduresIt is important that the diapers be

changed frequently and as soon as possi-ble after the passage of stool. The skinshould be gently but thoroughlycleansed with warm water after each di-aper change and then gently patted drywith a soft, smooth, cotton cloth. Keep-ing the diaper area clean, dry, and ex-posed to air promotes resolution of theinflammation. It is advisable that the in-fant be left without a diaper for 0.5 toone hour several times a day, as thispractice promotes rapid healing. If thedermatitis is extensive and severe,sitz-baths may provide soothing com-fort while cleansing the skin. Alterna-tively, Burow's solution (1:20 alumini-um acetate) on a clean cloth or gauzemay be applied four times a day for 15 to20 minutes before changing the diaper.5

Diapering PracticesThe use of disposable diapers con-

taining AGM has been reported to be as-sociated with a lower incidence and se-verity of diaper dermatitis.6 If cloth dia-pers are used, parents should be advisedto thoroughly clean and rinse them in or-der to remove laundry residues, whichmay act as irritants, particularly to al-ready compromised skin.Topical TherapyCreams and ointments, such as zinc

and castor oil, Zincofax, A & D oint-ment, Lassar's Paste, or soft paraffinointment, may be applied to protect theskin and maintain subsequent controlonce the inflammation has subsided.The skin should be completely dry be-fore ointments are applied.

Nonfluorinated low-potency topicalsteroids (e.g., hydrocortisone) may beused to control inflammatory changesunresponsive to the above measures orto control secondary eczematization.Careful control of steroid use is re-quired, as continued use may increasethe incidence of candidiasis in additionto causing skin atrophy, muscle wasting,and systemic effects. The use of fluori-nated steroids is more likely to result inthese problems and may also be asso-ciated with the development of gran-uloma gluteale infantum.

AntibioticsTopical or systemic antibiotics may

be indicated in severe cases where sec-ondary bacterial infection can be dem-onstrated. A swab for culture and sensi-

tivity should be taken before commenc-ing antibiotic therapy. It is important toremember that oral antibiotic therapyhas been associated with an increasedrecovery of C. albicans from the rectumand skin, and antibiotic therapy can,therefore, increase the risk of candidia-sis in these patients.

If candidiasis (primary or secondary)is suspected, nystatin suspension orally,in addition to a topical antifungal prepa-ration, is indicated for two to three weeksto reduce gut carriage of C. albicans.

ConclusionDiaper dermatitis can be frustrating

for parents and physicians from whomparents seek advice. Most often, how-ever, it will respond to simple measuresif detailed instructions are given and arecarefully followed. For those patientswith severe dermatitis, regular followup with encouragement, reinforcement,and adjustment of therapy as indicatedis important. Cases resistant to therapy,or those with atypical features, warrantreferral in order to exclude rare, but po-tentially serious, disorders. a

AcknowledgementsI thank Dr. R.I. Kellen and Dr. R.

Spooner for manuscript advice and Ms.W. Erickson for secretarial assistance.

References1. Jordan WE, Lawson KD, Berg RW, Franx-man JJ, Marrer AM. Diaper dermatitis: fre-quency & severity among a general infant pop-ulation. Pediatr Dermatol 1986;3(3):198-207.

2. Honig RJ, Gribetz B, Leyden JJ, McGinleyKJ, Burke LA. Amoxicillin and diaper derma-titis. JAMAcadDermatol 1988; 19(2):275-9.

3. Cambell RL, Seymour JL, Stone LC, Milli-gan, LC. Clinical studies with disposable dia-pers containing absorbent gelling materials:evaluation of effects on infant skin condition. JAm Acad Dermatol 1987; 17(6):978-87.

4. Rook AW, Wilkinson DS, Ebling FJG.Textbook of dermatology. 3rd ed. Oxford:Blackwell Scientific Publications, 1979:202.

5. Gaunder BN, Plummer E. Diaper rash:managing and controlling a common problemin infants and toddlers. J Pediatr Health Care1987; 1(1):26-34.

6. Austin AP, Milligan MC, Pennington K,Tweito DH. A survey of factors associatedwith diaper dermatitis in thirty-six pediatricpractices. J Pediatr Health Care 1988;2(6):295-9.

CAN. FAM. PHYSICIAN Vol. 36: SEPTEMBER 1990