Diaper dermatitis is a non-specific term. It includes inflammatory skin eruptions that develop in the area covered by the diaper. Irritant contact diaper dermatitis is by far the most common form of diaper dermatitis. It occurs so frequently that it is used synonymously with diaper dermatitis. Therefore, speaking of diaper dermatitis here, I refer to irritant contact diaper dermatitis.
Irritant contact diaper dermatitis results from disruption of the stratum corneum and subsequent inflammation. Certain factors contribute to the disruption of the skin barrier function during diaper dermatitis. These factors include friction, moisture, increased pH, and enzymatic activity of stool and urine. The acidic pH of the stratum corneum is important to sustain the permeability barrier and the antimicrobial defense of the skin.
During irritant contact diaper dermatitis, the pH level beneath the diaper increases. This increase is observed due to the interaction of urease, an enzyme produced by fecal bacteria, with urine. Elevated pH prompts the activation of fecal protease and lipase. These enzymes directly damage the skin, resulting in an inflammatory skin reaction. The increase in pH levels also alters the cutaneous microbiome, which makes the skin more susceptible to colonization by certain organisms (eg, Staphylococcus aureus, Streptococcus pyogenes, Candida albicans).
A number of factors increase the risk of diaper dermatitis:
- Infrequent diaper changing.
- Continuous skin irritation due to diarrhea or chronic stooling.
- Use of broad-spectrum antibiotics
The severity of irritant diaper dermatitis may range from mild erythema with minimal maceration and frictional irritation to severe inflammation with glossy-appearing extensive erythema with painful papules, nodules, and erosions.
Diaper dermatitis is typically episodic. Conventionally treated episodes of mild to moderate diaper dermatitis usually last two to three days. Persistence of the rash for more than three days despite the treatment should arouse suspicion of secondary infection with C. albicans.
Cases left untreated for more than three days may become secondarily infected with C. albicans or, less frequently, S. aureus, S. pyogenes, or herpes simplex virus.
The best diagnostic criterion is the location of the rash, which appears on the convex areas and spares skin folds. Involvement of the folds and appearance of tiny papules and pustules on the lesion’s periphery. It is characteristic of candida superinfection.
The most important aspect is the prevention of irritant contact dermatitis through parent/caregiver education.
Prevention measures include:
- Frequent diaper change
- Cleansing the diaper area with a non-detergent cleanser and running water
- Application of barrier preparations (e.g. zinc oxide, petrolatum, lanolin)
Treatment of mild to moderate irritant contact diaper dermatitis:
- Prevention measures should be reinforced
- Elimination of aggravating factors (friction, moisture)
- Topical barrier preparations should be applied with every diaper change
- Frequent diaper-free time
Treatment of severe irritant contact dermatitis:
- Topical low-potency corticosteroid (e.g., 1% hydrocortisone). Topical corticosteroids are applied twice a day for up to 7 days simultaneously with barrier preparations. Barrier products should be applied last.
- Potent or fluorinated corticosteroids should be avoided in the diaper area because the occlusion promotes systemic absorption and may result in adrenal suppression and iatrogenic Cushing syndrome.
- In case of secondary C. albicans infection, antifungal agents, such as nystatin, clotrimazole, and ketoconazole, are effective topical therapies. They are usually applied twice daily for 2 weeks. Combination creams available on the market usually contain topical corticosteroids that are too potent. This may cause undesirable corticosteroid side effects (skin atrophy and adrenal suppression)
- In case of secondary bacterial infection, topical or systemic antibiotics may be used. Localized, mild staphylococcal infections may be treated with topical mupirocin applied for up to seven days twice daily. Ointments containing neomycin or bacitracin may incite allergic contact dermatitis, hence should be avoided in the diaper area. Streptococcal perianal dermatitis and severe infections are treated orally.
Powders such as talcum pose a significant respiratory risk if aspirated and should be avoided.
To sum up:
- Frequent diaper changing,
- Air exposure
- Gentle skin cleansing
- Topical barrier ointments or creams
- Low-potency nonhalogenated topical corticosteroids such as 1% hydrocortisone (for severely inflamed irritant diaper dermatitis)
Potent or fluorinated corticosteroids
Powders such as talcum
Topical barriers with an irritant or allergic potential (medications that contain fragrance, preservatives, neomycin, bacitracin)
Combination of topical corticosteroids and antifungal creams
- Potent or fluorinated corticosteroids
- Powders such as talcum
- Topical barriers with an irritant or allergic potential (medications that contain fragrance, preservatives, neomycin, bacitracin)
- Combination of topical corticosteroids and antifungal creams
Hope this helps!
Dr. Armine Adilkhanyan, Pediatric Dermatologysts, “ArBeS” Healthcare CenterDermatologistsAdilkhanyan