Diaper Dermatitis

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Diaper dermatitis is caused by overhydration of the skin, maceration, prolonged contact with urine and feces, retained diaper soaps, and topical preparations and is a prototypical example of irritant contact dermatitis. [1] Signs and symptoms are restricted in most individuals to the area covered by diapers. [2, 3]

The photograph below depicts a 3-week-old female neonate with diaper rash.

Diaper rash affects the areas within the confines of the diaper. Increased wetness in the diaper area makes the skin more susceptible to damage by physical, chemical, and enzymatic mechanisms. Wet skin increases the penetration of irritant substances. Superhydration urease enzyme found in the stratum corneum liberates ammonia from cutaneous bacteria. Urease has a mild irritant effect on nonintact skin. Lipases and proteases in feces mix with urine on nonintact skin and cause an alkaline surface pH, adding to the irritation. (Feces in breastfed infants have a lower pH, and breastfed infants are less susceptible to diaper dermatitis.) [4]  The bile salts in the stools enhance the activity of fecal enzymes, adding to the effect.

Candida albicans has been identified as another contributing factor to diaper dermatitis; infection often occurs after 48-72 hours of active eruption. It is isolated from the perineal area in as many as 92% of children with diaper dermatitis. Other microbial agents have been isolated less frequently, perhaps more as a result of secondary infections.

The following causes have been noted:

Overhydration of the skin [5]

Maceration

Prolonged contact with urine and feces

Retained diaper soaps

Topical preparations

More than 3 diarrheal stools per day

Adverse effects of oral antibiotics

Early sign of biotin deficiency [6]

No racial difference is observed.

No sexual difference is noted.

Diaper dermatitis commonly affects infants, with peak incidence occurring when the individual is aged 9-12 months. One study determined that at any given time, diaper dermatitis is prevalent in 7-35% of the infant population. [7]

Diaper dermatitis can affect persons of any age who wear diapers, in particular, elderly people.

If treated using the ABCDE acronym (air, barrier, cleansing, diaper, and education), the prognosis is excellent for most patients with diaper dermatitis.

With the exception of an individual who is immunocompromised, no mortality is associated with diaper rash when correctly diagnosed. However, a rash incorrectly diagnosed as diaper dermatitis certainly may lead to significant morbidity and mortality if associated with a serious illness.

Morbidity associated with diaper dermatitis is discomfort and the possibility of secondary bacterial or candidal infection, which may be more severe in an individual who is immunocompromised.

Providing education to the parents and/or caregivers of the patient is important in the treatment and further prevention of diaper dermatitis. [8]  Note the following:

Keep the skin clean and dry.

Provide diaper education. Frequently change diapers. Use disposable diapers with superabsorbent material. When compared with cloth diapers, disposable diapers provide a lower prevalence and severity of diaper dermatitis.

Wash genitalia with warm water and mild soap.

Frequently apply a bland protective topical agent after thorough washing.

For patient education resources, see the Skin, Hair, and Nails Center and Children’s Health Center. Also, see the patient education articles Diaper Rash, Contact Dermatitis, and Skin Rashes in Children.

Ersoy-Evans S, Akıncı H, Doğan S, Atakan N. Diaper Dermatitis: A Review of 63 Children. Pediatr Dermatol. 2016 May. 33 (3):332-6. [Medline].

Runeman B. Skin interaction with absorbent hygiene products. Clin Dermatol. 2008 Jan-Feb. 26(1):45-51. [Medline].

Ravanfar P, Wallace JS, Pace NC. Diaper dermatitis: a review and update. Curr Opin Pediatr. 2012 Aug. 24(4):472-9. [Medline].

Ersoy-Evans S, Akıncı H, Doğan S, Atakan N. Diaper Dermatitis: A Review of 63 Children. Pediatr Dermatol. 2016 May. 33 (3):332-6. [Medline].

Berg RW, Milligan MC, Sarbaugh FC. Association of skin wetness and pH with diaper dermatitis. Pediatr Dermatol. 1994 Mar. 11(1):18-20. [Medline].

Higuchi R, Mizukoshi M, Koyama H, et al. Intractable diaper dermatitis as an early sign of biotin deficiency. Acta Paediatr. 1998 Feb. 87(2):228-9. [Medline].

Jordan WE, Lawson KD, Berg RW, et al. Diaper dermatitis: frequency and severity among a general infant population. Pediatr Dermatol. 1986 Jun. 3(3):198-207. [Medline].

Adam R. Skin care of the diaper area. Pediatr Dermatol. 2008 Jul-Aug. 25(4):427-33. [Medline].

Collipp PJ, Kuo B, Castro-Magana M, et al. Hair zinc, scalp hair quantity, and diaper rash in normal infants. Cutis. 1985 Jan. 35(1):66-70. [Medline].

Benedix F, Hermann U, Brod C, et al. [Transient zinc deficiency in preterm infants]. Hautarzt. 2008 Jul. 59(7):563-6. [Medline].

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. [Medline].

Ramos Pinheiro R, Matos-Pires E, Baptista J, Lencastre A. Granuloma Glutaeale Infantum: A Re-emerging Complication of Diaper Dermatitis. Pediatrics. 2018 Feb. 141 (2):[Medline].

Fölster-Holst R. Differential diagnoses of diaper dermatitis. Pediatr Dermatol. 2018 Mar. 35 Suppl 1:s10-s18. [Medline].

Castilho S, Ferreira S, Fortunato F, Santos S. Intertrigo of streptococcal aetiology: a different kind of diaper dermatitis. BMJ Case Rep. 2018 Mar 20. 2018:[Medline].

Stamatas GN, Tierney NK. Diaper dermatitis: etiology, manifestations, prevention, and management. Pediatr Dermatol. 2014 Jan-Feb. 31(1):1-7. [Medline].

Patrizi A, Neri I, Ricci G, Cipriani F, Ravaioli GM. Advances in pharmacotherapeutic management of common skin diseases in neonates and infants. Expert Opin Pharmacother. 2017 May. 18 (7):717-725. [Medline].

Chiriac A, Birsan C, Podoleanu C, Chiriac AE, Stolnicu S. Pragmatic management of (suspected allergic) diaper dermatitis. Contact Dermatitis. 2017 Feb. 76 (2):129-130. [Medline].

Blume-Peytavi U, Kanti V. Prevention and treatment of diaper dermatitis. Pediatr Dermatol. 2018 Mar. 35 Suppl 1:s19-s23. [Medline].

Xhauflaire-Uhoda E, Henry F, Pierard-Franchimont C, Pierard GE. Electrometric assessment of the effect of a zinc oxide paste in diaper dermatitis. Int J Cosmet Sci. 2009 Oct. 31(5):369-74. [Medline].

Manzoni P, Gomirato G. [Effectiveness of topical acetate tocopherol for the prevention and treatment of skin lesions in newborns: a 5 years experience in a 3rd level Italian Neonatal Intensive Care Unit]. Minerva Pediatr. 2005 Oct. 57(5):305-11. [Medline].

Nourbakhsh SM, Rouhi-Boroujeni H, Kheiri M, Mobasheri M, Shirani M, Ahrani S, et al. Effect of Topical Application of the Cream Containing Magnesium 2% on Treatment of Diaper Dermatitis and Diaper Rash in Children A Clinical Trial Study. J Clin Diagn Res. 2016 Jan. 10 (1):WC04-6. [Medline].

Mahmoudi M, Adib-Hajbaghery M, Mashaiekhi M. Comparing the effects of Bentonite & Calendula on the improvement of infantile diaper dermatitis: A randomized controlled trial. Indian J Med Res. 2015 Dec. 142 (6):742-6. [Medline].

Blanco D, van Rossem K. A Prospective Two-Year Assessment of Miconazole Resistance in Candida Spp. with Repeated Treatment with 0.25% Miconazole Nitrate Ointment in Neonates and Infants with Moderate to Severe Diaper Dermatitis Complicated by Cutaneous Candidiasis. Pediatr Dermatol. 2013 May 16. [Medline].

Farahani LA, Ghobadzadeh M, Yousefi P. Comparison of the Effect of Human Milk and Topical Hydrocortisone 1% on Diaper Dermatitis. Pediatr Dermatol. 2013 Apr 22. [Medline].

Martin E. Weisse Stephen C. Aronoff. Candida. Kliegman. Nelson Textbook of Pediatrics. 18th ed. Saunders; 2007. 231.

Ruchir Agrawal, MD Chief, Allergy and Immunology, Aurora Sheboygan Clinic

Ruchir Agrawal, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, American Medical Association, American Academy of Pediatrics

Disclosure: Nothing to disclose.

Vijay Sammeta, MD Medical Information Services, Adventis Pharmaceutical

Disclosure: Nothing to disclose.

Isabelle Thomas, MD Associate Professor, Department of Dermatology, University of Medicine and Dentistry of New Jersey, New Jersey Medical School; Chief of Dermatology Service, Veterans Affairs Medical Center of East Orange

Isabelle Thomas, MD is a member of the following medical societies: American Academy of Dermatology, Sigma Xi

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Kevin P Connelly, DO Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University School of Medicine; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center

Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, American Osteopathic Association

Disclosure: Nothing to disclose.

Diaper Dermatitis

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