Irritant contact diaper dermatitis
Recommendations for clinical scenarios
Irritant contact diaper dermatitis is an acute inflammatory skin
reaction from repetitive contact with urine and feces enzymes.
It can be characterized by erythema, maceration, erosions, and/or
a candidal (monilial) rash throughout the perianal, perineal and
genital areas. The epidermal layer may or may not be intact. The
more severe forms include bright red, confluent plaques or ulcerations
involving the suprapubic, intertriginous and buttock area. It
is at this phase that nerve endings are exposed and pain is experienced.
The clinical features of a candidal rash are erythema with “satellite”
papules and pustules often associated with pruritis.
Frequent diaper changes, use of superabsorbent disposable diapers
(which contain gelling material), proper cleansing of the skin
and application of topically applied barrier creams or ointments
promote healing of compromised skin. Low potency topical corticosteroids,
such as hydrocortisone cream, are generally safe in children when
used in moderation, and are commonly recommended in the treatment
of moderate to severe diaper dermatitis. I discourage the use
of combination agents containing mid- to high-potency corticosteroids
like clotrimazole and betamethasone dipropionate. The absorption
of corticosteroids is significantly increased in the areas of
thin skin, and potential for atrophy and adrenal suppression must
be considered. The practice of leaving the diaper area open to
air or blowing air onto the skin is not supported in research.
In addition, the use of heat lamps and blow dryers is strongly
discouraged due to the risk of burns to the perineal area.
Prior to instituting any skin care regimen, however, it is important
to determine the appropriate intervention by accurately assessing
the presence of a coexisting candidal rash and whether the epidermis
is intact.
An algorithm I created to standardize the care of patients with
diaper dermatitis utilizes pH-balanced skin cleansers, oatmeal
and/or astringent soaks to promote healing; moisture barrier creams
or ointments to protect the skin; and topical antifungal products
to treat candidal yeast infections, which often are associated
with diaper dermatitis.
This algorithm guides interventions based upon accurate assessment
of skin integrity status. Parents should be advised not to remove
the entire protective barrier with each diaper change. Each time
the skin is cleansed there is an increased likelihood that new
epithelial growth will be disrupted. I advise removing only the
soiled portion of the protective barrier and then reapplying the
barrier layer. Soak or bathe off the entire protective barrier
layer every 12 to 24 hours to assess skin condition.
Five- to 10-minute therapeutic soaks or baths with oatmeal colloidal
soaks such as Aveeno every 12 to 24 hours may be indicated for
relief of irritated, pruritic skin often associated with candidal
yeast rashes. Astringent agents such as Domeboro may be indicated
for relief of inflammatory skin conditions requiring drying out
of denuded, weepy skin.
Dermatitis treatment recommendations based on specific
clinical scenarios
Instruct parents and care providers to be consistent with a skin
care regimen so its effectiveness can be assessed. Moderate to
severe perineal skin breakdown often does not show signs of healing
for several days to a week, particularly if stool frequency persists.
Therefore, changes to a skin care program should not be initiated
until 48 to 72 hours after implementation. The following are four
possible scenarios and their treatment suggestions:
Scenario 1 The epidermal
layer appears intact with the presence of erythema and no coexisting
candidal rash.
Apply a thick layer of zinc oxide-based ointment or cream (e.g.,
Desitin or Toys-R-Us Diaper Rash Cream) to protect skin from contact
with urine and stool. Cover the barrier with a non-talc powder
to decrease the adherence of the ointment into the absorbent gel
layer in disposable diapers. If the barrier does not withstand
the amount or consistency of the stool, or if there is no improvement
in 48 to 72 hours, switch the barrier layer to a thicker product
such as Ilex paste covered with petroleum jelly. If there is no
improvement, or skin integrity worsens, change the barrier layer
again—try Criticaid paste covered with powder. This product
needs to be special-ordered through the manufacturer or pharmacy.
Scenario 2 The epidermal
layer is not intact and no candidal rash is present.
Apply a small amount of powder where the skin is denuded to absorb
moisture and provide a dry base. This will enhance the adherence
of a moisture barrier ointment or cream. Next, apply a thick layer
of moisture barrier cream and cover with powder for the first
48 to 72 hours. If there is no improvement, refer to Regimen 1
for sequence of applying moisture barrier layers.
Scenario 3 The epidermis
is intact and there is a coexisting candidal rash present.
Apply a thin layer of antifungal ointment (not cream, since it
penetrates intact epidermis poorly). Then refer to Regimen 1 for
the sequence of applying moisture barrier.
Scenario 4 The epidermis
is not intact and there is a coexisting candidal rash.
Apply an antifungal powder to open, denuded areas and antifungal
ointment to surrounding intact skin. Then refer to Regimen 1 for
sequence of applying moisture barrier layers.
Evaluation of the skin integrity is critical
in evaluating interventions.
When stool frequency persists for more than 7 to 10 days, consider
a stool screening to rule out pathogenic organisms. If diaper
dermatitis persists in spite of an aggressive skin care regimen,
consider seeing the child in the office and doing a work-up of
other conditions that may result in skin compromise, such as:
• Allergic reaction to diaper product
• Bullous impetigo
• Psoriasis
• Nutritional deficiencies
• Seborrheic dermatitis
• Congenital syphilis
• H.S.V.
• Parasitic infestations
If the above conditions exist, you may want to consider referring
to a dermatologist.
