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Patient Story
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A 2-month-old baby girl was brought to the office with a severe diaper rash that was not getting better with Desitin. Upon examination, the physician noted a white coating on the tongue and buccal mucosa. The diaper area was red with skin erosions and satellite lesions (Figure 95-1). The whole picture is consistent with candidiasis of the mouth (thrush) and the diaper region. The child was treated with oral nystatin suspension and topical clotrimazole cream in the diaper area with good results.

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FIGURE 95-1

Candida diaper dermatitis in an infant who has oral thrush. (Used with permission from Richard P. Usatine, MD.)

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Introduction
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Diaper rash is a general term used to describe any type of red or inflammatory skin rash that is located in the diaper area.

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Synonyms
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Diaper dermatitis, napkin dermatitis.

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Epidemiology
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  • Diaper dermatitis is the most common dermatitis of infancy.

  • Variability in prevalence of 4 to 35 percent among children in their first 2 years of life in different studies.1

  • Diaper rash is thought to be present in 25 percent of children presenting for outpatient visits.2

  • No differences in prevalence between genders or among ethnic groups.

  • One study showed an incidence of 19.4 percent in children ages 3 to 6 months.1

  • Higher incidence among formula-fed compared with breastfed infants.1

  • Condition typically begins around age 3 weeks, peaks at age 9 to 12 months, and then decreases with age until it resolves completely with toilet training.

  • Individual episodes last from 1 day to 2 weeks.

  • Aggravating factors include poor skin care, diarrhea, recent antibiotic use, and urinary tract abnormalities.

  • Perianal streptococcal dermatitis occurs in children between 6 months and 10 years of age (Figures 95-2 and 95-3).

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FIGURE 95-2

Perianal dermatitis caused by group A β-hemolytic streptococci. (From Sheth S, Schechtman AD. Itchy perianal erythema. J Fam Pract. 2007;56(12):1025-1027. Reproduced with permission from Frontline Medical Communications.)

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FIGURE 95-3

A positive rapid strep test taken from a swab of the perianal area of the infant in the previous photo. (From Sheth S, Schechtman AD. Itchy perianal erythema. J Fam Pract. 2007;56(12):1025-1027. Reproduced with permission from Frontline Medical Communications.)

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Etiology and Pathophysiology
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  • Primary diaper dermatitis—An acute skin inflammation in the diaper area with a multifactorial etiology.3 The main cause is irritation of thin skin as a result of prolonged contact with moisture including feces and urine. The multiple factors involved are:

    • Occlusion/lack of exposure to air.

    • Friction and mechanical trauma.

    • Local irritants—Fecal proteases and ...

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