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.
Candida diaper dermatitis in an infant who has oral thrush. (Used with permission from Richard P. Usatine, MD.)
Diaper rash is a general term used to describe any type of red or inflammatory skin rash that is located in the diaper area.
Diaper dermatitis, napkin dermatitis.
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).
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.)
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.)
Etiology and Pathophysiology
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 lipases.
Maceration of the stratum corneum with loss of the protective barrier function of skin.
Irritant diaper dermatitis (IDD) is a combination of intertrigo (wet skin damaged from chafing) and miliaria (heat rash) when eccrine glands become obstructed from excessive hydration. It is a noninfectious, nonallergic, often asymptomatic contact dermatitis that typically lasts for less than 3 days after a change in diaper practices.
Candidal diaper dermatitis—Within 3 days, 45 to 75 percent of diaper rashes are colonized with Candida albicans of fecal origin.
Bacterial diaper dermatitis may be a secondary infection caused by Staphylococcus aureus or Streptococcus pyogenes. Other common bacterial isolates include Escherichia coli, Peptostreptococcus, and Bacteroides. Usually occurs during the warm summer months.
Perianal streptococcal dermatitis is caused by group A β-hemolytic streptococci (Figures 95-2 and 95-3).
IDD begins with shiny erythema with or without scale and poorly demarcated margins on the convex skin surfaces in areas covered by diapers. Moderate cases can have papules, plaques, vesicles, and small superficial erosions that can progress to well-demarcated ulcerated nodules typically with sparing of skin folds (Figure 95-4).
Pustules or papules beyond the rash border (called “satellite lesions”), involvement of the skin folds, and white scaling all indicate a fungal infection with Candida (Figure 95-5).
Secondary bacterial infections can have redness, honey-colored crusting, swelling, red streaking, and/or purulent discharge. With impetigo in the diaper area, bullae are not usually intact but instead present as superficial erosions.
Perianal streptococcal dermatitis is a bright red, sharply demarcated rash sometimes associated with blood-streaked stools (Figure 95-2).
Irritant diaper dermatitis precipitated by diarrhea secondary to amoxicillin-clavulanate prescribed to treat otitis media. Note the absence of satellite lesions and how it spares the deep folds. (Used with permission from Richard P. Usatine, MD.)
Close-up of a Candida diaper dermatitis in a 5-month-old infant. Note the superficial scaling around the satellite lesions. (Used with permission from Richard P. Usatine, MD.)
Diaper dermatitis is primarily found on the buttocks, the genitalia, the mons pubis and lower abdomen, and the medial thighs. Be sure to evaluate for rashes outside of the diaper area as well. If Candida is suspected, the oropharynx should be inspected for signs of thrush, such as adherent white plaques on the mucosa. If seborrheic dermatitis is suspected, look at the scalp and face.
Clinical diagnosis is based primarily on the physical examination. Rarely indicated tests that are occasionally used in more complicated cases include potassium hydroxide preparation for fungal elements, mineral oil preparation for scabies, complete blood count with differential, zinc level, or skin biopsy (Figure 95-6). A rapid strep test can be used to diagnose perianal streptococcal dermatitis (Figures 95-2 and 95-3).
Acrodermatitis enteropathica caused by zinc deficiency. The child also had perioral dermatitis that appeared similar to the diaper dermatitis. (Used with permission from Richard P. Usatine, MD.)
There are three distinctive severe variants of irritant diaper dermatitis:
Erosive diaper dermatitis (dermatitis of Jacquet) is a severe, slow-healing diaper dermatitis in children with persistent diarrhea.4 The erosions that can lead to nodular lesions with heaped-up borders (Figures 95-7 and 95-8).
Granuloma gluteale infantum is a rare primary diaper dermatitis that presents with granulomatous nodules that can be large and raised with rolled margins (Figure 95-9). Contributing factors are inflammation, candida superinfection and high potency topical steroids. This can resolve over the course of a few months with good diaper care and removal of offending agents. It may leave residual scarring and hyperpigmentation.5
Pseudoverrucous papules and nodules are shiny, smooth, red, moist, flat-topped perianal lesions that occur with chronic diarrhea. They are commonly confused with the genital warts and can occur with Hirschsprung disease (Figure 95-10).
Erosive diaper dermatitis of Jacquet in an infant with prolonged diarrhea. Note the red erosions and the elevated nodules. (Used with permission from Richard P. Usatine, MD.)
Erosive diaper dermatitis of Jacquet with bright red erythema, punched-out ulcers and elevated nodules with rolled borders. (Used with permission from Weinberg SW, Prose NS, Kristal L, Color Atlas of Pediatric Dermatology, 4th edition, Figure 8-42, New York, NY: McGraw-Hill, 2008.)
Granuloma gluteal infantum with two large nodules in the diaper area. While these nodules are brown they can also have a red or purplish hue. In this case, topical steroids were one factor in this nodular granulomatous response. (Used with permission Kane KS, Lio P, Stratigos AJ, Johnson RA. Color Atlas and Synopsis of Pediatric Dermatology, 2nd edition, Figure 3-5, McGraw-Hill, 2009.)
Pseudoverrucous papules and nodules. The flat-topped or round lesions are shiny, erythematous and moist. This unique diaper dermatitis was originally described in the skin surrounding urostomies, but can occur as a result of chronic diarrhea (sometimes from Hirschsprung’s disease), encopresis or urinary incontinence. (Used with permission from Weinberg SW, Prose NS, Kristal L, Color Atlas of Pediatric Dermatology, 4th edition, Figure 8-45, New York, NY: McGraw-Hill, 2008.)
Secondary diaper dermatitis is an eruption in the diaper area with a defined etiology. Atopic dermatitis, seborrheic dermatitis, and psoriasis are examples of rashes that can appear anywhere on the body and can be exaggerated in the groin as a result of wearing diapers (Figure 95-11). Family history of atopy or psoriasis and rash in other locations besides the groin can be helpful. Look on the scalp for seborrheic dermatitis (cradle-cap) (see Chapter 135, Seborrheic dermatitis).
Severe seborrheic dermatitis in a 1-year-old boy. Note that this condition is not just confined to the diaper area. The whitish-yellow scale is characteristic of seborrhea and the child had involvement on the cheeks and “cradle cap” in the scalp. No satellite pustules of candidiasis are noted. This is not irritant dermatitis as it does not spare the deep folds and the distribution strongly suggests seborrheic dermatitis not candida diaper dermatitis, which would be restricted largely to diaper area or other skin folds. (Image used with permission from Robert Brodell, MD.)
Congenital syphilis, scabies, HIV, Langerhans cell histiocytosis (Figure 95-12), and acrodermatitis enteropathica (Figure 95-6) are examples of rashes in the diaper area unrelated to the diaper. Allergic contact dermatitis as a result of an allergen in the diaper itself is possible but rare. Suspect acrodermatitis enteropathica caused by zinc deficiency when the diaper dermatitis is severe and accompanied by perioral dermatitis (Figure 95-6). The serum zinc level will be low and zinc supplementation will be needed.
Langerhans cell histiocytosis in the diaper area. This presented as a refractory diaper rash with scattered erythematous papules and a petechial component. Note the petechiae are particularly prominent on the lower abdomen and the eruption is not only confined to the diaper area. A skin biopsy revealed Langerhans’ cells to confirm the diagnosis. (Used with permission Kane KS, Lio P, Stratigos AJ, Johnson RA. Color Atlas and Synopsis of Pediatric Dermatology, 2nd edition, Figure 3-6, McGraw-Hill, 2009.)
Intertrigo is an inflammatory condition that occurs in intertriginous areas such as in the inguinal folds (Figure 95-13). Other areas involved may be under the neck, in the axillae, or in the gluteal cleft. The term is nonspecific as to the etiology and one should always look for causes such as candida, seborrhea, and psoriasis.
Intertrigo with bright red erythema in the inguinal folds. One should always look for the contributing factors in any case of intertrigo. Three etiologies to consider are: (1) Irritant dermatitis: This is NOT the classic appearance of an irritant from urine and feces that effects outer skin and spares the deep fold. (2) Candida: Note the papules and papulovesicles on the left abdomen and a few on the thighs (satellite papules and papulovesicles) (3) Seborrheic dermatitis: Look on the scalp and face as this could be a principle cause of this rash. (Image used with permission from Robert Brodell, MD.)
Parental behavior change to keep the skin as exposed and dry as possible. SOR B Frequent diaper changes (as soon as they are wet or soiled and at least every 3 to 4 hours); use disposable diapers. SOR B Frequent gentle cleaning of the affected area with lukewarm tap water instead of commercial wipes containing alcohol and pat dry. A squeeze bottle with lukewarm water can be used to avoid rubbing the delicate skin.
Superabsorbent diapers that pull moisture away from the skin are helpful.1 SOR B
Apply barrier preparations, including zinc oxide paste, petroleum jelly, Vitamin A & D ointment, or Burow solution to affected area after each diaper change.1 SOR B Pastes are better than ointments, which, in turn, are better than creams or lotions. Avoid products with fragrances or preservatives to minimize allergic potential. Apply thickly like “icing on a cake.” These barrier preparations should be used on top of other indicated therapies.
For moderate to severe inflammation, consider a nonfluorinated, low-potency topical steroid such as 1 percent hydrocortisone ointment (up to 3 times daily) to the affected area until the dermatitis is gone. To avoid skin erosions, atrophy, and striae, it is best to not go beyond 2 weeks of therapy with any topical steroid on a baby’s bottom.
For Candida, use topical nonprescription antifungal creams such as clotrimazole, miconazole after every diaper change until the rash resolves. SOR B For concomitant oral thrush, treat with oral nystatin swish and swallow 4 times daily.
Avoid combination antifungal–steroid agents that contain steroids stronger than hydrocortisone (e.g., Lotrisone). Potent topical steroids can cause striae and skin erosions, hypothalamus–pituitary–adrenal axis suppression, and Cushing syndrome.1
For mild bacterial infections, use topical antibiotic ointments such as bacitracin or mupirocin after every diaper change until the rash resolves. SOR B
For more severe bacterial infections, consider a broad-spectrum oral antibiotic such as amoxicillin-clavulanate. Perianal bacterial dermatitis has been reported to be predominantly caused by S. aureus.6 Oral cephalexin is a good choice because it covers S. aureus and group A β-hemolytic streptococcus. If methicillin-resistant S. aureus (MRSA) is suspected, consider trimethoprim-sulfamethoxazole. SOR B
Ciclopirox 0.77 percent topical suspension (Loprox), a broad-spectrum agent with antifungal, antibacterial, and antiinflammatory properties, was used safely and effectively in 1 trial of 44 children to treat diaper dermatitis caused by Candida.1 SOR B
Recommend dye-free diapers for allergic contact dermatitis. SOR B
Prevention and Routine Skin Care
Keep the diaper region as dry and clean as possible.
Promote the use of barrier preparations daily to maintain skin integrity.
There is no evidence to suggest that topical vitamin A prevents diaper dermatitis.7 SOR B
Disposable diapers—Although many individual trials show benefits, a 2006 Cochrane Review found that there is not enough evidence from good quality, randomized, controlled trials to support or refute the use and type of disposable diapers for the prevention of diaper dermatitis in infants.8 SOR B
Diaper dermatitis has an excellent prognosis when treated as previously described.
No follow-up needed unless the rash worsens or persists. The exception is severe bacterial infection where follow-up is recommended because recurrences are common.
Prevention and early treatment are the best strategies. Keep the child’s diaper area as clean, cool, and dry as possible with frequent diaper changes. Do not use creams that contain boric acid, camphor, phenol, methyl salicylate, compound of benzoin, or talcum powder or cornstarch. Reassure parents that, although this common condition is sometimes distressing for parents and uncomfortable for children, it is rarely dangerous.
H. Diaper dermatitis-frequency and contributory factors in hospital attending children. Pediatr Dermatol. 2007:24(5):483–488.
R. Skin care of the diaper area. Pediatr Dermatol. 2008:25(4):427–433.
et al.. Jacquet erosive diaper dermatitis: a therapeutic challenge. Clin Exp Dermatol. 2009:34(7):e385–e386.
S. A forgotten complication of diaper dermatitis: granuloma Gluteale Infantum. J Family Community Med. 2010;17(2):107–109.
N. Recent microbiological shifts in perianal bacterial dermatitis: Staphylococcus aureus predominance. Pediatr Dermatol. 2009:26(6):696–700.
KL. Topical vitamin A, or its derivatives, for treating and preventing napkin dermatitis in infants. Cochrane Database Syst Rev. 2005 Oct 19;(4):
KJ. Disposable nappies for preventing napkin dermatitis in infants. Cochrane Database Syst Rev. 2006 Jul 19;(3):