Diaper dermatitis generally refers to the irritant contact dermatitis
that may result from multiple factors in the area: macerated skin
(softened by being wet), rubbing and wiping, and possibly the presence
of ammonia in urine and proteases and lipases in stool, which cause
skin irritation and breakdown. It can become complicated by secondary
bacterial or yeast infections as well.
The so-called “Greek method” of washing the
soiled diaper area under a running tap of warm water rather than
using abrasive wipes is said to prevent diaper dermatitis.
Synonym Diaper rash, nappy rash.
Age Most babies develop some form
of diaper dermatitis during their diaper wearing years.
Prevalence At any one point in
time, up to one-third of infants may have diaper dermatitis. The
prevalence of severe diaper dermatitis (defined as erythema with
ulcerations, oozing papules, and pustules) is 5%.
Etiology Excessive hydration of
the skin and frictional injury leads to a compromised skin barrier
and irritation from ammonia, feces, cleansing products, fragrances,
and possible superinfection with Candida albicans or bacteria.
Season Reportedly highest during
winter months, perhaps due to less frequent diaper changing.
The warm moist environment inside the diaper and frictional damage
decreases the protective barrier function of the skin in the diaper
area. Then predisposing factors such as seborrhea, atopic dermatitis,
and systemic disease, as well as activating factors such as allergens
(in detergents, rubbers, and plastic), primary irritants (ammonia
from urine and feces), and infection (by yeast or bacteria) lead
to a rash in the diaper area.
Type of Lesion Ranges from macular
erythema (Fig. 3-1) to papules, plaques, vesicles, erosions, and
rarely ulcerated nodules.
Diaper dermatitis Red,
macerated areas in the diaper region of an infant.
Color Ranges from mild erythema
to diffuse beefy redness.
Palpation Ranges from nonindurated
to prominently elevated lesions.
Distribution Diaper area, convex
surfaces involved, folds spared. Severe cases may involve folds
and have characteristic C. albicans satellite pustules.
Diagnosis The diagnosis of diaper
dermatitis may be made clinically, although refractory response
to conventional treatments should raise the suspicion of less common
rashes in the diaper area.
Differential Diagnosis Diaper dermatitis
must be differentiated from psoriasis, granuloma gluteale infantum
(foreign body reaction, typically to baby powder, or topical steroids),
primary candidiasis (perianal or intertriginous involvement with
satellite lesions), seborrheic dermatitis, acrodermatitis enteropathica
(AE; caused by zinc deficiency), and histiocytosis X.