Diaper Dermatitis: Clinic, diagnosis and treatment

Medical review: Dr. Marina Alexandre, Dermatologist, Avicenne Hospital, France.

Dr. Marina Alexandre

Key messages

Diaper dermatitis in infants presents as acute inflammatory skin lesions.
They are manifested in children from birth to 3 years old by redness, erythematous lesions, sometimes accompanied by vesicles, pustules, fissures, or ulcerations.
They are strongly linked with maceration of the skin in diapers.
There are several clinical forms divided between irritant dermatitis, allergic contact dermatitis, and fold dermatitis.
Their treatment and prevention are based on the infant's hygiene: change of diapers, cleaning and application of a barrier cream are essential steps.

Infant diaper dermatitis presents as acute inflammatory skin lesions that occur on the skin under the baby’s diaper.
It is one of the most common dermatoses in children aged 0 to 3^2,4.
Symptoms of diaper dermatitis in infants usually include redness, erythematous lesions with sharp borders, sometimes with vesicles or pustules, fissures or ulcerations.
These lesions can be very painful and may cause crying and irritability in the infant^2,4.

Good to know:

Treating diaper dermatitis starts with preventative measures, such as:

Changing diapers frequently.
Using suitable diapers.
Using mild soap to wash baby.
Drying the area thoroughly.
Finally, applying a barrier cream.
For more severe lesions, an antifungal cream or other topical ointments may be prescribed by a healthcare professional to relieve inflammation and promote healing^2,4,5.

The physiopathology of this dermatitis is complex, involving factors such as maceration, inflammation, infection and immune response^2,4,5.
The skin in the diaper area is subjected to a moist, macerated environment, which facilitates the growth of microorganisms such as bacteria and fungi.
Urine and feces, which remain in contact with the skin for long periods of time, increase moisture and irritation of the skin.
This maceration and irritation induce an increased production of inflammatory proteins such as cytokines and chemokines.
These pro-inflammatory mediators attract cells such as neutrophils and macrophages to the diaper area, which worsens the inflammation.
Neutrophils produce enzymes that damage skin tissue, while macrophages produce cytokines that worsen the inflammation in a vicious circle^2,4.

Good to know:

Microorganisms in the stool (bacterial and fungal agents) can infect the skin, leading to inflammation and more severe skin damage.
Fungal infections, particularly those caused by Candida albicans, are often implicated in the most severe cases of diaper dermatitis in babies^2,4.

Irritant Dermatitis^2,4

It has become less frequent since the appearance of more absorbent diapers, but it remains the leading cause of diaper rash, and is more frequent in cases involving diarrhoea.
The clinical appearance is suggestive; it affects the areas where diapers rub on the convexities of the diaper area (inner thighs, scrotum, labia majora, lower abdomen), sparing the folds and roughly forming a W shape.
Erythema is sometimes erosive^2,4.

Complications from Irritant Dermatitis

Candidiasis superinfection: the erythema becomes bright red with the presence of micro-pustular satellite lesions.
Staphylococcal bacterial superinfection: presence of pustules on a background of erythema, rapidly breaking leaving raw skin, surrounded by a desquamative collar.
Gluteal granuloma: currently rare, it was related to the application of local corticosteroids on the erythema in a prolonged way, triggering the appearance of confluent papulo-nodules.

Allergic Contact Dermatitis^2,4

The increasingly more elaborate diapers are factors of acute contact eczema, with the appearance of erythematous vesicular placard. It is most commonly seen on:

The lateral sides of the hips and the external parts of the buttocks and thighs related to the adhesives of the diapers. Due to the particular localization of this acute or subacute eczema of the infant or young child, we speak of "Lucky Luke" syndrome (as if the baby was wearing pistol holsters).
The abdomen and the inner sides of the thighs due to the elasticated sides ("rubber dermatitis").

Fold Dermatitis or Intertrigo^2,4

It is a primary involvement of the inguinal folds, crural folds and the intergluteal fold.
Clinically, the Y-shaped appearance is characteristic, associating erythema and maceration.
It is less frequent than the involvement of convexities.
Fold dermatitis is essentially of digestive or urinary origin (Candida, staphylococcus, streptococcus).
It can spread from perianal dermatitis (streptococcal anitis beginning at the anal margin and extending to the buttocks) but can also develop directly in the folds.

Seborrheic Dermatitis³

In infants aged 2 to 3 months old, development of an erythematous-squamous rash with oily scales, beginning in the inguinal and crural folds and extending to the genitals, perineum, hypogastric region and thighs.
Colonization by Malassezia furfur is part of the pathogenesis of seborrheic dermatitis.
In addition, a similar involvement of the scalp (bipolar dermatitis) is often found, which facilitates the diagnosis.

Fig: Seborrheic dermatitis in infants

Diaper Psoriasis¹

The clinical appearance may be identical to seborrheic dermatitis, but most often the rash is bright red, discreetly scaly and, above all, perfectly limited to the region of the seat with clear borders.
Psoriasis is induced and perpetuated by the Köbner phenomenon related to diaper friction.
Progression to psoriasis vulgaris occurs in 20% of cases before the age of 15.

Rare Forms

Acrodermatitis Enteropathica⁶

It is manifested by erosive diaper rash, diarrhoea and hair loss.
Gluteal involvement is accompanied by erythematous, crusty and oozing periorificial patches (nose, mouth).
This is a genetic disorder of zinc absorption.
Breast milk contains a compensating element that binds zinc and facilitates absorption in the newborn.
The onset of acrodermatitis enteropathica will therefore be rapid in premature and non-breastfed newborns and delayed to the weaning period in breastfed infants.

Fig: Acrodermatitis Enteropathica

Langerhans Cell Histiocytosis⁷

It is a severe systemic disease.
It may begin with a diaper rash resembling seborrheic dermatitis, but the haemorrhagic and erosive nature of the condition should quickly become a warning.
It is associated with purpuric, crusty and scaly patches of the scalp.
Damage to the bone marrow, liver, lungs, kidneys and nervous system carries a lethal risk.

Hygiene of the Infant’s Diaper Area^2,4,5

Change after each urination and especially after each bowel movement.
Clean with a mild medical cosmetic product (avoid wipes).
Application of a medical cosmetic barrier cream or oleo-calcareous liniment. Avoid greasy pastes that keep the baby's skin occluded and moist.

In the case of a dermatosis, these treatments are associated with a specific therapy:

Irritant Dermatitis

It is most often related to hygiene errors: insufficient diaper changes and application of unsuitable cosmetics, especially creams and ointments that are too greasy and promote maceration.
Informing parents allows a rapid regression of the symptomatology, often more frequent diapers associated with the cessation of aggravating topicals +/- a drying product is sufficient^2,4,5.

Allergic Contact Dermatitis^2,4

Removal of the offending contact: use of adhesive-free or elastic-free diapers
Local corticosteroid therapy of low or medium activity without fluoride in the evening for 10 days.

Candidiasis Superinfection^2,4

Application of an imidazole or ciclopirox olamine-based cream, morning and evening for 15 days.
Treatment of the digestive tract: orally taken amphotericin B, adapted to the child's weight, for 15 days.

Bacterial Superinfection

Local antibiotic therapy adapted to the germ responsible: fusidic acid cream for staphylococcus and mupirocin for streptococcus and staphylococcus, often combined with general antibiotic therapy for 10 days: penicillin or macrolides (erythromycin)^2,4.

Seborrheic Dermatitis

Topical imidazoles in the form of cream or milk for 15 days, with possible use of brief topical corticosteroid therapy (10 to 15 days), using a non-fluorinated level 2 corticosteroid if imidazoles fail³.

Psoriasis

Brief (10-15 days) local corticosteroid therapy using a low or medium potency non-fluorinated corticosteroid to control the flare¹.

Acrodermatitis Enteropathica

Regular zinc supplementation: zinc gluconate⁶.

Langerhan Histiocytosis

Prompt referral to a specialized facility⁷.

What about products traditionally used locally such as trolamine, fish liver oil + zinc oxide, dexpanthenol?

The best-known product based on trolamine contains many preservatives. Products based on fish liver oil + zinc oxide and those based on dexpanthenol are good repairers but be wary of their lanolin content (risk of sensitization).

Is there a place for dyes such as eosin?

There is no point in using dyes because they are troublesome when evaluating erythema. The drying effect may be interesting, but other non-colored products will have the same effect and are less irritating.

What cosmetics can be used to act as a "barrier" to natural excretions: to use both on healthy skin as a preventative measure and on a non-infected diaper rash?

Use ointments, creams or balms; in case of oozing or maceration, use a drying lotion containing copper and zinc instead.

Can talcum powder help?

In case of dermatitis, it is strictly to be excluded because it can produce talcoma. On healthy skin, however, it has a protective effect.

We hear that you should stop using liniment once the diaper dermatitis has set in because it worsens the process instead of improving it. Is this true?

The oleo-calcareous liniment does not bring anything in the cure of the diaper dermatitis, it is better to use barrier creams. However, it can have an interesting preventive effect in the long run.

What is meant by "persistent dermatitis"? How long does it last?

A persistent dermatitis is a dermatitis that lasts several days with a tendency to worsen despite local treatment.

Diaper Dermatitis: Clinic, diagnosis and treatment

Digest

Definition

Etiology and physiopathology

Clinic

Differential diagnosis

Treatments

Questions your patients may have

References