A lthough diaper dermatitis (DD) is a common condition, it often prompts parents to seek medical attention. The eruption can look worrisome, and children are often fussy with diaper changes when they have diaper dermatitis. This article will focus on the clinical presentation of the most common causes of diaper dermatitis and practical strategies for management. Few prospective trials comparing best management strategies exist so many of the suggestions are experience-based. Occasionally, diseases not typical in the diaper area will masquerade as diaper dermatitis; these will not be addressed here.

Case Presentation
An 11-month-old baby presented with a 4-day history of erythematous, scaly plaques with mild erosions in his groin. It involved the folds, buttocks and genitals. Some red papules extended to surrounding normal skin. The baby’s past history includes atopic dermatitis, which is easily controlled with mild cortisones. He had antibiotics 1 week before presentation for an otitis media and developed diarrhea. He was otherwise well but became fussy when his diaper area was cleansed and a moisturizing lotion applied. The baby’s mother had, therefore, cut down the number of diaper changes. Half-strength betamethasone valerate ointment originally prescribed for his eczema helped a little.

Common Causes of DD
Irritant Diaper Dermatitis (IDD). This is the most common cause of DD, either as the sole problem or a contributing problem. It can be recurrent. It can present as early as the first weeks of life1 or occur anytime during the time diapers are worn, which is typically up to the age of 2 to 3 years. One author notes a peak of IDD between 6 to 9 months of age.2

IDD can present with erythema only in the early stages. With more severe eruptions there can be superficial erosions and scale. Ulcerations can also occur. When the ulcers have a punched-out quality and are primarily on the labia, the term used is “Jacquet’s erosive diaper dermatitis.”3

A characteristic feature of IDD is that it spares the folds. As the folds do not come into direct contact with the diaper they are spared the inflammation. In addition to the buttocks and genitals, IDD can appear on the upper inner thighs.

The cause of this eruption is not fully understood. It’s possible that a certain susceptibility exists. Increased wetness and elevated pH have both been associated with more severe diaper dermatitis.4 Children with diarrhea are more prone to IDD.

In older children with encopresis (fecal soiling secondary to fecal obstruction) the frequent soiling can lead to an irritant dermatitis if they are still wearing diapers.

Management of irritant DD includes:
1. preventing further contact of the irritants (urine, stool)
2. avoiding friction (repetitive harsh wiping)
3. keeping the skin as dry as possible
4. treating existing inflammation.

Specifically, diapers should be changed frequently while the baby is awake. One study found that super-absorbent disposable diapers kept the skin drier and retained more liquid than cloth diapers and conventional disposable diapers.5 Some experts will recommend an uncovered diaper area to limit irritation and promote dry skin. However, this is often impractical for parents.

When irritant diaper dermatitis has reached the point of erosions or ulcerations, I suggest a temporary discontinuation of wipes with tepid bath rinses instead for each diaper change. This can also be time-consuming and impractical so it’s intended as a short-term strategy until the erosions have healed.

I also recommend that parents do not attempt to remove all of the old barrier cream from the previous change because that can increase friction. The goal is to remove the stool and urine and if some clean, barrier cream is still present afterward it can be left on and extra barrier cream applied. I recommend the thick, zinc-oxide-based preparations applied thickly during treatment phase and for prevention of future episodes.

Finally, a 1% hydrocortisone cream can be used twice daily to help with the inflammation. Remind parents that the hydrocortisone goes against the skin and under the barrier cream. Stronger cortisones should be avoided given potential side effects. Cushing syndrome has been reported after long-term clobetasol propionate use for diaper dermatitis in a 9 month old.6

Some advocate the application of talc or cornstarch to the diaper area to reduce moisture. Others believe that cornstarch will promote candidal growth. One study showed that cornstarch did not promote growth of Candida.7 However, reports of aspiration pneumonia from both talc powder and cornstarch have been reported, 8 and so the routine practice of using such agents should be avoided.

Candida diaper dermatitis (CDD). Candida may live in feces and on normal skin, but it appears more frequently on skin affected with diaper dermatitis.9 Candidal diaper dermatitis can occur alone or complicate IDD. There are distinct morphologic features that help separate CDD from IDD. Candidal DD often presents as a sharply demarcated “beefy” erythematous patch or plaque with some scale. Satellite erythematous papules and pustules are classic with Candida. The folds in CDD are involved as the moist, warm environment supports Candida growth. Reports exist of a generalized psoriasiform id reaction following a candidal diaper dermatitis.10

Antibiotics can not only lead to diarrhea and IDD but can increase Candida albicans isolates by 14-fold — leading to CDD.11 By releasing keratinases, the Candida gains access to the epidermis.

Treatment with a topical antifungal, with or without the addition of 1% hydrocortisone, is standard. Many agents can be used successfully such as the azoles or nystatin, usually twice daily. The addition of oral nystatin does not provide any added benefit to local topical therapy.12 A recent study showed ciclopirox (Loprox) to be safe and effective for candidal diaper dermatitis.13 One study found that mupirocin (Bactroban) had excellent antifungal properties against Candida and cleared the dermatitis more quickly than nystatin.14 This was likely due to the clearance of associated bacteria that cleared with mupirocin. Of course, if there are features of IDD, then they should be addressed as above.

Seborrheic DD (SDD). This is a common inflammatory dermatosis that affects the scalp, central face and intertriginous areas including the diaper area. One study found seborrheic dermatitis to have its highest prevalence in the first 3 months of life decreasing by 1 year of age.15 There is no evidence to suggest these infants go on to the adult form of the disease. Seborrheic DD presents with well-demarcated erythematous plaques that may involve the folds. On the scalp the scale is typically thick, greasy and yellow. There may be less scale in the intertriginous sites and diaper area. Post-inflammatory hypopigmentation is frequently seen.3 A commonly implicated etiologic factor is Malassezia furfur.

It is occasionally difficult to distinguish seborrheic dermatitis from atopic dermatitis. Atopic dermatitis involves the face and extensors in infancy and is much less common in the diaper area. Furthermore, atopic dermatitis is usually accompanied by pruritus and xerosis. It can also be difficult to distinguish SDD from psoriasis (see below).

Both cortisone and antifungal agents have been used to treat seborrheic dermatitis.

Less Common Causes of Diaper Dermatitis
Psoriasis DD (PDD). Psoriasis in children can occur in the typical extensor pattern seen in adults but has been well-recognized to occur in the diaper area as well. It presents as “inverse psoriasis” with sharply-marginated erythematous plaques and little scale. This can be a difficult to differentiate from seborrheic dermatitis. Involvement of scalp and intertriginous areas with greasy yellow scale would favor SDD. Nail changes may be present in 10% of cases, which would favor psoriasis.3 Treatment is typically mild topical cortisones and avoidance of the more irritating psoriasis treatments.

Perianal dermatitis. This perianal eruption is caused by Group A beta-hemolytic streptococci. It presents with itching, rectal pain and perianal dermatitis. It’s most common under the age
of 4.16 If a case of DD is not responding to treatment as expected, consider swabbing to rule out a group A Strep infection. Treat with oral penicillin.

Atopic dermatitis. This common, recurring dermatitis usually presents in early infancy. The classically involved areas in infancy include the face and the extensors. The diaper area is an uncommon location for atopic dermatitis. Treatment, as with other involved body areas, includes emollients and cortisones. A 1% hydrocortisone is the best choice in the groin area given the recurrent nature and requirement for repeated use.

Rare Causes of Diaper Dermatitis
Granuloma Gluteale infantum. This is a benign disorder with red-purple nodules in the diaper area that, in fact, are not truly granulomas.17 Some consider it a complication of potent topical steroids. Others believe it is related to Candida.18 It may require biopsy to rule out other nodular conditions such as mastocytosis or juvenile xanthogranuloma. These nodules can resolve spontaneously over months. Any Candida should be treated.

Granular parakeratosis. This uncommon acquired disorder of keratinization has been reported to occur in the diaper area.19 It presents as well-defined, hyperpigmented, hyperkeratotic plaques in intertriginous and occluded areas. There is a distinctive histopathology showing a thick cornified layer with compact parakeratosis with marked retention of keratohyaline granules.19 No definitive treatments have been identified, but spontaneous resolution has occurred after months.20

Other Conditions
Many other uncommon causes of diaper dermatitis have been reported, such dermatophyte infection 21 and herpes.22 Early Kawasaki disease can give a characteristic erythematous peeling in the perineal area that may be mistaken for diaper dermatitis.23 One would expect the further development of the classic findings of Kawasaki Disease.

Problems Masked by Diaper Dermatitis
Zinc deficiency. Zinc deficiency can occur from a variety of causes including inherited inability to adequately absorb Zn (acrodermatitis enteropathica) and inadequate supply through breast milk in breast-fed premature babies. The clinical presentation is a sharply-marginated eczematous-like eruption involving the face, acral skin and diaper area. Infants can also be irritable, have diarrhea and alopecia. Rapid improvement is seen when treatment with zinc sulphate is initiated. Biotin deficiency can lead to a similar eruption but usually has neurologic signs as well.

Langerhans cell histiocytosis. Langerhans cell histiocytosis represents a group of systemic diseases characterized by clonal proliferation of Langerhans’ cells. The Lettere-Siwe variant classically presents in infancy with a seborrhea dermatitis-like eruption that can present in the diaper area. In addition to yellow scale and erythema, petechiae are common. A seborrheic-dermatitis like eruption that is not healing or presents with petechiae should raise suspicion of LCH and should be biopsied.

Back To Our Case
The baby had irritant diaper dermatitis with Candida. The involvement of the folds and satellite lesions suggests the associated Candida. His recent use of antibiotics would have greatly increased the amount of Candida on his skin. The diarrhea would have increased the irritation of the skin. Moisturizing lotion offers little protection and may in fact be irritating for a baby. The acute nature ruled out the more worrisome, chronic problems and atopic dermatitis doesn’t typically affect the diaper area.

The baby was managed with frequent diaper changes with super-absorbent diapers. Lukewarm water replaced wipes for several days. Hydrocortisone 1% powder in clotrimazole replaced the stronger cortisone. The moisturizing lotion was replaced with zinc-oxide barrier cream. The mother was reassured that while the routine is time-consuming, most babies heal quickly. The baby’s eruption cleared completely by 10 days.

The Dermatologists Role in DD
Diaper dermatitis is a common problem in family practice and pediatrics. Patients referred to dermatologists tend to have cases of DD that are more difficult to manage. Dermatologists can help by ensuring the correct diagnosis is made. This includes considering the more uncommon causes of diaper dermatitis and considering swabs, biopsy or ancillary tests (e.g., zinc levels) to confirm the diagnosis. Dermatologists can suggest appropriate management, for example eliminating high-potency topical cortisones or ensuring that Candida is adequately treated. For resistant irritant diaper dermatitis, dermatologists can counsel parents on the need to adhere to the diapering routines — albeit time-consuming — to ensure prompt recovery. If a systemic disease (e.g., LCH) or encopresis are the cause of diaper dermatitis, referral to a pediatrician is advisable.

With attention to morphologic clues to distinguish the more uncommon eruptions and perseverance in maintaining the therapeutic strategies, most diaper dermatitis can be managed successfully.