March 1996
MIAMI BEACH, Fla.—Diaper dermatitis, once it progresses beyond a simple rash, can be a serious matter.
To help decide the best treatment for the condition and how to determine whether the dermatitis has a simple or complex cause, Ronald C. Hansen, MD, offered several guidelines here at the Fifth Annual Masters of Pediatrics meeting.
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When treating simple irritant contact dermatitis, it is important to remember that "convex" surfaces, "those which poke into the wet diaper are most preferentially irritated. Urine is usually the culprit," he said.
Once the skin is irritated by wetness, increased frictional damage occurs, and that leads to lipid loss, or chapping.
"This low-grade damage to the epithelium makes the skin more susceptible to other irritants and infections. Exacerbating the problem is exposure to stool digestive enzymes, which are activated by ammonia," said Hansen, Professor of Pediatrics and Dermatology, University of Arizona School of Medicine, Tucson, Ariz.
He discussed research that showed ammonia, a by-product of urea, is not responsible for diaper rashes. "It raises the pH, and that reactivates fecal digestive enzymes, which are additive irritants. They can have a very profound effect on irritant diaper rash," he said.
More complicated diaper rashes may have elements of Candida or staphylococcal infection. These children may experience atopic diathesis or seborrheic dermatitis, but the "generic" features of diaper rash, always present, increase the problem.
"Seborrheic dermatitis, for example, repeatedly gets infected with Candida," he said.
Perianal streptococcal infection causes chronic scratching, which can lead to lichenification and excoriation, so it is important to take cultures from these children and treat them appropriately, he said.
Other complicated cases can include skin desquamation from a bad staphylococcal infection and lichen sclerosis, a chronic, but rare inflammatory dystrophy. Psoriasis, when it begins in infancy, is almost invariably accompanied by bad diaper rashes that are hard to treat, he said.
"It is possible for psoriasis to be limited to the diaper area. When this is the presentation, it usually takes a dermatologist to make the diagnosis," he said.
Other complicated presentations include condyloma lata from secondary syphilis infection, histiocytosis X, or Langerhans' cell histiocytosis and anogenital warts.
"Molluscum can look like warts and are mainly glistening dome shaped papules, some of which may be umbilicated in the diaper area. They are often elongated, and mold together like a mosaic.
"Often these lesions get mistaken as condyloma. Whereas condyloma should raise the question of sexual abuse, I have never seen a case of molluscum that was caused by abuse. Although it has been reported, it is uncommon. Therefore, distinguishing between molluscum and condyloma is very important," he said.
Irritant papules in the diaper area also may be caused by chronic diarrhea and the contact with fecal material.
"Irritant changes can look just like warts, however. You may see this presentation, for example, in children who have had surgical intestinal pull-throughs for gut trouble. They can get chronic fecal irritation, which must be treated like any other diaper rash," he said.
When it comes to the treatment of diaper dermatitis, common sense rules, Hansen believes.
"First, reduce the urine and fecal contact with the skin, and that means frequent diaper changes, and use of barrier ointments such as zinc oxide or petrolatum. Powder and talc are less useful," he said.
The type of diaper used is also important. If cloth diapers are used, the plastic or rubber pants must be avoided; disposables, changed frequently, may be preferable.
Additionally, parents and caretakers must be very gentle when cleansing irritated skin. Hansen tells parents, "The less you do the better. Use water only and pat dry. The major point you need to counsel is don't overdo cleansing. Tell them, also that soap can be further irritating," he said.
Cleansing with Cetaphil (Galderma), mineral oil, or baby oil to avoid disturbing newly formed epithelial cells are good options.
Topical corticosteroids may be indicated in selected cases. For example, "Consider using 0.5% to 1% hydrocortisone cream if the eruption lasts more than 5 days. Avoid fluorinated steroids in the diaper area," he said.
A secondary candidal infection may develop if the rash persists for more than 5 days. The newer antifungals are even more effective than nystatin in these cases, he said, and include miconazole, clotrimazole, econazole, and ciclopirox.
Presented at the Fifth Annual Masters of Pediatrics meeting, Miami Beach, Fla, Jan 25-29, 1996.
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