Diaper dermatitis

Diaper dermatitis (diaper rash) is a cutaneous reaction localized to the diaper area. The most common causes are irritant diaper dermatitis and candida diaper dermatitis. Other causes include infection (e.g., with Staphylococcus aureus or Streptococcus pyogenes) and allergic diaper dermatitis. The diagnosis is usually clinical. Diagnostic studies are reserved for severe manifestations, diagnostic uncertainty, or to confirm infection. Management is usually empiric and includes diaper hygiene, low-potency topical glucocorticoids, and treatment of identified infections (i.e., with antifungals or antibiotics).

• Can occur in any individual wearing diapers; typically seen in infants
• Peak incidence: 9–12 months of age ^[4]

Epidemiological data refers to the US, unless otherwise specified.

• Irritant diaper dermatitis (most common cause) due to: ^[2][3][10]
  • Persistent moisture (e.g., from urine and feces); often due to infrequent diaper changes ^[1]
  • Friction between the diaper and skin
  • Hygiene products (e.g., scented soaps, wipes, or moisturizers)
• Candida diaper dermatitis (second most common cause) due to C. albicans
• Other
  • Bacterial infection: S. aureus, S. pyogenes
  • Allergic contact dermatitis: type IV hypersensitivity reaction to allergens (e.g., fragrances, preservatives, adhesives) in diapers, disposable wipes, moisturizers. ^{[3][10][11][12]}

See “Overview of diaper dermatitis” for a comparison.

Features of irritant diaper dermatitis ^[1][2][3]

• Affects convex skin surfaces in contact with the diaper
• Skin folds are characteristically spared.
• Well-defined (appearance varies based on severity)
  • Mild: painless, scattered red papules with minimal erythema
  • Moderate: widespread erythema with painful maceration and superficial erosions
  • Severe : widespread erythema with painful papules, nodules, and punched-out erosions

Features of candida diaper dermatitis ^[1][2][3]

• Skin fold involvement
• Satellite lesions
• Recent glucocorticoid or antibiotic use
• See “Candida diaper dermatitis” for additional features.

Features suggestive of other causes ^[1][2][3]

• Systemic symptoms (e.g., fever, diarrhea, severe pruritus)
• Concentric perianal erythema, bullae, honey-colored crusts
• Recurrence and/or inadequate response to treatment for irritant diaper dermatitis

Suspect severe infections such as staphylococcal scalded skin syndrome (SSSS) or herpes simplex virus (HSV) infection in individuals with systemic symptoms, rapidly evolving rash, and/or vesicles. ^[10]

Candida diaper dermatitis ^[1][2][3][5]

• Etiology
  • Infection with C. albicans
  • Associated with recent glucocorticoid or broad-spectrum antibiotic use
• Clinical features
  • Persistent rash for > 3 days that affects the convex areas of skin under the diaper ^[2][3]
  • Dark red plaques
  • Fine peripheral scaling (collarettes)
  • Satellite lesions: discrete papules and/or pustules extending past the primary area of involvement ^[6][13]
  • Involves skin folds (intertriginous areas)
  • Patients may have concurrent oropharyngeal candidiasis.
• Diagnosis
  • Usually a clinical diagnosis
  • Confirmatory tests for diagnostic uncertainty
    • KOH test: budding yeasts, hyphae, and pseudohyphae ^[6]
    • Fungal culture: positive for C. albicans
• Treatment
  • Start one of the following topical antifungals. ^[2][3][5]
    • Nystatin ^[5]
    • An azole, e.g., clotrimazole , miconazole , or miconazole/zinc oxide ^[5]
  • Concurrent oropharyngeal candidiasis: Add an oral antifungal.
    • Nystatin ^[2][3][7]
    • Fluconazole ^[2][3][7]
  • Provide management of diaper dermatitis.
  • If symptoms are recurrent or refractory, consider: ^[2][3]
    • Confirmatory fungal studies
    • Treatment with oral antifungals
    • Evaluation for immunosuppression (e.g., HIV infection, primary immunodeficiency, diabetes), especially if associated with recurrent oropharyngeal candidiasis ^[5]
    • Dermatology referral

Diagnosis is typically based on history and physical examination. Diagnostic studies and their indications include: ^[1][2][10]

• Rapid strep test and culture of the perianal region for suspected perianal streptococcal infection ^[14]
• Fungal studies (e.g., KOH test, fungal culture) for suspected severe fungal infection and/or poor response to empiric topical antifungals ^[1][2]
• Bacterial cultures for suspected severe bacterial infection and/or poor response to empiric antibiotics ^[1][2]
• Patch testing for diagnostic uncertainty in suspected allergic contact dermatitis ^[3]

Consider child maltreatment in patients with chronic and/or severe diaper dermatitis. ^[2][15]

Consider non-irritant causes of diaper dermatitis in individuals with systemic symptoms, cutaneous lesions extending outside the diaper region, or lesions that persist despite appropriate management. ^[2][3][16]

• Chronic skin conditions ^[3]
  • Seborrheic dermatitis
  • Atopic dermatitis
  • Psoriasis (e.g., napkin psoriasis)
  • Lichen sclerosus
• Other ^[2][3]
  • Child maltreatment (e.g., neglect, nonaccidental burns) ^[2][15]
  • Scabies ^[2][10]
  • Folliculitis
  • Langerhans cell histiocytosis
  • Acrodermatitis enteropathica

The differential diagnoses listed here are not exhaustive.

Approach ^[2][3][16]

• Start appropriate treatment.
  • All patients: Start diaper hygiene.
  • Inflammation: Consider short-term use ; (i.e., < 2 weeks) of a low-potency topical glucocorticoid (e.g., hydrocortisone ). ^[2][10][17]
  • Infectious causes: Provide treatment for identified infections.
• Consider alternative causes and/or dermatology referral for:
  • Inadequate response to treatment ^[16]
  • Unexplained recurrent episodes
  • Diagnostic uncertainty

Use glucocorticoids cautiously in candidal and bacterial infections as they can mask or worsen symptoms. ^[18]

Diaper hygiene (ABCDE) ^{[2][3][10][19]}

• Air: Allow diaper-free time to let the skin fully dry out.
• Barrier
  • Liberally apply barrier emollients containing zinc oxide and/or petrolatum.
  • Avoid combination products that contain a glucocorticoid.
• Clean
  • Gently clean the diaper area with lukewarm water with or without a mild cleanser.
  • Do not remove emollients; reapply if needed to maintain barrier protection.
• Diaper
  • Recommend more frequent diaper changes.
  • Recommend superabsorbent, breathable diapers.
• Education: Discuss the treatment plan.

Avoid using diaper powders (e.g., talc, cornstarch) due to the risk for inhalation pneumonitis. ^[1][16][20]

Ointments and pastes are preferred to creams. ^[21]

• Frequent diaper changes to prevent excessive moisture
• Avoidance of potential allergens
  • Use of unscented mild soaps, wipes, and clothing detergents
  • A soft towel dampened with water may be used instead of wipes.
• Recurrent episodes of irritant diaper dermatitis: The ABCDE approach of diaper hygiene may be used prophylactically.