Skip to content

Diaper Dermatitis

Basics

  • Rash occurring under the diaper area; named by location, not etiology.
  • Usually irritant contact dermatitis initially; can have systemic contributions.
  • Rarely serious but causes patient discomfort and caregiver anxiety.
  • Systems affected: skin/exocrine.
  • Synonyms: diaper rash, nappy rash, napkin dermatitis.
  • Geriatric considerations: incontinence is a significant risk factor.

Epidemiology

  • Most common dermatitis in infancy.
  • Peak incidence: 7–12 months of age.
  • Lower incidence in breastfed infants due to lower skin pH and enzyme activity.
  • Prevalence varies from 4-35% in first 2 years of life.
  • Up to 75% of infants experience episodes of varying severity.
  • Severity breakdown: 58% mild, 34% moderate, 8% severe.

Etiology and Pathophysiology

  • Immature infant skin differs histologically and biochemically from mature skin.
  • Wet skin from urine and feces leads to chemical, enzymatic, and physical injury.
  • Fecal proteases and lipases irritate skin.
  • Urease enzyme liberates ammonia, increasing skin irritation.
  • Diarrhea increases fecal enzyme activity, raising risk.
  • Secondary Candida albicans infection common in rashes lasting >3 days (40-75% colonization).
  • Bacterial role via fecal pH reduction and enzyme activation.
  • Allergy as a cause is rare.

Risk Factors

  • Infrequent diaper changes.
  • Improper laundering of cloth diapers.
  • Family history of dermatitis.
  • Hot, humid weather.
  • Recent oral antibiotic use.
  • Diarrhea (>3 stools/day).
  • Dye allergy.
  • Pre-existing eczema.

General Prevention

  • Rigorous hygiene and frequent diaper changes.
  • Use of superabsorbent diapers.
  • Avoid impermeable waterproof pants during treatment.

Commonly Associated Conditions

  • Contact (allergic or irritant) dermatitis.
  • Seborrheic dermatitis.
  • Candidiasis.
  • Atopic dermatitis.

Diagnosis

History

  • Onset, duration, rash progression.
  • Presence of rashes outside diaper area.
  • Associated symptoms: scratching, crying.
  • Exposure to infants with similar rash.
  • Recent illness, diarrhea, antibiotic use.
  • Fever, pustular drainage, lymphangitis.

Physical Exam

  • Mild: shiny erythema Β± scale; margins not always clear.
  • Moderate: papules, vesicles, superficial erosions.
  • Severe: well-demarcated ulcerated nodules β‰₯1 cm.
  • Common sites: buttocks, medial thighs, mons pubis, scrotum.
  • Skin folds usually spared; involvement suggests secondary Candida or Staph infection.
  • Tidemark dermatitis: bandlike erythema at diaper margins.
  • Possible id reaction outside diaper area.

Differential Diagnosis

  • Contact dermatitis.
  • Seborrheic dermatitis.
  • Candidiasis.
  • Atopic dermatitis.
  • Scabies.
  • Acrodermatitis enteropathica.
  • Letterer-Siwe disease.
  • Congenital syphilis.
  • Child abuse.
  • Streptococcal/staphylococcal infection.
  • Kawasaki disease.
  • Biotin deficiency.
  • Psoriasis.
  • HIV infection.

Diagnostic Tests

  • Rarely needed.
  • Consider culture or KOH prep if infection suspected.
  • Mineral oil prep for scabies.
  • Biopsy rarely needed; may show spongiotic dermatitis.

Treatment

General Measures

  • Air exposure of buttocks.
  • Mild, slightly acidic or neutral pH cleansers; pat dry gently.
  • Avoid impermeable diapers.
  • Frequent diaper changes.
  • Use superabsorbent diapers.
  • Discontinue baby lotions, powders (except zinc oxide).
  • Alcohol and fragrance-free baby wipes are safe.
  • Barrier creams: zinc oxide ointment applied early and frequently.
  • Avoid talcum powders; cornstarch may reduce friction.

Medications

  • First Line:
  • Low-potency topical steroids (hydrocortisone 0.5-1% TID for 3-5 days) for irritant dermatitis.
  • Antifungals for suspected or persistent candidiasis: miconazole, econazole, clotrimazole, ketoconazole creams/powders.
  • Combination antifungal/steroid creams (e.g., clioquinol-hydrocortisone) if inflammation is prominent.
  • Topical or systemic antibiotics for secondary bacterial infection (mupirocin, oral antistaphylococcal agents).
  • Precautions:
  • Avoid moderate/high potency steroids or prolonged steroid use in diaper area.
  • Second Line:
  • Sucralfate paste for resistant cases.
  • Hydrocolloid dressings may speed healing.
  • Topical tacrolimus 0.03% (not approved <2 years old) in refractory cases.

Issues for Referral

  • Suspected systemic disease (Langerhans cell histiocytosis, acrodermatitis enteropathica, HIV).

Admission/Inpatient Considerations

  • Febrile neonates.
  • Toxic-appearing infants.
  • Recalcitrant rash suggestive of immunodeficiency.
  • Provide hygiene education for caregivers.

Ongoing Care

  • Weekly recheck until rash clears.
  • Monitor for recurrences.

Patient Education

  • Importance of hygiene.
  • Frequent diaper changes.
  • Recognize signs of infection.

Prognosis

  • Rapid, complete resolution with appropriate treatment.
  • Secondary candidiasis may persist weeks after therapy initiation.

Complications

  • Secondary bacterial infection (consider MRSA).
  • Rare necrotizing fasciitis due to group A Ξ²-hemolytic streptococcus.
  • Secondary yeast infection.

ICD10 Codes:
- L22 Diaper dermatitis
- B37.2 Candidiasis of skin and nail

Clinical Pearls:
- Hygiene is key to prevention.
- Persistent rashes require evaluation for secondary Candida or Staphylococcus infection.
- MRSA should be considered in non-responsive pustular dermatitis.