Diaper Dermatitis

Diaper Dermatitis

A common condition

- Occurs in infants and in elderly diaper-wearing nursing home residents

- Other names: diaper rash, nappy rash

- Generally occurs in infants > 1 month old, although can develop earlier

- Newer disposable diapers with wicking properties reduce the # cases of diaper rash

> 1 month

diaper dermatitis generally occurs in infants ____________ old

Moisture

Both reusable and disposable diapers create a warm and humid environment

- Traps urine and feces

- Skin and GI tract flora interacts with skin and diaper

- Edema of stratum corneum alters skin barrier

- Causes dermatitis

> 24 hours

skin exposed to water for ___________ is more likely to have erosions following friction

maceration

softening through liquid; overhydration

- promotes overgrowth of bacteria and yeast

Risk Factors (Diaper Rash)

- Moisture retention

- Friction & contact irritation

- Urine & ammonia

- Feces & alkaline pH

- Some foods may increase urine pH

- Infants with atopic or seborrheic dermatitis

- Psoriasis

- Incontinence (leaking of urine)

> Includes the elderly

- Immobility

- Vigorous cleansing (Esp. with soaps or detergent)

ammonia

is a known skin irritant & can raise pH

» Does not cause diaper rash, but aggravates it, esp. if skin is damaged/broken/chafed

Feces

- Lipases and proteolytic enzymes are present in _________

» Can induce contact irritant dermatitis

» Can raise skin pH (to alkaline) - lose barrier function

Drug-Induced Diaper Dermatitis

- Ethylenediamine

- Lanolin

- Neomycin

- PABA derivatives

- Parabens

- Penicillin

- Peruvian Balsam

- Sulfonamides

- Thiomerisol

- Topical antihistamines

alcohol

should avoid use in the diaper area as it can cause dehydration

benzocaine

should avoid use in the diaper area as it can cause contact sensitivity

camphor

should avoid use in the diaper area as it can cause seizures

methyl salicylate

should avoid use in the diaper area as it can cause salicylate intoxication and/or metabolic acidosis

Candida albicans

Fungus involved in diaper rash

- Most frequent cause (also present in some babies without diaper rash)

- Most often found in periphery of intense diaper rashes

- Requires drug treatment

Candida albicans

what is the most frequent cause of diaper rash?

Staph aureus

Bacteria involved in diaper rash

- A frequent colonizer of dermatitic skin

- Occasionally causes severely inflamed dermatitis with follicular pustules

- Requires drug treatment

Goals of Therapy

- Relief of Symptoms

- Resolution of diaper dermatitis

- Prevent complications

- Prevent recurrences

- Provide cost-effective therapy

- Minimize adverse reactions from therapies

Untreated/infected diaper dermatitis

can result in skin ulcerations, infection of penis/vulva, urinary tract infections

Clinical Presentation

"Geographic location" of rash - ie boundaries are areas covered by diaper

> Rash generally spares inguinal skin folds, except for Candida diaper rashes

- Erythematous rash, often with shiny patches over convex surfaces of diaper area

> May appear dusky purple on darker skin

- Severe rashes: may have vesicles, may have oozing and widespread erosions

inguinal skin folds

Rash generally spares _____________________, except for Candida diaper rashes

Erythematous rash (Clinical Presentation)

often with shiny patches over convex surfaces of diaper area

> May appear dusky purple on darker skin

Severe Rash (Clinical Presentation)

may have vesicles, may have oozing and widespread erosions

Candida Diaper Rash (Clinical Presentation)

Early maceration of anal mucosa and perianal skin

- Confluent tomato-red plaques, papules, pustules, etc.

- Culture positive for Candida

- Almost always involves the inguinal folds

Candida diaper rash

Almost always involves the inguinal folds

Refer

- If rash does not respond after a week of recommended therapies

- If rash does not heal in 7-10 days

- Increase in pain, inflammation, or itching

- Oozing blisters or pus seen

- Deep ulcerations present

- Acute onset of dermatitis

- Frequent recurrences; chronic cases

- Complicated by secondary infection

- Systemic signs or symptoms present (fever, diarrhea, n/v, rash or skin lesions elsewhere in the body)

- Immunodeficiency present

- Dermatitis is related to another disease state

- Behavioral changes present in the patient

7-10 days

if rash does not heal in ___________ patient should be referred

week

If rash does not respond after a _______ of recommended therapies, patient should be referred

Management (Diaper Rash)

A - air, absorptives, antifungals, anti-inflammatories

B - barriers

C - cleansing

D - diaper

E - education

- Air drying

Air drying

Part of management for diaper rash

- Remove diaper as long as practical

» E.g. during diaper changes, cleansing etc.

- Do not dry buttocks using hairdryer

- Do not use infrared lamps

ABCDE (air/absorptives/antifungals/anti-inflammatories, barriers, cleansing, diaper, education)

What are the key aspects for managing diaper rash?

Imidazoles

Topical antifungals that are treatment of choice for yeast diaper rash

- Efficacy 70-90%

- Miconazole 1% or clotrimazole 2%

- Use bid x 7 days

Miconazole 1% or clotrimazole 2%

Imidazoles are the treatment of choice for yeast diaper rash; what 2 agents are used?

BID x 7 days

What is the dosing for Miconazole 1% or clotrimazole 2% (Imidazoles) for treating yeast diaper rash?

Nystatin

Topical antifungal for yeast

- efficacy < imidazoles

- need to treat for 14 days

- may cause staining

14 days

when using Nystatin to treat yeast diaper rash, you need to treat for...

Butenafine

Topical Antifungal

- An OTC butyl-amine

- Used for athlete's foot

- Also has efficacy vs Candida (80%)

barrier cream

Antifungal should be applied FIRST, followed by a...

d/c antifungal, continue barrier cream

after inflammation subsides, what should you tell the patient to do with the antifungal and barrier cream?

Hydrocortisone

Topical anti-inflammatory for use in severe inflammation only

- 0.5 - 1%

- Do not recommend to < 2 y.o. without physician supervision

- Should be used in discrete, short periods of 1-2 weeks

- Better to add ________________ powder into anti-yeast product

2 years old

Hydrocortisone should not be recommended in those under __________ without physician supervision

1-2 weeks

Hydrocortisone should be used in discrete, short periods of...

hydrocortisone

If Hydrocortisone is used together with an anti-yeast preparation, which should be applied first?

1% hydrocortisone

DO NOT USE MORE POTENT STEROIDS than ______________________ - systemic absorption!

Powders

Non-drug barrier

- Do not use (esp. talc) due to risk of accidental inhalation.

- Talc and Cornstarch

Talc

Powder barrier, should NEVER be used

- Finely milled hydrous magnesium silicate

Cornstarch

Powder barrier, should be avoided

» Reduces friction

» May serve as culture medium for C. albicans

» Sometimes used in adults as carrier for antifungal powder (as Rx Tx of fungal infection)

Petrolatum (Yellow or White)

Non-drug barrier

» Provides a water-impermeable barrier

» Traps moisture. No absorptive ability

» May cause maceration if overhydrating the skin

Zinc Oxide

- Astringent, absorptive, antiseptic

- 15% for prevention of diaper rash (eg. Zincofax)

- Up to 40% for treatment of diaper rash

» Greater astringent and absorptive properties

» E.g. Zincofax Extra Strength, zinc oxide paste

15

____% Zinc Oxide can be used for prevention of diaper rash

40

____% Zinc Oxide can be used for treatment of diaper rash

» Greater astringent and absorptive properties

Anhydrous Lanolin

from sheep wool fat

- "absorption" base

- Contact Allergen!!!

- Best to avoid!

Anhydrous Eucerin

wool fat alcohol extract

- "absorption" base

- Contact Allergen!!!

- Best to avoid!

Silicone-based barriers

- Dimethicone or dimethylpolysiloxane

- Synthetic bases

- Water repellent only. Not absorption bases

Cleansing

Gentle

- Decrease frequency whenever possible

- Mild soaps, or non-soap cleansers

- Avoid commercial diaper wipes containing alcohol, fragrance, lanolin, or soap

- Wet compresses to oozing skin

- Wet soaks to crusted areas

wet compresses

should be used to clean oozing skin

wet soaks

should be used to clean crusted areas

Diaper

Change frequently

- Discourage double diapering to lengthen intervals between changes

- NEVER use visually unsoiled part of diaper to wipe or clean the diaper area

- Avoid plastic pants when using cloth diapers

- Disposable diapers with absorbent gelling core material (superabsorbent) are better for moisture - wicks moisture away from baby's skin

absorbent gelling core

Disposable diapers with ___________________ material (superabsorbent) are better for moisture - wicks moisture away from baby's skin

barrier cream

should be applied after each diaper change

- zinc oxide 10-20%, silicone, petrolatum

> zinc oxide 25-40% if needed

foods

ones that frequently cause diarrhea should be avoided

- Avoid irritants (citrus, spicy foods etc.) in mother's diet if breastfed