Presentation
History
One study review performed in the United Kingdom reported that irritant diaper dermatitis does not usually develop immediately after birth; onset is generally between 3 weeks and 2 years of age, with prevalence highest between 9 and 12 months. This study showed that one fifth of all pediatric dermatology visits for children up to the age of 5 years were to treat diaper dermatitis.
Diagnosis of diaper dermatitis is based largely on the physical examination. A careful history, however, could elicit clues that aid in narrowing the differential diagnosis.
Important points to obtain on history include the following:
Onset, duration, and change in the nature of the rash
Presence of rashes outside the diaper area
Associated scratching or crying
Contact with infants with a similar rash
Recent illness, diarrhea, or antibiotic use
Assessment of current diapering practices (eg, change frequency, type of diapers used, creams or ointments applied, methods used to clean the diaper area)
Irritant contact dermatitis, miliaria (heat rash), and intertrigo
Usually follows a bout of diarrhea
Exacerbated by scrubbing and the use of commercial wipes or strong detergents
Lasts less than 3 days after more diligent diaper changing practices are initiated
Asymptomatic (except for miliaria)
Candidal diaper dermatitis
Lasts even after more diligent diaper changing practices are started
Should be suspected in all rashes lasting more than 3 d (Candida is isolated in 45-75% of such cases)
Painful - Parents often report severe crying during diaper changes or with urination and defecation.
May follow recent antibiotic use
Secondary bacterial infection
Fever
Pustular drainage
Lymphangitis
Granuloma gluteale infantum
Rash lasts months
Resistant to treatments with barrier creams, antifungal agents, and topical steroids
Asymptomatic
Atopic dermatitis
Family or personal history of allergic rhinitis, hay fever, or asthma is common.
Pruritic
Associated with current or previous flares of rash on the face and extensor limb surfaces in infants
Seborrheic dermatitis
Usually occurs in infants aged 2 weeks to 3 months
Consists of an eruption of an oily, scaly, crusted dermatitis of the scalp (cradle cap), face, retroauricular regions, axilla, and presternal areas
Asymptomatic
Any child with widespread seborrheic dermatitis, diarrhea, and failure to thrive should be evaluated for Leiner disease, a functional defect of the C5 component of complement.
Psoriasis
A family history of psoriasis can be a clue.
Not responsive to barrier creams, antifungal agents, and standard topical steroids
Involved areas include the scalp and nails
Impetigo
Common in the first 6 months of life
-
Usually occurs during the warmer summer months
Langerhans cell histiocytosis
Severe hemorrhagic diaper dermatitis unresponsive to any treatment
Other involved areas include the scalp and retroauricular areas
Diarrhea
Acrodermatitis enteropathica
Associated with diarrhea, hair loss, and erosive perioral dermatitis
Patient may have a predisposition for malabsorption (ie, cystic fibrosis) or malnutrition
Scabies
Acute onset
Pruritic
History of close contacts with recent onset of a similar erythematous serpiginous eruption
Concurrent rash may be found in web spaces of hands or feet
Human immunodeficiency virus
History of HIV exposure or risk factors
Associated cytomegalovirus or herpes infection
Physical Examination
The pertinent physical examination focuses on the skin in the diaper area. Findings vary depending on which subset of diaper rash is most prominent.
The following are characteristic physical findings:
Irritant contact dermatitis
Mild forms consist of shiny erythema with or without scale.
Margins are not always evident.
Moderate cases have areas of papules, vesicles, and small superficial erosions.
It can progress to well-demarcated ulcerated nodules that measure a centimeter or more in diameter.
It is found on the prominent parts of the buttocks, medial thighs, mons pubis, and scrotum.
Skin folds are spared or involved last.
Tidemark dermatitis refers to the bandlike form of erythema of irritated diaper margins.
Diaper dermatitis can cause an id (autoeczematous) reaction with reaction outside the diaper area.
Intertrigo
Occurs in skin creases where skin surfaces are in apposition
Characterized by slight to severe erythema in the inguinal area, intergluteal area, or folds of the thighs
Pustules or erosions are not present.
Miliaria
Consists of multiple discrete, pruritic, erythematous papulovesicles, and sterile vesiculopustules.
Similar lesions on the face, neck, and axilla may be present.
Candidal dermatitis
Distinctive clusters of erythematous papules and pustules are present, which later coalesce into a beefy red confluent rash with sharp borders.
Satellite lesions frequently are found beyond these borders.
Skin folds commonly are involved.
White scales may be observed occasionally.
The oropharynx should be inspected for the white plaques of thrush.
Secondary bacterial infection
Edema
Erythema
Tenderness
Purulent discharge
Red streaking
Granuloma gluteale infantum
Uncommon disorder
Painless reddish-brown to purplish nodules are observed.
These granulomatous nodules can have large, raised erosions with rolled margins and a purple, almost Kaposi sarcoma–like color.
Nodules range in size from 0.5-4 cm.
Limited to prominent areas of the groin, such as the thighs, abdomen, and genitalia.
Axilla and neck involvement has been reported.
Jacquet diaper dermatitis (dermatitis syphiloids posterosiva) is a term used to describe a severe noduloerosive lesion with an umbilicated or craterlike presentation in the diaper area. It is probably closely related to granuloma gluteale and is a variant of diaper dermatitis.
Atopic dermatitis
Acute lesions appear as poorly demarcated, erythematous, scaly, weepy, and crusted.
Chronic lesions are poorly defined, thickened, hyperpigmented, and often excoriated.
Lichenification can occur with chronic disease.
Distribution rarely involves the diaper area. It is more commonly observed on the face and extensor limb surfaces in children of diaper-wearing age.
Seborrheic dermatitis
Well-demarcated erythematous patches or plaques with an occasional greasy yellow scale.
When found in the groin area, the skin creases show more severe involvement.
Skin folds are not spared.
There are no satellite lesions.
Oily, scaly, crusted lesions also can be found in areas with a predominance of sebaceous glands (eg, scalp, face, retroauricular regions, axilla, presternal area).
Psoriasis
Bright, red, well-defined plaques
Unlike typical psoriatic lesions elsewhere, silvery scales usually are not present in the diaper area due to the dampness of the area.
Inguinal folds typically are involved.
Involvement outside the diaper area is most common (>90% of cases) and may appear as retroauricular erythema or as nail dystrophy or pitting.
Impetigo
Vesicles, pustules, bullae, or crusts are commonly found in the periumbilical area.
In the diaper area, bullae are not usually intact.
They actually present as superficial erosions with a thin peripheral rim of bullous tissue.
Langerhans cell histiocytosis
Discrete, yellow-brown scaly or erythematous papules, purpuric papules, petechiae, deep ulcerations, and skin atrophy are present.
Hemorrhagic features are typical.
Usually involves skin folds
May have associated anemia, lymphadenopathy, and hepatosplenomegaly
May have associated involvement of the CNS, lungs, bones, and bone marrow
Acrodermatitis enteropathica
Typically involves the perioral, perineal, and acral areas
Erythematous, well-demarcated, scaly plaques and erosions
Alopecia and growth failure
Irritability
Congenital syphilis
Symmetric desquamation of palms and soles can be found.
Papulosquamous, reddish-brown lesions are observed in the diaper area. Rarely, these can be erosive or bullous.
Associated with anemia, hepatosplenomegaly, jaundice, and osseous lesions
Scabies
Papules, vesicles, burrows, nodules, and excoriations are found.
The generalized distribution has a predilection for the palms, soles, face, scalp, and genitalia.
Human immunodeficiency virus
When this presents as a diaper rash, severe erosions and ulcerations are often present.
Distribution to the perineal area, especially the gluteal cleft, may be observed.
Perianal pseudoverrucous papules
This condition is characterized by 2-8 shiny, smooth, red, moist, flat-topped, round lesions with acanthosis or psoriasiform spongiotic dermatitis.
Whereas granuloma gluteale can be confused with Kaposi sarcoma, perianal pseudoverrucous papules are most commonly confused with genital warts.
Perianal pseudoverrucous papules and nodules can occur in the context of Hirschsprung disease.
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Diaper rash.
Diaper rash.
Diaper rash.
Diaper rash pathophysiology scheme.
Author
Rania Dib, MD Pediatric Senior Specialist, Procare Riaya Hospital, Al Khobar, Saudia Arabia
Disclosure: Nothing to disclose.
Coauthor(s)
Amin Antoine Kazzi, MD Professor of Clinical Emergency Medicine, Department of Emergency Medicine, American University of Beirut, Lebanon
Amin Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.
Specialty Editor Board
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Chief Editor
Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, Yale-New Haven Children's Hospital
Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.
Additional Contributors
Jerry R Balentine, DO, FACEP, FACOEP Vice President, Medical Affairs and Global Health, New York Institute of Technology; Professor of Emergency Medicine, New York Institute of Technology College of Osteopathic Medicine
Jerry R Balentine, DO, FACEP, FACOEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, American College of Osteopathic Emergency Physicians, American Association for Physician Leadership, American Osteopathic Association
Disclosure: Nothing to disclose.
Sections Diaper Rash
- Overview
- Practice Essentials
- Pathophysiology
- Etiology
- Epidemiology
- Prognosis
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- History
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- DDx
- Workup
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- Treatment
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- Medication
- Medication Summary
- Corticosteroid, topical
- Antifungal agents
- Antibiotics, topical
- Antibiotics, oral
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- Questions & Answers
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