My baby got dat’ rash or is My baby got dat’ rash or is it Thrash?it Thrash?

Scott CarneyScott Carney

Diaper DermatitisDiaper DermatitisPrevalencePrevalence

Represents 10 to 20 percent of all Represents 10 to 20 percent of all skin disorders evaluated by the skin disorders evaluated by the general pediatrician general pediatrician

Of those seen 1:4 is diagnosed with Of those seen 1:4 is diagnosed with Diaper dermatitisDiaper dermatitis

From 1990-1997 8.2 million From 1990-1997 8.2 million outpatient visitsoutpatient visits

EpidemiologyEpidemiology

Peak frequency 9-12 Peak frequency 9-12 monthsmonths

Risk Factors:Risk Factors: Poor hygiene Poor hygiene

(infrequent diaper (infrequent diaper changes)changes)

Past history of Past history of dermatitisdermatitis

DiarrheaDiarrhea ThrushThrush Toilet trainingToilet training

Path to pain…Path to pain…

Trifecta of factors that lead to dermatitis:Trifecta of factors that lead to dermatitis: Increased skin hydrationIncreased skin hydration Chemical irritationChemical irritation FrictionFriction

A little’s good a lot’s mo’ A little’s good a lot’s mo’ bettabetta

Increased hydrationIncreased hydration More liquid feces and More liquid feces and

urine leads to urine leads to increased breakdown increased breakdown of stratum corneumof stratum corneum

Increases risk of Increases risk of frictional trauma, frictional trauma, penetration of penetration of irritants and microbesirritants and microbes

It’s the pee right? It’s gotta be It’s the pee right? It’s gotta be the pee..the pee..

Study of 26 infants Study of 26 infants with diaper with diaper dermatitis found dermatitis found that high ammonia that high ammonia level on intact skin level on intact skin had no effect had no effect compared with compared with those without those without dermatitisdermatitis

But….But….

Fecal bacteria produce ureaseFecal bacteria produce urease Degrades urine to ammonia Degrades urine to ammonia Increases stool pHIncreases stool pH Reactivates fecal enzymes protease and Reactivates fecal enzymes protease and

lipaselipase Increases breakdown further of stratum Increases breakdown further of stratum

corneumcorneum

Other risk factorsOther risk factors

Diet:Diet: Breast fed children Breast fed children

have decreased have decreased incidence of DD incidence of DD likely due to a lower likely due to a lower stool pH from stool pH from Breast feedingBreast feeding

Antibiotic usage:Antibiotic usage: Patients with Patients with

chronic antibiotic chronic antibiotic usage have usage have increased risk of increased risk of antibiotic antibiotic associated diarrhea associated diarrhea and increased risk and increased risk of altered stool flora of altered stool flora increasing risk for increasing risk for Candidal infectionCandidal infection

Clinical features:Clinical features:

Wide range of presentationsWide range of presentations Asymptomatic erythema to painful Asymptomatic erythema to painful

scaling papules and superficial erosions scaling papules and superficial erosions Skin folds are sparedSkin folds are spared Traditionally involves convex areas of Traditionally involves convex areas of

diaper areasdiaper areas Including the buttocks, lower abdomen, Including the buttocks, lower abdomen,

genitalia, and upper thighs genitalia, and upper thighs

Pretty straightforward right?Pretty straightforward right?

Not so fast, spectrum extends Not so fast, spectrum extends beyond classical diaper dermatitis to beyond classical diaper dermatitis to more severe forms includingmore severe forms including Tidewater dermatitis Tidewater dermatitis Jacquet's erosive dermatitis Jacquet's erosive dermatitis Granuloma gluteale infantum Granuloma gluteale infantum

Differential Dx:Differential Dx:

Allergic ContactAllergic Contact IntertrigoIntertrigo Atopic DermAtopic Derm SeborrheaSeborrhea Langerhan’sLangerhan’s PsoriasPsorias Child AbuseChild Abuse Zinc deficiencyZinc deficiency Biotin deficiencyBiotin deficiency

HerpesHerpes ScabiesScabies CandidaCandida Bacterial infectionBacterial infection SyphillisSyphillis

Tidewater/Lucky Luke/Diaper Tidewater/Lucky Luke/Diaper Dye DermatitisDye Dermatitis

Erythema and scaling at the diaper Erythema and scaling at the diaper margin due to friction and cycles of margin due to friction and cycles of wetness and drynesswetness and dryness

Also thought to be due to rubber Also thought to be due to rubber components of diapercomponents of diaper

Tidewater DermatitsTidewater Dermatits

Jacquet's erosive dermatitisJacquet's erosive dermatitis

Well-demarcated Well-demarcated papules, nodules, papules, nodules, and punched-out and punched-out ulcerations in the ulcerations in the perineal region perineal region

Granuloma Gluteale Granuloma Gluteale InfantumInfantum

Reddish-purple Reddish-purple nodules in the inguinal nodules in the inguinal folds, scrotum, folds, scrotum, buttocks, and medial buttocks, and medial thighs thighs

Presents within 2-9 mo Presents within 2-9 mo ageage

Associated with use of Associated with use of steroid creams and steroid creams and chronic Candidal chronic Candidal infections.infections.

Oh Candida!Oh Candida!

Thought to have increased liklihood if it Thought to have increased liklihood if it has persisted for > 3 days due to has persisted for > 3 days due to previously mentioned factors.previously mentioned factors.

Beefy red plaques, satellite papules, and Beefy red plaques, satellite papules, and superficial pustulessuperficial pustules

Does not spare foldsDoes not spare folds Typically associated with oral thrush (52%)Typically associated with oral thrush (52%) In patients treated with abx for 10 days In patients treated with abx for 10 days

found to have 10x increased riskfound to have 10x increased risk

Oh Candida!Oh Candida!

SebhorreaSebhorrea Salmon colored, Salmon colored,

well-demarcated well-demarcated scaling plaques scaling plaques especially in inguinal especially in inguinal foldsfolds

Greasy scaling Greasy scaling lesions elsewherelesions elsewhere

Appears by 3-4 Appears by 3-4 weeks resolves by 3-weeks resolves by 3-4 mo.4 mo.

IntertrigoIntertrigo Moist sharply Moist sharply

demarcated demarcated erythema in folds erythema in folds with minimal scalewith minimal scale

No satellite lesionsNo satellite lesions

SebhorreaSebhorrea Intertrigo Intertrigo

Langerhan’sLangerhan’s

Hematologic/oncologic disorder Hematologic/oncologic disorder Present during infancy or early Present during infancy or early

childhood childhood Red/orange or yellow/brown scaly Red/orange or yellow/brown scaly

papules, erosions, or petechiae most papules, erosions, or petechiae most commonly in the groin, intertriginous commonly in the groin, intertriginous regions, and scalp regions, and scalp

Langerhan’sLangerhan’s

Zinc DeficiencyZinc Deficiency

Aka Acrodermatitis EnteropathicaAka Acrodermatitis Enteropathica Typical in breast fed patients that are Typical in breast fed patients that are

not supplemeneted with vitaminsnot supplemeneted with vitamins Erythema, peeling of skin in multiple Erythema, peeling of skin in multiple

areas including hands, face, feet and areas including hands, face, feet and nail changesnail changes

Zinc DeficiencyZinc Deficiency

ManagementManagement

Education, Education, EducationEducation, Education, Education Prevention is key!Prevention is key! Frequent diaper changesFrequent diaper changes Gentle cleansing, avoiding harsh Gentle cleansing, avoiding harsh

soaps/frequent cleaningsoaps/frequent cleaning Barrier protectionBarrier protection Antifungals/Anti-inflammatoriesAntifungals/Anti-inflammatories

Wave of the future…Wave of the future…

Disposable diapers in place of cloth diapers have Disposable diapers in place of cloth diapers have led to a decrease in incidence due to their super led to a decrease in incidence due to their super absorbant natureabsorbant nature

New diapers provide continuous administration of New diapers provide continuous administration of zinc oxide/petroleum to skinzinc oxide/petroleum to skin

Keep it clean…Keep it clean…

Removal of diaper as soon as it is Removal of diaper as soon as it is soiled/wet to prevent interaction of soiled/wet to prevent interaction of enzymesenzymes

Removal should be with a soft cloth Removal should be with a soft cloth and water to avoid removal of stool and water to avoid removal of stool only and not barrier creamonly and not barrier cream

Avoid baby wipes that contain Avoid baby wipes that contain alcohol as they may increase drying alcohol as they may increase drying out.out.

BarriersBarriers

Work to prevent overhydration of skinWork to prevent overhydration of skin Reduces transepidermal loss of water and Reduces transepidermal loss of water and

repels further water from entering skin.repels further water from entering skin. Disadvantages to using barriers are mostly Disadvantages to using barriers are mostly

due to the difficulty in removing themdue to the difficulty in removing them Ways to avoid:Ways to avoid:

Use of mineral oil to soften paste Use of mineral oil to soften paste Cornstarch instead of talcum powder to reduce Cornstarch instead of talcum powder to reduce

frictional injury.frictional injury.

Barrier creamBarrier cream

AntifungalsAntifungals

Indications:Indications: Satellite lesionsSatellite lesions Confirmation with KOH slideConfirmation with KOH slide Present for at least 3 daysPresent for at least 3 days

Nystatin, ketoconazole, miconazole all equally effectiveNystatin, ketoconazole, miconazole all equally effective

SteroidsSteroids

Treatment limited to three to five days 2x Treatment limited to three to five days 2x daily and only to treat severely inflamed daily and only to treat severely inflamed irritant diaper dermatitis due to increased irritant diaper dermatitis due to increased absorbtionabsorbtion

Only the lowest potency, nonhalogenated Only the lowest potency, nonhalogenated topical corticosteroids should be topical corticosteroids should be prescribed; over-the-counter 1% prescribed; over-the-counter 1% Hydrocortisone percent cream or ointment Hydrocortisone percent cream or ointment is often sufficient.is often sufficient.

AntibioticsAntibiotics

Topical onlyTopical only Only for secondarily infected.Only for secondarily infected. Mild: Mupirocin 2x dailyMild: Mupirocin 2x daily Avoid: Avoid:

Neosporin/Bacitracin due to increased Neosporin/Bacitracin due to increased allergic likelihood to neomycinallergic likelihood to neomycin

The EndThe End