Background:
A prototypical example of irritant contact dermatitis, diaper dermatitis is caused by overhydration of the skin, maceration, prolonged contact with urine and feces, retained diaper soaps, and topical preparations. Signs and symptoms are restricted in most individuals to the area covered by diapers.
Pathophysiology:
Diaper rash affects the areas within the confines of the diaper. Increased wetness in the diaper area makes the skin more susceptible to damage by physical, chemical, and enzymatic mechanisms. Wet skin increases the penetration of irritant substances. Superhydration urease enzyme found in the stratum corneum liberates ammonia from cutaneous bacteria. Urease has a mild irritant effect on nonintact skin. Lipases and proteases in feces mix with urine on nonintact skin and cause an alkaline surface pH, adding to the irritation. (Feces in breastfed infants have a lower pH, and breastfed infants are less susceptible to diaper dermatitis.) The bile salts in the stools enhance the activity of fecal enzymes, adding to the effect.
Candida albicans has been identified as another contributing factor to diaper dermatitis; infection often occurs after 48-72 hours of active eruption. Whether C albicans is the cause or the effect is controversial; however, it was isolated from the perineal area in as many as 92% of children with diaper dermatitis. Other microbial agents have been isolated less frequently, perhaps more as a result of secondary infections.
Mortality/Morbidity:
- With the exception of an individual who is immunocompromised, no mortality is associated with diaper rash when correctly diagnosed. However, a rash incorrectly diagnosed as diaper dermatitis certainly may lead to significant morbidity and mortality if associated with a serious illness.
- Morbidity associated with diaper dermatitis is discomfort and the possibility of secondary bacterial or candidal infection, which may be more severe in an individual who is immunocompromised.
Race:
- No racial difference exists.
Sex:
- No sexual difference exists.
Age:
- Diaper dermatitis commonly affects infants, with peak incidence occurring when the individual is aged 9-12 months. One study determined that at any given time, diaper dermatitis is prevalent in 7-35% of the infant population.
- Diaper dermatitis can affect persons of any age who wear diapers, in particular, elderly people.
Diaper dermatitis or diaper rash is an irritation of the skin covering the groin, lower stomach, upper thighs and buttocks. The term diaper rash includes a variety of disorders of the skin that occur in infants, young children and incontinent or paralyzed individuals. This condition is seen more commonly in infants and early childhood prior to 2 years of age. Diaper dermatitis usually occurs between one and two months of age and may continue until the child no longer wears diapers. Diaper dermatitis may become irritated or difficult to treat if the area becomes infected or the patient becomes allergic to one of the medications applied to the area.
Diaper dermatitis starts with irritation from prolonged contact with urine and feces. After the skin becomes red and inflamed, bacteria and yeast grow on the raw areas. This will inflame the already irritated skin, making the diaper rash worse. Antibiotic treatment for throat and ear infections can cause yeast overgrowth making diaper dermatitis worse.
The best treatment for diaper dermatitis is to prevent it from starting. This is most easily done by using absorbent disposable diapers. These do not allow urine to come into contact with the skin. Modern absorbent disposable diapers can hold large amounts of urine and keep it away from the skin. For all practical purposes these diapers only need to be changed when they become soiled with feces or they get so heavy that they are down near the child's ankles. It is the mixture of urine and feces that causes the rash.
If one plans to use reusable cloth diapers, they must be changed each time after they become wet or every one to two hours. When using disposable diapers, it is important to prevent tape from adhering to the infant's skin. The adhesive can lead to skin break down. Contrary to popular belief, powder is not needed to keep the baby dry or to prevent diaper rash - in fact it may cause diaper rash to become inflamed particularly in the creases of the legs. Desitin (and other zinc oxide containing pastes), applied at bedtime are often helpful. This helps prevent a rash from starting if there is a nighttime bowel movement.
Keep the diaper area as dry as possible by using absorbent disposable diapers or by frequent changes of conventional diapers. Triple paste is an ointment that can be applied to the diapered area with every diaper change. A pharmacist usually makes this up by prescription. Lotrimin AF or Micatin creams can be used for diaper rash and can be purchased without a prescription. Avoid the use of Neosporin ointment, since this is a common product causing allergies. A dermatologist can help clear a diaper rash that does not easily clear with these instructions.
