Irritant diaper dermatitis

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Irritant diaper dermatitis
Other namesdiaper dermatitis, napkin dermatitis" [1] : 80  diaper rash, nappy rash
Irritant diaper dermatitis.jpg
Benign diaper rash on male infant
Specialty Dermatology   OOjs UI icon edit-ltr-progressive.svg

Irritant diaper dermatitis [2] (IDD, also called a diaper or nappy rash) is a generic term applied to skin rash in the diaper (in British and Australian English "nappy") area that are caused by various skin disorders and/or irritants.

Contents

Generic irritant diaper dermatitis is characterized by joined patches of erythema and scaling mainly seen on the convex surfaces, with the skin folds spared.

Diaper dermatitis with secondary bacterial or fungal involvement tends to spread to concave surfaces (i.e. skin folds), as well as convex surfaces, and often exhibits a central red, beefy erythema with satellite pustules around the border.

It is usually considered a form of irritant contact dermatitis. The word "diaper" is in the name not because the diaper itself causes the rash but rather because the rash is associated with diaper use, being caused by the materials trapped by the diaper (usually feces). Allergic contact dermatitis has also been suggested, but there is little evidence for this cause. [3] In adults with incontinence (fecal, urinary, or both), the rash is sometimes called incontinence-associated dermatitis (IAD). [4] [5]

The term diaper candidiasis is used when a fungal origin is identified. The distinction is important because the treatment is different (antifungals).

Causes

Irritant diaper dermatitis develops when skin is exposed to prolonged wetness, increased skin pH caused by the combination, and subsequent reactions, of urine and feces, and resulting breakdown of the stratum corneum, or outermost layer of the skin. [6] This may be due to diarrhea, frequent stools, tight diapers, overexposure to ammonia, or allergic reactions. [7] In adults, the stratum corneum is composed of 25 to 30 layers of flattened dead keratinocytes, which are continuously shed and replaced from below. These dead cells are interlaid with lipids secreted by the stratum granulosum just underneath, which help to make this layer of the skin a waterproof barrier. The stratum corneum's function is to reduce water loss, repel water, protect deeper layers of the skin from injury, and to repel microbial invasion of the skin. In infants, this layer of the skin is much thinner and more easily disrupted. [8]

Urine

Cloth diaper Cloth diaper gogreenpocketdiapercom.jpg
Cloth diaper

Although wetness alone has the effect of macerating the skin, softening the stratum corneum, and greatly increasing susceptibility to friction injury, urine has an additional impact on skin integrity because of its effect on skin pH. While studies show that ammonia alone is only a mild skin irritant, when urea breaks down in the presence of fecal urease it increases pH because ammonia is released, which in turn promotes the activity of fecal enzymes such as protease and lipase. [6] These fecal enzymes increase the skin's hydration and permeability to bile salts which also act as skin irritants.

There is no substantial difference in rates of diaper rash in conventional disposable diaper wearers and reusable cloth diaper wearers. "Babies wearing superabsorbent disposable diapers with a central gelling material have fewer episodes of diaper dermatitis compared with their counterparts wearing cloth diapers. However, keep in mind that superabsorbent diapers contain dyes that were suspected to cause allergic contact dermatitis (ACD)." [9] Whether wearing cloth or disposable diapers they should be changed frequently to prevent diaper rash, even if they do not feel wet. To reduce the incidence of diaper rash, disposable diapers have been engineered to pull moisture away from the baby's skin using synthetic non-biodegradable gel. Today, cloth diapers can use newly available superabsorbent microfiber cloth placed in a pocket with a layer of light permeable material that contacts the skin. This design serves to pull moisture away from the skin in to the microfiber cloth. This technology is now widely used in commercial pocket cloth diapers brands in developed markets.

Diet

The interaction between fecal enzyme activity and IDD explains the observation that infant diet and diaper rash are linked because fecal enzymes are in turn affected by diet. Breast-fed babies, for example, have a lower incidence of diaper rash, possibly because their stools have higher pH and lower enzymatic activity. [10] Diaper rash is also most likely to be diagnosed in infants 8–12 months old, perhaps in response to an increase in eating solid foods and dietary changes around that age that affect fecal composition. Any time an infant's diet undergoes a significant change (i.e. from breast milk to formula or from milk to solids) there appears to be an increased likelihood of diaper rash. [11]

The link between feces and IDD is also apparent in the observation that infants are more susceptible to developing diaper rash after treating with antibiotics, which affect the intestinal microflora. [12] [13] Also, there is an increased incidence of diaper rash in infants who have had diarrhea in the previous 48 hours, which may be because fecal enzymes such as lipase and protease are more active in feces which have passed rapidly through the gastrointestinal tract. [14]

Secondary infections

The significance of secondary infection in IDD remains controversial. There seems to be no link between presence or absence of IDD and microbial counts. [6] Although apparently healthy infants sometimes culture positive for Candida and other organisms without exhibiting any symptoms, there does seem to be a positive correlation between the severity of the diaper rash noted and the likelihood of secondary involvement. [15] A wide variety of infections has been reported, including Staphylococcus aureus, Streptococcus pyogenes, Proteus mirabilis , enterococci and Pseudomonas aeruginosa , but it appears that Candida is the most common opportunistic invader in diaper areas. [15] [16] [17] [18]

Diagnosis

The diagnosis of IDD is made clinically, by observing the limitation of an erythematous eruption to the convex surfaces of the genital area and buttocks. If the diaper dermatitis occurs for greater than 3 days it may be colonized with Candida albicans , giving it the beefy red, sharply marginated, appearance of diaper candidiasis. [19]

Differential diagnosis

Other rashes that occur in the diaper area include seborrhoeic dermatitis and atopic dermatitis. Both Seborrheic and Atopic dermatitis require individualized treatment; they are not the subject of this article.

Treatments

Use of medicinal herbs in north Cameroon Autres Medicaments traditionnels pour rouge fesse a Maroua.jpg
Use of medicinal herbs in north Cameroon

Possible treatments include minimizing diaper use, and using barrier creams, mild topical cortisones, and antifungal agents. A variety of other inflammatory and infectious processes can occur in the diaper area and an awareness of these secondary types of diaper dermatitis aids in the accurate diagnosis and treatment of patients. [20]

Overall, there is sparse evidence of sufficient quality to be certain of the effectiveness of the various treatments. Washcloths with cleansing, moisturising and protective properties may be better than soap and water, and skin cleansers may also be better than soap and water, but the certainty of evidence with regard other treatments is very low. [21]

Diaper changing

The most effective treatment, although not the most practical one, is to discontinue use of diapers, allowing the affected skin to air out. [22] Another option is simply to increase the frequency of diaper changing. [19] Thorough drying of the skin before diapering is a good preventive measure because it is the excess moisture, either from urine and feces or from sweating, that sets the conditions for a diaper rash to occur. [23]

Diaper type

Some sources claim that diaper rash is more common with cloth diapers. [6] Others claim the material of the diaper is relevant insofar as it can wick and keep moisture away from the baby's skin, and preventing secondary Candida infection. [24] However, there may not be enough data from good-quality, randomized controlled trials to support or refute disposable diaper use thus far. [25] Furthermore, the effect of non-biodegradable diapers on the environment is a concerning matter for public policy. [26]

Creams, ointments

Another approach is to block moisture from reaching the skin, and commonly recommended remedies using this approach include oil-based protectants or barrier cream, various over-the-counter "diaper creams", petroleum jelly, dimethicone and other oils. Such sealants sometimes accomplish the opposite if the skin is not thoroughly dry, in which case they serve to seal the moisture inside the skin rather than outside.

Zinc oxide-based ointments such as zinc and castor oil cream, Sudocrem or Pinxav can be effective treatments, [27] [28] [29] especially in prevention, because they have both a drying and an astringent effect on the skin, being mildly antiseptic without causing irritation. [20]

A 2005 meta-analysis found no evidence to support the use of topical vitamin A to treat the condition. [30]

Dangers of using powders

Various moisture-absorbing powders, such as talcum or starch, reduce moisture but may introduce other complications. Airborne powders of any sort can irritate lung tissue, and powders made from starchy plants (corn, arrowroot) provide food for fungi and are not recommended by the American Academy of Dermatology. [31]

Antifungals

In persistent or especially bad rashes, an antifungal cream often has to be used. In cases that the rash is more of an irritation, a mild topical corticosteroid preparation, e.g. hydrocortisone cream, is used. As it is often difficult to tell a fungal infection apart from a mere skin irritation, many physicians prefer a corticosteroid-and-antifungal combination cream such as hydrocortisone/miconazole.

Related Research Articles

<span class="mw-page-title-main">Diaper</span> Undergarment for incontinence containment

A diaper or a nappy is a type of underwear that allows the wearer to urinate or defecate without using a toilet, by absorbing or containing waste products to prevent soiling of outer clothing or the external environment. When diapers become wet or soiled, they require changing, generally by a second person such as a parent or caregiver. Failure to change a diaper on a sufficiently regular basis can result in skin problems around the area covered by the diaper.

<span class="mw-page-title-main">Dermatitis</span> Inflammatory disease of the skin

Dermatitis is a term used for different types of skin inflammation, typically characterized by itchiness, redness and a rash. In cases of short duration, there may be small blisters, while in long-term cases the skin may become thickened. The area of skin involved can vary from small to covering the entire body. Dermatitis is also called eczema but the same term is often used for the most common type of skin inflammation, atopic dermatitis.

<span class="mw-page-title-main">Lanolin</span> Yellow waxy substance secreted by the sebaceous glands of wool-bearing animals

Lanolin, also called wool fat, wool yolk, wool wax, sheep grease, sheep yolk, or wool grease, is a wax secreted by the sebaceous glands of wool-bearing animals. Lanolin used by humans comes from domestic sheep breeds that are raised specifically for their wool. Historically, many pharmacopoeias have referred to lanolin as wool fat ; however, as lanolin lacks glycerides, it is not a true fat. Lanolin primarily consists of sterol esters instead. Lanolin's waterproofing property aids sheep in shedding water from their coats. Certain breeds of sheep produce large amounts of lanolin.

<span class="mw-page-title-main">Dandruff</span> Skin condition of the scalp

Dandruff is a skin condition that mainly affects the scalp. Symptoms include flaking and sometimes mild itchiness. It can result in social or self-esteem problems. A more severe form of the condition, which includes inflammation of the skin, is known as seborrhoeic dermatitis.

<span class="mw-page-title-main">Tinea cruris</span> Fungal infection

Tinea cruris (TC), also known as jock itch, is a common type of contagious, superficial fungal infection of the groin and buttocks region, which occurs predominantly but not exclusively in men and in hot-humid climates.

<span class="mw-page-title-main">Contact dermatitis</span> Inflammation from allergen or irritant exposure

Contact dermatitis is a type of acute or chronic inflammation of the skin caused by exposure to chemical or physical agents. Symptoms of contact dermatitis can include itchy or dry skin, a red rash, bumps, blisters, or swelling. These rashes are not contagious or life-threatening, but can be very uncomfortable.

<span class="mw-page-title-main">Nummular dermatitis</span> Medical condition

Nummular dermatitis is one of the many forms of dermatitis. It is characterized by round or oval-shaped itchy lesions. The name comes from the Latin word "nummus," which means "coin."

<span class="mw-page-title-main">Tinea capitis</span> Cutaneous fungal infection of the scalp

Tinea capitis is a cutaneous fungal infection (dermatophytosis) of the scalp. The disease is primarily caused by dermatophytes in the genera Trichophyton and Microsporum that invade the hair shaft. The clinical presentation is typically single or multiple patches of hair loss, sometimes with a 'black dot' pattern, that may be accompanied by inflammation, scaling, pustules, and itching. Uncommon in adults, tinea capitis is predominantly seen in pre-pubertal children, more often boys than girls.

<span class="mw-page-title-main">Moisturizer</span> Type of cosmetics

A moisturizer, or emollient, is a cosmetic preparation used for protecting, moisturizing, and lubricating the skin. These functions are normally performed by sebum produced by healthy skin. The word "emollient" is derived from the Latin verb mollire, to soften.

<span class="mw-page-title-main">Intertrigo</span> Inflammatory skin rash within bodily folds

Intertrigo, commonly called “skin fold dermatitis”, refers to a type of inflammatory rash (dermatitis) of the superficial skin that occurs within a person's body folds. These areas are more susceptible to irritation and subsequent infection due to factors that promote skin breakdown such as moisture, friction, and exposure to bodily secretions and excreta such as sweat, urine, or feces. Areas of the body which are more likely to be affected by intertrigo include the inframammary fold, intergluteal cleft, armpits, and spaces between the fingers or toes. Skin affected by intertrigo is more prone to infection than intact skin.

<span class="mw-page-title-main">Cradle cap</span> Crusting or scaling of a babys scalp

Cradle cap is crusty or oily scaly patches on a baby's scalp. The condition is not painful or itchy, but it can cause thick white or yellow scales that are not easy to remove. Cradle cap most commonly begins sometime in the first three months but can occur in later years. Similar symptoms in older children are more likely to be dandruff than cradle cap. The rash is often prominent around the ear, the eyebrows or the eyelids. It may appear in other locations as well, where it is called infantile seborrhoeic dermatitis. Cradle cap is just a special—and more benign—case of this condition. The exact cause of cradle cap is not known. Cradle cap is not spread from person to person. It is also not caused by poor hygiene. It is not an allergy, and it is not dangerous. Cradle cap often lasts a few months. In some children, the condition can last until age 2 or 3.

Vulvitis is inflammation of the vulva, the external female mammalian genitalia that include the labia majora, labia minora, clitoris, and introitus. It may co-occur as vulvovaginitis with vaginitis, inflammation of the vagina, and may have infectious or non-infectious causes. The warm and moist conditions of the vulva make it easily affected. Vulvitis is prone to occur in any female especially those who have certain sensitivities, infections, allergies, or diseases that make them likely to have vulvitis. Postmenopausal women and prepubescent girls are more prone to be affected by it, as compared to women in their menstruation period. It is so because they have low estrogen levels which makes their vulvar tissue thin and dry. Women having diabetes are also prone to be affected by vulvitis due to the high sugar content in their cells, increasing their vulnerability. Vulvitis is not a disease, it is just an inflammation caused by an infection, allergy or injury. Vulvitis may also be symptom of any sexually transmitted infection or a fungal infection.

<span class="mw-page-title-main">Perioral dermatitis</span> Medical condition

Perioral dermatitis, also known as periorificial dermatitis, is a common type of inflammatory skin rash. Symptoms include multiple small (1–2 mm) bumps and blisters sometimes with background redness and scale, localized to the skin around the mouth and nostrils. Less commonly, the eyes and genitalia may be involved. It can be persistent or recurring, and resembles particularly rosacea and to some extent acne and allergic dermatitis. The term "dermatitis" is a misnomer because this is not an eczematous process.

gDiapers are a hybrid diaper, so users can choose to use either a cloth insert or a disposable insert that can be flushed or composted. Co-founders are Jason and Kimberley Graham-Nye. gDiapers began being sold in 2004. gDiapers are licensed from Kuver Designs Pty Ltd, Tasmania, "Eenee designs" diapers.

<span class="mw-page-title-main">Swim diaper</span> Diaper that is made for those who have fecal incontinence

A swim diaper or swim nappy is a diaper that is made for those who have fecal incontinence, which is worn underneath a bathing suit, or as a bathing suit. Swim diapers can be reusable and disposable. They are not intended to be absorbent, but only to contain solid waste (feces); the lack of absorbency prevents the swim diaper from swelling with water.

A barrier cream is a topical formulation used in industrial applications and as a cosmetic to place a physical barrier between the skin and contaminants that may irritate the skin. There are many other terms for creams designed to protect skin from harmful substances, including skin protective creams, pre-work creams, antisolvent gels, protective ointments, and shielding lotions. Three classes of barrier creams are used: water repellent creams, water-soluble creams, and creams designed for special applications. Barrier creams may contain substances such as zinc oxide, talc or kaolin to layer over the skin. For hand care they are designed to protect against the harm from detergents and other irritants.

<span class="mw-page-title-main">Streptococcal intertrigo</span> Medical condition

Streptococcal intertrigo is a skin condition that is secondary to a streptococcal bacterial infection. It is often seen in infants and young children and can be characterized by a fiery-red color of the skin, foul odor with an absence of satellite lesions, and skin softening in the neck, armpits or folds of the groin. Newborn children and infants commonly develop intertrigo because of physical features such as deep skin folds, short neck, and flexed posture. Prompt diagnosis by a medical professional and treatment with topical and/or oral antibiotics can effectively relieve symptoms.

Perianal cellulitis, also known as perianitis or perianal streptococcal dermatitis, is a bacterial infection affecting the lower layers of the skin (cellulitis) around the anus. It presents as bright redness in the skin and can be accompanied by pain, difficulty defecating, itching, and bleeding. This disease is considered a complicated skin and soft tissue infection (cSSTI) because of the involvement of the deeper soft tissues.

Granuloma gluteale infantum is a cutaneous condition that appears in the anogenital region of infants as a complication of diaper dermatitis. According to some, no granulomas are found.

Topical antifungaldrugs are used to treat fungal infections on the skin, scalp, nails, vagina or inside the mouth. These medications come as creams, gels, lotions, ointments, powders, shampoos, tinctures and sprays. Most antifungal drugs induce fungal cell death by destroying the cell wall of the fungus. These drugs inhibit the production of ergosterol, which is a fundamental component of the fungal cell membrane and wall.

References

  1. ↑ James WD, Berger T, Elston D (2006). Andrews' diseases of the skin : clinical dermatology (10th ed.). Philadelphia: Saunders Elsevier. ISBN   978-0-7216-2921-6.
  2. ↑ Rapini RP, Bolognia JL, Jorizzo JL (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. ISBN   978-1-4160-2999-1.
  3. ↑ Harper J, Oranje AP, Prose NS (2006). Textbook of pediatric dermatology. Wiley-Blackwell. pp. 160–. ISBN   978-1-4051-1046-4 . Retrieved 9 May 2010.
  4. ↑ Payne D (March 2017). "Stop the rash: managing incontinence-associated dermatitis in the community". British Journal of Community Nursing. 22 (Suppl 3): S20–S26. doi:10.12968/bjcn.2017.22.Sup3.S20. PMID   28252336.
  5. ↑ Barthel W, Markwardt F (October 1975). "Aggregation of blood platelets by adrenaline and its uptake". Biochemical Pharmacology. 24 (20): 1903–1904. doi:10.1016/0006-2952(75)90415-3. PMID   20.
  6. 1 2 3 4 Shin HT (April 2014). "Diagnosis and management of diaper dermatitis". Pediatric Clinics of North America. Pediatric Dermatology. 61 (2): 367–382. doi:10.1016/j.pcl.2013.11.009. PMID   24636651.
  7. ↑ "What is diaper rash: What causes diaper rash?". MedicalBug. Archived from the original on 8 September 2012. Retrieved 31 August 2012.
  8. ↑ Chiou YB, Blume-Peytavi U (2004). "Stratum corneum maturation. A review of neonatal skin function". Skin Pharmacology and Physiology. 17 (2): 57–66. doi:10.1159/000076015. PMID   14976382. S2CID   84937490.
  9. ↑ Dib R. "Diaper Rash". Medscape. Retrieved 31 August 2012.
  10. ↑ Hockenberry MJ (2003). Wong's Nursing Care of Infants and Children. St. Louis, MO: Mosby, Inc.
  11. ↑ Atherton D, Mills K (July 2004). "What can be done to keep babies' skin healthy?". RCM Midwives. 7 (7): 288–290. PMID   15314924.
  12. ↑ Borkowski S (2004). "Diaper rash care and management". Pediatric Nursing. 30 (6): 467–470. PMID   15704594.
  13. ↑ Gupta AK, Skinner AR (November 2004). "Management of diaper dermatitis". International Journal of Dermatology. 43 (11): 830–834. doi:10.1111/j.1365-4632.2004.02405.x. PMID   15533067. S2CID   34330025.
  14. ↑ Atherton DJ (May 2004). "A review of the pathophysiology, prevention and treatment of irritant diaper dermatitis". Current Medical Research and Opinion. 20 (5): 645–649. doi:10.1185/030079904125003575. PMID   15140329. S2CID   34454726.
  15. 1 2 Ferrazzini G, Kaiser RR, Hirsig Cheng SK, Wehrli M, Della Casa V, Pohlig G, et al. (2003). "Microbiological aspects of diaper dermatitis". Dermatology. 206 (2): 136–141. doi:10.1159/000068472. PMID   12592081. S2CID   25202981.
  16. ↑ Ward DB, Fleischer AB, Feldman SR, Krowchuk DP (September 2000). "Characterization of diaper dermatitis in the United States". Archives of Pediatrics & Adolescent Medicine. 154 (9): 943–946. doi: 10.1001/archpedi.154.9.943 . PMID   10980800.
  17. ↑ Wolf R, Wolf D, Tüzün B, Tüzün Y (November 2000). "Diaper dermatitis". Clinics in Dermatology. 18 (6): 657–660. doi:10.1016/s0738-081x(00)00157-7. PMID   11173200.
  18. ↑ Weston WL, Lane AT, Weston JA (October 1980). "Diaper dermatitis: current concepts". Pediatrics. 66 (4): 532–536. doi:10.1542/peds.66.4.532. PMID   7432838. S2CID   26153621.
  19. 1 2 Hay WW, Levin MJ, Deterding RR, Abzug MJ (2014-04-29). Current diagnosis & treatment : pediatrics (Twenty-second ed.). New York. ISBN   978-0-07-182734-8. OCLC   877881324.{{cite book}}: CS1 maint: location missing publisher (link)
  20. 1 2 Scheinfeld N (2005). "Diaper dermatitis: a review and brief survey of eruptions of the diaper area". American Journal of Clinical Dermatology. 6 (5): 273–281. doi:10.2165/00128071-200506050-00001. PMID   16252927. S2CID   34429805.
  21. ↑ Beeckman D, Van Damme N, Schoonhoven L, Van Lancker A, Kottner J, Beele H, et al. (November 2016). "Interventions for preventing and treating incontinence-associated dermatitis in adults". The Cochrane Database of Systematic Reviews. 11 (8): CD011627. doi:10.1002/14651858.CD011627.pub2. PMC   6464993 . PMID   27841440.
  22. ↑ "Nappy Rash". Medinfo. Retrieved 31 August 2012.
  23. ↑ "How to Treat Baby Rash? Identify and Treat Baby Rash". thebabyrash.com. 2017-05-02. Retrieved 2017-05-21.
  24. ↑ Akin F, Spraker M, Aly R, Leyden J, Raynor W, Landin W (2001-08-01). "Effects of breathable disposable diapers: reduced prevalence of Candida and common diaper dermatitis". Pediatric Dermatology. 18 (4): 282–290. doi:10.1046/j.1525-1470.2001.01929.x. PMID   11576399. S2CID   6695787.
  25. ↑ Baer EL, Davies MW, Easterbrook KJ (July 2006). "Disposable nappies for preventing napkin dermatitis in infants". The Cochrane Database of Systematic Reviews. 2014 (3): CD004262. doi:10.1002/14651858.CD004262.pub2. PMC   8769680 . PMID   16856040.
  26. ↑ Prasad HR, Srivastava P, Verma KK (October 2004). "Diapers and skin care: merits and demerits". Indian Journal of Pediatrics. 71 (10): 907–908. doi:10.1007/bf02830834. PMID   15531833. S2CID   24468797.
  27. ↑ Williams, Cheryll (1 July 2012). Medicinal Plants in Australia Volume 3: Plants, Potions and Poisons. Rosenberg Publishing. p. 309. ISBN   978-1-925078-07-7. Archived from the original on 20 April 2023. Retrieved 8 March 2023.
  28. ↑ Nathan, Alan (2010). Non-prescription Medicines. Pharmaceutical Press. p. 206. ISBN   978-0-85369-886-9 . Retrieved 8 March 2023.
  29. ↑ Waddilove, Rachel (2008). The Toddler Book: How to Enjoy Your Growing Child. Lion Books. p. 141. ISBN   978-0-7459-5296-3.
  30. ↑ Davies MW, Dore AJ, Perissinotto KL (October 2005). "Topical vitamin A, or its derivatives, for treating and preventing napkin dermatitis in infants". The Cochrane Database of Systematic Reviews. 2005 (4): CD004300. doi:10.1002/14651858.CD004300.pub2. PMC   6718230 . PMID   16235358.
  31. ↑ "Mom and baby skin care". American Academy of Dermatology. Archived from the original on 17 August 2012. Retrieved 31 August 2012.
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