Diaper rash Clinical consideration and evaluation THE 2ND AL JAHRA INTERNATIONAL PEDIATRIC CONFERENCE Diaper rash Clinical consideration and evaluation Dr. Shehab Al-Dhafiri, MD, FRCPC Consultant Dermatologist Al-Jahra Hospital

Introduction Diaper dermatitis, also called diaper rash, napkin dermatitis, and nappy rash. The most common skin eruption in infants and toddlers. Diaper dermatitis is a form of irritant contact dermatitis in most cases. Can also be seen in people who are incontinent or paralyzed. Shin HT. Diagnosis and management of diaper dermatitis. Pediatr Clin North Am 2014; 61:367. Klunk C, Domingues E, Wiss K. An update on diaper dermatitis. Clin Dermatol 2014; 32:477.

Introduction Typically occurs on convex skin surfaces that are in direct contact with the diaper. Usually Sparing the skin folds, unless there is Candida superinfection. May also be the manifestation of unrelated skin conditions that coincidently manifest in the diaper area, such as seborrheic dermatitis or atopic dermatitis. Clinical features, diagnosis, treatment, and prevention of irritant diaper dermatitis will be reviewed.

Pattern for irritant diaper dermatitis

Irritant Contact Dermatitis

Irritant Contact Dermatitis Irritant Contact Dermatitis: Diaper dermatitis: Erythematous eczematous plaques with microvesiculation and erosions involving diaper region of a female infant. Note the sparing of the skin folds (see arrows) which are usually involved in candidal infection.

Classification of diaper dermatitis Associated with diaper use Regardless of diaper use Irritant diaper dermatitis Seborrheic dermatitis Candidal dermatitis Child abuse Jacquet's erosive dermatitis Psoriasis Granuloma gluteale infantum Atopic dermatitis Allergic contact dermatitis Impetigo Scabies Langerhans histiocytosis Nutritional deficiency Immunodeficiency Data from: Singalavanija S, Frieden IJ. Diaper dermatitis. Pediatr Rev 1995; 16:142. Graphic 81540 Version 2.0

EPIDEMIOLOGY The reported incidence and age of onset of diaper dermatitis vary worldwide. Differences in diaper use, toilet training, hygiene, and child- carepractices in different countries. In the United States, dermatitis of the diaper area represents 10 to 20 percent of all skin disorders evaluated by the general pediatrician. Ward DB, Fleischer AB Jr, Feldman SR, Krowchuk DP. Characterization of diaper dermatitis in the United States. Arch Pediatr Adolesc Med 2000; 154:943.

EPIDEMIOLOGY 1990-1997 National Ambulatory Medical Care Survey, there were 8.2 million pediatric visits for diaper dermatitis. In infants, the estimated prevalence of diaper dermatitis ranges from 7 to 35 percent. Diaper dermatitis can develop as early as one week of age, but the peak incidence occurs between 9 and 12 months. Ward DB, Fleischer AB Jr, Feldman SR, Krowchuk DP. Characterization of diaper dermatitis in the United States. Arch Pediatr Adolesc Med 2000; 154:943.

PATHOGENESIS Several factors are involved in the pathogenesis. Excessive moisture, friction, increased pH, and high enzymatic activity. Disruption of the skin barrier function. The normal acidic pH of the stratum corneum ("acid mantle") has an important role in the formation and maintenance of the permeability barrier and the normal microflora. Provides innate antimicrobial protection against invasion by pathogenic bacteria and yeasts. Ali SM, Yosipovitch G. Skin pH: from basic science to basic skin care. Acta Derm Venereol 2013; 93:261.

PATHOGENESIS The increased moisture in the diaper area due to a combination of the occlusive effect of the diaper with the presence of fecal and urinary waste. leads to maceration of the skin and disruption of the stratum corneum. Maceration increases the susceptibility to frictional damage from the diaper. Further impairment of the skin barrier function. Kazaks EL, Lane AT. Diaper dermatitis. Pediatr Clin North Am 2000; 47:909.

PATHOGENESIS An altered skin barrier permits increased permeation of chemical irritants and micro-organisms. The primary chemical irritants in the diaper area are derived from the synergistic action of urine and stool. Fecal bacteria produce the enzyme urease, which interacts with urine to increase the pH level beneath the diaper. 20. Berg RW, Buckingham KW, Stewart RL. Etiologic factors in diaper dermatitis: the role of urine. Pediatr Dermatol 1986; 3:102. 21. Buckingham KW, Berg RW. Etiologic factors in diaper dermatitis: the role of feces. Pediatr Dermatol 1986; 3:107.

PATHOGENESIS Elevated pH levels Activate fecal enzymes (protease and lipase) that directly irritate and damage the skin, causing an inflammatory skin reaction. Alters the cutaneous microbiome, making the skin more susceptible to colonization by pathogenic organisms (eg, Staphylococcus aureus, Streptococcus pyogenes) and organisms found in the stool, such as Candida albicans. Ferrazzini G, Kaiser RR, Hirsig Cheng SK, et al. Microbiological aspects of diaper dermatitis. Dermatology 2003; 206:136.

RISK FACTORS Infants with diarrhea o have an increased risk of developing diaper dermatitis due to continuous local skin irritation. Breast-fed infants have a lower incidence of diaper dermatitis than formula-fed infants, possibly because breast-fed infants have lower stool pH. Recent use of broad-spectrum antibiotics may predispose infants to develop diaper dermatitis by increasing the risk of developing diarrhea and secondary yeast infections.

CLINICAL FEATURES Irritant diaper dermatitis typically occurs on convex skin surfaces that are in direct contact with the diaper. Buttocks, lower abdomen, genitalia, and upper thighs. Skin folds (areas not in direct contact with the diaper) are classically spared.

CLINICAL FEATURES Mild diaper dermatitis: Scattered erythematous papules or mild asymptomatic erythema over limited skin areas with minimal maceration and frictional irritation. Moderate diaper dermatitis: More erythema with maceration or superficial erosions. Pain and discomfort are associated symptoms. Severe diaper dermatitis: Extensive erythema with a glossy appearance, painful erosions, papules, and nodules.

Miliaria rubra: Scattered tiny red papules and papulovesicles mostly at elasticized openings of the diaper with limited erythema. Limited erythema and scattered erythematous papules are present in the diaper area of this child with mild diaper dermatitis.

Severe diaper dermatitis with diffuse erythema and large eroded areas.

Extensive erythema, scaling, and nodules in the diaper area of this child with severe diaper dermatitis.

Rare clinical variants of severe chronic irritant diaper dermatitis

Jacquet's Erosive Dermatitis: Multiple perianal moist erosions with ill-defined diffuse erythema involving the buttocks and both proximal thighs of a 5 months old infant.

Jacquet's erosive diaper dermatitis Rare, distinctive, severe variant of irritant contact diaper dermatitis. More common in infants and children with chronic diarrhea or incontinence. It is characterized by well-demarcated, punched-out ulcers, or erosions with crater-like borders. Treated in the same manner as irritant diaper dermatitis. Rodriguez-Poblador J, González-Castro U, Herranz-Martínez S, Luelmo-Aguilar J. Jacquet erosive diaper dermatitis after surgery for Hirschsprung disease. Pediatr Dermatol 1998; 15:46. Paradisi A, Capizzi R, Ghitti F, et al. Jacquet erosive diaper dermatitis: a therapeutic challenge. Clin Exp Dermatol 2009; 34:e385.

Granuloma gluteale infantum Reddish-purple nodules in the inguinal folds, scrotum, buttocks, and medial thighs. Precipitating factors including the use of high-potency topical corticosteroids and preexisting candidal infections. Clinically resemble a neoplastic process; however, it is considered a benign inflammatory dermatosis. Skin biopsy may help confirm the diagnosis. Improves with the avoidance of inciting factors and aggressive barrier protection. Bluestein J, Furner BB, Phillips D. Granuloma gluteale infantum: case report and review of the literature. Pediatr Dermatol 1990; 7:196. De Zeeuw R, Van Praag MC, Oranje AP. Granuloma gluteale infantum: a case report. Pediatr Dermatol 2000; 17:141.

Clinical Course Diaper dermatitis is typically episodic. Each episode of mild to moderate diaper dermatitis treated with conventional therapies has an average duration of two to three days. Morbidity associated with diaper dermatitis Discomfort. Secondary candidal or less commonly bacterial infection. Diaper dermatitis that persists for more than three days despite standard treatment may be secondarily infected with C. albicans.

Erythematous plaques and satellite pustules in an infant.

Candidal Intertrigo: Well-defined erythematous plaque involving diaper area with multiple satellite papules and pustules in a female infant.

Candidal infection Presents with beefy red plaques with satellite papules, and pustules at the periphery. Commonly involve the skin folds. History of diarrhea, recent antibiotic use, or oral thrush. Diagnosis Based on the clinical presentation, Confirmed by (KOH) preparation demonstrating pseudohyphae. Fungal culture. Persistent candidal diaper rash in young children may be a sign of type 1 DM, chronic mucocutaneous candidiasis, or an underlying immune deficiency.

Bullous impetigo in an infant

Bullous impetigo of the diaper area presenting with superficial erosions with a collarette of scale.

Impetigo Secondary infection from S. aureus and, less frequently, from S. pyogenes also may develop. Hallmarks of impetigo include 1 to 2 mm fragile pustules and honeycolored crusted erosions. Bullous impetigo: Large, flaccid, bullae that tend to rupture easily, leaving erosions with a collarette of scale. Caused by Staphylococcus aureus Phage group II, types 71 and 55 Produce exfoliative or epidermolytic toxins. These toxins are restricted to the area of infection in B.impetigo. If these toxins spread hematogenously, they can produce Staphylococcal Scalded Skin Syndrome (SSSS syndrome).

Impetigo It is mainly seen in children younger than 2 years. Gram stain and bacterial culture of a pustule may be performed to confirm the diagnosis. Treatment with antibiotics is required.

Intense perianal erythema with well-defined margins characterizes perianal infection from group A Streptococcus pyogenes.

Streptococcal perianal dermatitis Infants and young children may develop perianal group A streptococcal infection. Clinical features include a sharply demarcated painful, bright red, perianal erythema. The patient and/or household contacts may have a history of recurrent streptococcal pharyngitis. Treatment with antibiotics is required. Brilliant LC. Perianal streptococcal dermatitis. Am Fam Physician 2000; 61:391.

Examples of non-diaper causes of diaper dermatitis.

Moist, glistening, erythematous plaques involving multiple intertriginous areas in this infant with seborrheic dermatitis.

Infantile Seborrheic Dermatitis Due to trans-placental passage of maternal androgen hormones to the fetus. In infants, seborrheic dermatitis of the scalp is often called "cradle cap. Infantile seborrheic dermatitis is a self-limited condition that resolves usually within 3-6 months Following the disappearance of maternal sex hormones from the circulation of the newborn. Seborrheic dermatitis may be associated with Leiner disease Severe generalized SD, recurrent diarrhea, recurrent skin and internal infections, and failure to thrive. Functional defect of the C5 component of complement

Sarcoptes scabiei and eggs

In infants, atopic dermatitis characteristically spares the diaper area.

Erythematous and scaling plaques in an infant with psoriasis Erythematous and scaling plaques in an infant with psoriasis. Note the involvement of the diaper area, usually spared in infants with atopic dermatitis.

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Yellow-brown and erythematous papules, erosions, and crusts are present on this infant with Langerhans cell histiocytosis.

Langerhans Cell Histiocytosis Yellow-brown scaly or erythematous papules, purpuric papules, ulcerations, and skin atrophy are present. Severe hemorrhagic diaper dermatitis unresponsive to treatment usually involving skin folds. Other involved areas include the scalp and retroauricular areas May have associated anemia, lymphadenopathy, and hepatosplenomegaly, Involvement of the CNS, lungs, bones, and bone marrow. Diagnosis is confirmed by skin biopsy.

Acrodermatitis enteropathica in an infant Acrodermatitis enteropathica in an infant. Moist erythematous plaques are present on the cheeks and buttocks. The buttock lesions are typically symmetric.

Acrodermatitis Enteropathica Associated with diarrhea, hair loss, and erosive perioral dermatitis Patient may have a predisposition for malabsorption (ie, cystic fibrosis) or malnutrition Diagnosis is confirmed by low serum Zinc. Treatment is Zinc supplement.

MANAGEMENT

MANAGEMENT Skin care measures of the diaper area. Barrier preparations. Topical corticosteroids. Antifungal agents. Antibiotics.

SKIN CARE MEASURES: Limits prolonged skin contact with stool and urine and therefore is an essential aspect of the management of diaper dermatitis. Frequent diaper changing, air exposure, and gentle cleansing. The diaper area should be gently cleaned with warm water and a small amount of a mild cleansing product with physiologic pH (fragrance-free and alcohol-free baby wipes) .

Choice of diaper Controversial issue. Disposable diapers have an absorbent gel core that can absorb up to 80 times its weight in water. Not enough evidence from good-quality randomized controlled trials to support or refute the use and type of disposable diapers to prevent diaper dermatitis in infants. Baer EL, Davies MW, Easterbrook KJ. Disposable nappies for preventing napkin dermatitis in infants. Cochrane Database Syst Rev 2006; :CD004262. Odio M, Friedlander SF. Diaper dermatitis and advances in diaper technology. Curr Opin Pediatr 2000; 12:342.

WHAT IS THE BEST DIAPER RASH CREAM?

BARRIER PREPARATIONS Physically block chemical irritants and moisture from contacting the skin and minimize friction. Pastes and ointments generally are better barriers than creams and lotions, which are poorly adherent, minimally occlusive, and may contain fragrances and preservatives. The most common over-the-counter topical barriers contain zinc oxide, or petrolatum, both. Some also contain lanolin, paraffin, or dimethicone. Examples include Sudocrem, Mustela, QV etc. Humphrey S, Bergman JN, Au S. Practical management strategies for diaper dermatitis. Skin Therapy Lett 2006; 11:1.

BARRIER PREPARATIONS Ideally, the first-line therapy for diaper dermatitis is zinc oxide ointment or various products containing zinc oxide. Zinc oxide is an inexpensive treatment with the following properties: Antiseptic and astringent Significant role in wound healing Low risk for allergic or contact dermatitis Topical barriers are applied with every diaper change; they should be applied thickly and can be covered with petroleum jelly to prevent sticking to the diaper. Xhauflaire-Uhoda E, Henry F, Pierard-Franchimont C, Pierard GE. Electrometric assessment of the effect of a zinc oxide paste in diaper dermatitis. Int J Cosmet Sci. 2009 Oct. 31(5):369-74.

TOPICAL CORTICOSTEROIDS Has not been evaluated in randomized trials. A low-potency topical corticosteroid can reduce the inflammation in diaper dermatitis that persists despite skin care measures and use of barrier preparations. The use of potent or fluorinated corticosteroids in the diaper area should be avoided, Occlusion in the diaper area promotes systemic absorption and may cause adrenal suppression and iatrogenic Cushing syndrome. Semiz S, Balci YI, Ergin S, et al. Two cases of Cushing's syndrome due to overuse of topical steroid in the diaper area. Pediatr Dermatol 2008; 25:544.

ANTIFUNGAL AGENTS Antifungal agents such as nystatin, clotrimazole, miconazole, and ketoconazole are effective topical therapies for diaper dermatitis complicated by secondary Candida infection. The dermatitis has been present for at least three days increases the likelihood of secondary infection with Candida. Antifungal creams are applied to the diaper area beneath the barrier ointment two to three times a day until the rash has resolved.

BREAST MILK Breast milk is thought to have anti-inflammatory and antimicrobial properties. In one study including 150 infants with mild to moderate diaper dermatitis, breast milk was as effective as 1% hydrocortisone cream in clearing the rash after seven days of treatment. Another study compared breast milk with a zinc-oxide containing barrier cream in the treatment of moderate to severe diaper dermatitis in infants in the neonatal intensive care unit. The time to improvement was similar in the two groups. Farahani LA, Ghobadzadeh M, Yousefi P. Comparison of the effect of human milk and topical hydrocortisone 1% on diaper dermatitis. Pediatr Dermatol 2013; 30:725. Gozen D, Caglar S, Bayraktar S, Atici F. Diaper dermatitis care of newborns human breast milk or barrier cream. J Clin Nurs 2014; 23:515.

HARMFUL PRODUCTS American Academy of Pediatrics does not recommend using baby powder. Use of powders such as cornstarch or talcum powder pose a significant respiratory risk if accidentally aspirated. Baking soda and boric acid powders also should be avoided because of the risk of systemic toxicity with percutaneous absorption. Topical barriers or medications that contain fragrance, preservatives, and other ingredients with irritant or allergic potential ( neomycin) should be avoided . Products containing camphor, phenol, benzocaine, and salicylates also should be avoided because of the potential for systemic toxicity and/or methemoglobinemia. Silver P, Sagy M, Rubin L. Respiratory failure from corn starch aspiration: a hazard of diaper changing. Pediatr Emerg Care 1996; 12:108. Gonzalez J, Hogg RJ. Metabolic alkalosis secondary to baking soda treatment of a diaper rash. Pediatrics 1981; 67:820. Tush GM, Kuhn RJ. Methemoglobinemia induced by an over-the-counter medication. Ann Pharmacother 1996; 30:1251.

PREVENTION The most effective way to prevent irritant diaper dermatitis is to minimize direct skin contact with urine and feces. Frequent diaper change. Gentle cleansing with warm water and a soft cloth is sufficient. Fragrance-free and alcohol-free baby wipes can be used, but should be discontinued if the skin becomes irritated or broken down. Good hand washing is a must to help prevent infections.

Diaper rash stops being a problem once the child is toilet trained, and the child no longer wears a diaper.

Thank you THE 2ND AL JAHRA INTERNATIONAL PEDIATRIC CONFERENCE Dr. Shehab Al-Dhafiri, MD, FRCPC Consultant Dermatologist

Evaluation

DIAGNOSIS The diagnosis of irritant diaper dermatitis is made clinically: erythematous eruption that involves the convex surfaces of buttocks and genital area. Sparing of the skin folds is characteristic of irritant diaper dermatitis, unless there is Candida superinfection. Diagnosis of candidal infection Based on the clinical presentation, Confirmed by (KOH) preparation demonstrating pseudohyphae. Fungal culture.

DIAGNOSIS Gram stain and bacterial culture of a pustule may be performed to confirm the diagnosis. Viral culture, polymerase chain reaction (PCR), direct fluorescent antibody (DFA), or Tzanck preparation for the diagnosis of herpes simplex virus. A skin biopsy may be necessary in cases in which the rash is atypical or unresponsive to conventional therapy.