CANDIDA DIAPER DERMATITIS [Diaper rash; Napkin dermatitis; Nappy rash] Dr. Immaculate Kariuki Consultant Paediatrician Nairobi, Kenya

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Case presentation A previously healthy 7 month old, baby T.B. presents with a diaper rash for the last 2 weeks that is not getting better. Initially the rash was raised and red; now it has erosions. Baby is irritable and fussy. The mother uses disposable diapers and has not changed the brand since birth. What further information will help you manage this child?

Further history TW was introduced to solid food 1 month ago. She had cough, fever & diarrhoea 1 week prior to developing the symptoms above which were treated with oral antibiotics for 5 days. She also has mild facial eczema treated with emollients. Which factors above increase the likelihood of this baby getting diaper dermatitis? What things will you be looking for on the examination?

Introduction Diaper dermatitis (all causes) is the commonest dermatological condition in infancy (up to 1/5 of all dermatology visits in some series). Affects area covered by diaper - perineum, buttocks, inner thigh & abdomen sometimes. Peak 9 - 12 months. Persistent symptoms for more than 3 days likely due to an infectious component. Candida species are the commonest organisms associated with diaper dermatitis.

Etiology of Candida diaper dermatitis Candida albicans- most prevalent Rarer causes: C. tropicalis, C. glabrata, C. parapsilosis. Typically a superinfection of irritant dermatitis with Candida Candida species are present in <4% of diaper area without dermatitis

Risk Factors Irritation by stool, urine and diaper components Recurrent use of antibiotics Frequent stooling - a factor of age or diarrhoea. Immunosuppression Notes 1.Dietary factors- postulated from age at onset( around the time of weaning) & less frequent in breastfed infants. 2.Prolonged contact with stool, urine or diaper components worsens irritation. Dietary factors Different infant skin physiology

Young infants skin function Skin microbiome is different, colonized primarily by Firmicutes, as opposed to Actinobacteria  in adults. Breakdown products of filaggrin proteolysis, known as natural moisturization factor (NMF), is lower Newborn skin is drier with more trans-epidermal water loss (TEWL) initially as compared to older infants. Has smaller keratinocytes, denser microrelief structures thinner stratum corneum & epidermis. Source: Diapered regions: skin hydration and skin pH is higher than rest of skin. The microbial flora colonizing buttocks area is similar to GI flora.

Pathogenesis Excessive moisture Friction Impaired skin barrier function Excessive moisture Friction Increased PH Altered cutaneous microbiome Permeation by commensal candida. High enzymatic activity from stool and urine. Stool: The presence of lipases and proteases causes skin damage with filaggrin proteolysis and increased NMFa and TWELb Urine: Presence of urea causes irritation and is the base product for conversion to ammonia High enzymatic activity

Diaper area irritation Redrawn from Redrawn from Pediatric Dermatology 2013;31 (1) :1-17

PH imbalance Increased PH Urease in stool breaks down urea in urine Disrupted normal flora with higher risk of candidiasis Bathing products Increased PH leads to increased enzyme activity

Clinical Presentation Irritability due to burning sensation and itching Persisting diaper dermatitis (more than 3 days) despite conservative treatment Characteristic rash involving the groin and gluteal folds Severe cases - erosion and ulceration.

Candida diaper rash Raised edge, sharp margins with white scales, satellite papules and pustules - characteristic feature of Candida infection. Dutta et al Indian Pediatr 2015;52: 1100

Candida diaper dermatitis Red, erythematous & scaly plaques with maceration and edema on the perianal area, buttocks and inner thighs

Candida diaper dermatitis Red, erythematous & scaly plaques with maceration and edema on the perianal area, buttocks, lower abdomen, and inner thighs Satellite lesions Folds involved. http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=65

White scaly papules on folds http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=65

Scaly & dry rash Folds involved. Satellite lesions. Dry as opposed to wet Desquamation. http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=65

DIAGNOSIS Clinical Direct observation with KOH 10% shows pseudohyphae especially from the satellite lesions. Mycology culture

MANAGEMENT See NICE guidelines https://cks.nice.org.uk/nappy-rash#!topicsummary

ABCDE ACRONYMN Effective for any-cause diaper dermatitis: Air Barrier Cleansing Diaper Education

What may alter management? Consider and look for bacterial superinfection. Look for oral candidiasis. Take a swab especially if bacterial infection suspected.

Topical Antifungals IMIDAZOLES - Clotrimazole, miconazole, ketoconazole and bifonazole - Applied twice a day for 7–10 day with high cure rates (50 to 68%) NYSTATIN - Commonly used. - Less effective than imidazoles. Switch if no response in 2-3 days CICLOPIROX - applied twice daily for 7 days.¹ Gallup E, Plott T, Ciclopirox TS Investigators A multicenter, open-label study to assess the safety and efficacy of ciclopirox topical suspension 0.77% in the treatment of diaper dermatitis due to Candida albicans.J Drugs Dermatol. 2005;4:29–34 Bonifaz A, Tirado-Sánchez A, Graniel MJ, Mena C, Valencia A, Ponce-Olivera RM. The efficacy and safety of sertaconazole cream (2%) in diaper dermatitis candidiasis. Mycopathologia. 2013;175:249–254. doi: 10.1007/s11046-013-9642-3 SERTACONAZOLE ²   - fungicide with long skin durability (up to 72 h). - broad-spectrum third-generation applied twice daily for 14 days.

Oral antifungal agents Indicated for : - Concomitant GIT candidiasis, including oral - Severe cases Options - Fluconazole 3-6mg/kg /day - Nystatin 100,000 IU x 3-4 daily (not absorbed)

In addition to antifungals Remove the diaper - Eliminates the wet environment - Reduces contact between skin and stool & urine - Less irritation Consider steroids - Low potency for 1-2 weeks - Treat moderate to severe diaper dermatitis

If not resolving with conventional therapy? Underlying medical conditions: Type I diabetes Chronic mucocutaneous candidiasis Cow milk allergy Lactose intolerance Alternative diagnoses

Differential diagnoses Bacterial dermatitis mainly streptococcal & staphylococcal Psoriasis. Irritant contact dermatitis Exacerbations of seborrheic dermatitis or atopic dermatitis Scabies Nutrition deficiency especially zinc (acrodermatitis enteropathica) and rarely biotin deficiency

Streptococcal infection Picture 1: An update on diaper dermatitis. Klunk et al. Clinics in Dermatology;32 (5) :477-487 Picture 2 :AFP http://www.aafp.org/afp/2000/0115/p391.html Staphylococca Bright erythema in the perianal region due to beta hemolytic Streptococci Bullae (tense, flaccid or eroded), pustules or vesicles may be present in impetigo

Psoriasis Well-demarcated bright red erythema in the diaper area due to inverse psoriasis  (well demarcated, erythematous and glistening plaques with thin white scales, usually spares inguinal creases, involvement of the other body areas). 

Irritant contact dermatitis Involves convex surfaces of inner thigh, lower abdomen, buttock, sparing intertriginous creases

Seborrhoeic dermatitis Look at the scalp.

Zinc deficiency Can be Inherited (acrodermatitis enteropathica-rare) or acquired. Presentation is similar when deficiency is severe – perioroficial dermatitis Young infants are at higher risk of deficiency due to increased demand during growth. In young infants, dietary constraints such as delayed complimentary feeding and feeds high in phytate content also increase likelihood of defiency

Transcient Infantile Zinc deficiency Reference: Dassoni, Federica et al. “High Frequency of Symptomatic Zinc Deficiency in Infants in Northern Ethiopia.” Dermatology Research and Practice 2014 (2014): 719701. PMC. Web. 28 July 2017. Dassoni et al Dermatol ResPract2014;2014; 719701

Acrodermatitis enteropathica http://emedicine.medscape.com/article/912075-overview

Minimising diaper wear. Frequent diaper changes. Prevention Skin care practices that support skin barrier function and protect diaper area from urine & stool. Minimising diaper wear. Frequent diaper changes. Bathing at least daily in water with baby oil or water-dispersible creams. Cleansing gently. Barrier creams, ointments and pastes that are petrolatum based or contain zinc oxide, lanolin etc. 1. AKIN F et al Pediatr Dermatol. 2001 Jul-Aug;18(4):282-90. Effects of breathable disposable diapers: reduced prevalence of Candida and common diaper dermatitis

Does the type of diapers matter? Baer et al Disposable nappies for preventing napkin dermatitis in infants (data from 28 studies-upto 2003) Cochrane database syst Rev. 2006 Jul 19;(3):CD004262. There is not enough evidence from good quality randomised controlled trials to support or refute the use and type of disposable napkins for the prevention of napkin dermatitis in infants. The implications of this for practice are that health care workers, parents and infant caregivers are left to balance the many considerations in napkin choice without this evidence.

What about wipes or cleaning solutions? -Cleansing with wipes/water only -Bathing with water/ cleansing solution -Application of topical products Prevention of Diaper Dermatitis in Infants—a Literature Review 2014. There seems to be no information on whether single skincare practices such as cleansing, bathing, and application of topical preparations can prevent DD. High-quality randomized clinical trials are needed to show the effectiveness of skin care practices for controlling & preventing DD. Reference: Ulrike Blume-Peytavi, Pediatric Dermatology Vol. 31 No. 4 413–429, 2014 Blume-peytavi et al Pediatric Dermatology. 31; (4): 413-429

Summary Diaper dermatitis is a common skin condition of infancy Candida diaper dermatitis is the most frequent infection associated with diaper dermatitis Diagnosis is mainly clinical Prevention using proper diaper area skin care is KEY There is no type of diaper, cleansing agent, or barrier cream that has been found to be superior to others so far

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