- Email: [email protected]
TREATMENT OF DIAPER DERMATITIS
Current Therapy
0733-8635/99 $8.00
+ .OO
Bruce H. Thiers, Consulting Editor
TREATMENT OF DIAPER DERMATITIS Susan Boiko, MD
Diaper rash commonly affects infants. The largest reported group survey of diaper rash incidence recently took place in Great BritTwelve thousand parents of newborns were queried for a period of 4 weeks after their child’s birth. In this survey, 25% of parents noted diaper (nappy) rash at this early age, in contrast to previous studies describing diaper rash incidence at its peak in the range of ages 8 to 12 month^.'^,*^ Although many cases of diaper rash are transient, last 1 day, and resolve without treatment,13 caregiver concern about diaper rash is reflected by (1) the ever-increasing array of over-the-counter products promising rapid diaper rash relief, (2) a burgeoning of internet sites devoted to diaper rash, and (3) a multitude of visits to nurse practitioners, family practitioners, pediatricians, and dermatologists for diagnosis and treatment of diaper rash. This article discusses common and rare causes of diaper rash, suggests an approach to the infant or toddler with diaper rash, describes helpful treatments for diaper rash, and reviews hazardous or questionable treatments and practices. Several sources for reputable medical information are provided.
Dr. Boiko has been a paid consultant to the Procter and Gamble Company, Cincinnati, Ohio.
DIAPER RASH
As in real estate, the three tenets in making a diagnosis of diaper rash are ”location, location, location.” In this case, location refers to the cutaneous topography covered by the diaper. The specific boundaries are superiorly circumferenced around the abdomen and lumbar back at about the level of the umbilicus, and inferiorly, around the upper thighs, encompassing the genitalia, perineum, and buttocks. Diaper rash is a geographic diagnosis.6 It occurs in persons of any age who wear diapers, but the age range discussed in this article will be limited to infants and toddlers. Although diaper rash is most commonly caused or accentuated by wearing a diaper, cutaneous eruptions may occur independent of diaper wear.24Because of their location in the diaper area, these rashes must be recognized or treatment may be fruitless, and diagnosis of a systemic illness may be de1a~ed.I~ THE DIAPER AS A CAUSE OF DIAPER RASH
The climate in the diaper area may be described as tropical: warm and humid. There are two types of diapering systems in use in the United States today: reusable, employing
From the Southern California Permanente Medical Group, San Diego, California
DERMATOLOGIC CLINICS
-
VOLUME 17 NUMBER 1 *JANUARY1999
235
236
BOIKO
washable cotton cloth against the skin, and disposable, with a nonwoven water-permeable top sheet overlying an absorbent lining of wood pulp and polyacrylase gel. Both reusable and disposable diapers trap urine and feces against the skin surface. If the infant is not changed immediately when wet or soiled, the diaper becomes the container for a complex series of interactions between the covered skin, its cutaneous and gut flora, excreta, and the diaper itself (Display Box 1).
Display Box 1. Factors Contributing to Generic Diaper Rash
I
Friction: skin-to-skin and skin-to-diaper contact Urine: stratum corneum superhydration urease enzyme liberates ammonia from cutaneous bacteria; ammonia causes weak irritant effect on nonintact skin. Feces: digestive enzymes (lipases and proteases) mix with urine on nonintact skin; attack epidermis, raise surface pH to alkaline range
child develops diaper dermatitis. Problems such as diarrhea, neurogenic bowel or bladder, urinary incontinence, or ileostomy or colostomy closure may cause perianal dermatitis.26 Candida Diaper Dermatitis
A disrupted epidermal barrier is fertile ground for cutaneous Cundidu infection. Clinically characterized by early maceration of the anal mucosa and perianal skin, Cundidu infection progresses over days to confluent diaper area tomato-red plaques, papules, pustules, and satellite papules. The more distant satellite lesions are most likely to culture positive for Cundidu. Potassium hydroxide preparation should be made from satellite lesions rather than the larger plaques or eroded area. Cundidu may be introduced to the diaper area from the upper gastrointestinal (GI) tract via an intraoral Cundidu infection (thrush) with white plaques on the buccal mucosa, tongue, and gingivae. Lower GI tract colonization or infection from a caregiver’s hands are other sources of diaper area Cundidu expos~re.’~
Generic Diaper Rash
Miliaria Rubra
Disruption of the epidermal barrier results in a dermatitis, termed generic diaper rush by Rasmussen, and is categorized as a chafing rash, or irritant contact d e r m a t i t i ~Clinically, .~~ generic diaper rash appears as erythematous, often shiny patches over the convex surfaces of the diaper area with relative sparing, or in some cases, maceration of the skin folds (mild intertrigo). The infant may be asymptomatic. Generic diaper rash may resolve spontaneously but is commonly treated by caregivers and health care providers with barrier creams, topical cortisones, and topical antifungal preparations. The epidermal barrier may be further disrupted by aggravating factors. For example, diarrhea, specifically more than three unformed stools a day, is associated with an increased incidence of generic diaper rash,’3, 30, 32 as well as Cundidu diaper dermatitis.18 With constant urinary dribbling owing to congenital malformations, pseudoverrucous perianal papules and nodules of the diaper area have been reported, which resolve with cessation of,the incessant flow of urine.15There are special considerations when a hospitalized
Miliaria rubra, otherwise known as prickly heat or heat rush, clinically appears as tiny red papules and papulovesicles, sometimes pruritic. It is commonly seen in infants wearing disposable diapers, where the plastic outer covering is separated from the diaper by the nonwoven diaper liner, without intervening polyacrylase gel or wood pulp fluff. This usually occurs at the elasticized openings of the diaper and at the superolateral abdomen, where the diaper tapes attach to the front panel of the diaper (Susan Boiko, MD, unpublished observation, 1998).Miliaria rubra is caused by eccrine sweat duct occlusion and may also be found in overlapping skin folds in the infant, especially neck and axillary folds. DIAGNOSTIC APPROACH TO “GENERIC” DIAPER DERMATITIS Even before the diaper area is examined, a directed medical history will provide valuable clues as to whether the diaper rash is generic, whether the child’s life is in immedi-
TREATMENT OF DIAPER DERMATITIS
ate danger, and whether the examination may be limited to the diaper area, or will need to be more generalized. Clues that the diaper rash is not generic diaper dermatitis but is dermatitis of immediate serious concern include: Acute onset History of toxic substance applied to the diaper area (Table 1) Fever Systemic symptoms including severe vomiting, diarrhea, lethargy Rapid progression (spread, vesiculation) of lesions in minutes to hours Pain on palpation or with voiding (defecation) Entire diaper area involved Deep ulceration Signs of abuse or neglect (e.g., cutaneous wasting, poor hygiene, lacerations, bruising) Congenital abnormalities of the urinary or lower GI tract Systemic illness or immunodeficiency The differential diagnosis of such eruptions is extensive and is reviewed in several recent articles and textbook chapter^."^, 27, 31,36
237
A-Air A time-honored prescription is to remove the diaper so that the source of occlusion is removed. An adjunct to air is sunlight. In the late 1940s, my Aunt Mildred was arrested because of her daughter’s diaper rash. A physician advised her to take the 9-month-old infant to a local beach in New Jersey and expose the child’s diaper rash to the sunshine. At the beach, a woman was offended and insisted my aunt be arrested for indecent exposure of a child. Upon arriving at the police station, the charges were immediately dismissed (Mildred Boiko, personal communication, 1992).More than 50 years later, a greater concern would be for the long-term effects of ultraviolet light exposure on nonexposed skin. Alternatives to removing the diaper temporarily have included recommendations for drying of the buttocks skin with a hair dryer, which may cause chapping and severe burns even on the lowest setting, or exposure to the infrared rays of a gooseneck lamp, which may also provide a burn hazard. Air is the permanent cure, as children who no longer wear diapers can no longer get diaper rash. B-Barriers
THERAPY OF GENERIC DIAPER DERMATITIS Treatment of generic diaper rash can be summarized as air (A), barriers (B), cleansing (C), diaper (D), and education (E). This approach (A-E) is mainly empiric because there are few double-blind placebo-controlled studies to determine efficacy of topical diaper rash therapy.
Barriers and other topical products are the mainstay of generic diaper dermatitis therapy. The Food and Drug Administration (FDA) stringently regulates products labeled for infant use that are classified as ”over-thecounter” and prescription drugslo,ll; however, herbal preparations are sold over-the-counter with few instructions and no regulation as to purity or potential One internet site
Table 1. AVOID THESE TOXIC SUBSTANCES IN DIAPER AREA
Toxin
Effect
Baking soda (sodium bicarbonate) Benzocaine and resorcinol Boric acid Camphor Iodohydroxyquin, diiodohydroxyquin Isopropyl alcohol Naphthalene mothballs (diapers stored with) Potent topical steroids Salicylates
Hypokalemic metabolic alkalosis16 Methern~globinemia~~ Erythrcderma, GI, CNS toxicity” Seizures35 Blindness, neuropathy4 Hypotonia, lethargy, seizures, dehydration, hypoxia40 Fatal hemolytic anemia35 Cushing’s syndrome, cutaneous atrophy37 Salicylate intoxication with fever, vomiting, diarrhea, dehydration, metabolic acidosis’ Erythroderma, neurologic and renal toxicity2
Topical mercurials
Adaptedfrorn Boiko S Diapers and diaper rashes. Dermatology Nursing 9:33, 1997; with permission.
238
BOX0
of a dermatologist, should be limited to a recommends herbs such as oils of (1)sandalcourse of a few days and a small quantity wood, peppermint, and lavender mixed tod i ~ p e n s e dCombination .~~ topical steroid/angether, (2) calendula cream, or (3) chickweed tifungal creams should be avoided in the leaves, powdered marshmallow root, powdiaper area. Although betamethasone diprodered chickweed root, powdered comfrey prionate/clotrimazole cream (Lotrisone, root, goldenseal root powder, sweet almond Schering Corporation, Madison, NJ) is speoil, and beeswax to be heated in a cast-iron cifically noted as ”not recommended” for diapan and strained through cheesecloth before per dermatitis in the 1998 edition of the Phyapplying to the diaper rash.21 sicians Desk Reference, it has caused The most common ingredients in over-thegranuloma gluteale infantum and cutaneous counter diaper rash products are zinc oxide atrophy in a diaper-wearing t ~ d d l e r . ~ and petrolatum. Zinc oxide cream, ointment, For treatment of Candida dermatitis, topical or paste is commonly applied as a waterover-the-counter antifungal preparations (miimpermeable barrier. Percutaneous absorpconazole cream, clotrimazole cream) may be tion of zinc oxide has raised serum zinc levels used although these products are not labeled in normal adults: and in a child with acroderfor diaper rash therapy.12 They may be more matitis enteropathica where the compound effective than prescription topical nystatin was applied to the diaper area.28A 10-mg and should be applied at least 3 times a day dosage of zinc gluconate was orally adminisuntil the rash has cleared. It is not clear tered in a double-blind, placebo-controlled whether oral antifungal administration is study during the first 4 months .of infancy helpful in the absence of oral Candidiasis with a reported decrease in incidence of dia(thrush).19 per rash for those infants receiving zinc; howInnovative topical preparations have also ever, serum zinc levels were not mea~ured.~ been reported. A compounded preparation Petrolatum is a mixture of long-chain aliof 5% cholestyramine in Aquaphor has been phatic hydrocarbons. Until 1992 it was applied to the diaper or stoma area in situathought to act as an impermeable barrier betions in which there was high stool output, tween the epidermis and water. It is now with rash resolution reported in an infant and known to travel through the interstitial spaces some children.4I of the stratum comeum, aiding in barrier recover~.‘~ Combined with zinc oxide paste and aluminum acetate solution, it is a constituent C-Cleansing of the Diaper Rash of 1-2-3 Paste and is especially useful for diaper rash associated with diarrhea or increased Procter and Gamble (Cincinnati, Ohio) stool output.26Although vitamins are popular manufactures a baby wipe called “Rash additives to diaper rash products, one study Care,” but this product is actually meant to found no advantage to a vitamin A-fortified prevent diaper rash. Most wipes recommend cream compared to zinc oxide, lanolin, and that use be discontinued if the skin is broken. petrolatum Physicians may recommend aluminum aceZinc oxide and petrolatum are the prime tate (Domeboro soaks, Bayer Corporation, ingredients in most commercial diaper rash West Haven, CT) as an astringent, but there preparations, but they are not the sole conare no studies comparing this treatment to tents. If there is a concern that the child may soaking with tap water alone. Anecdotally, be developing a reaction to one of these prodoilated oatmeal baths have been recomucts, it is essential to scrutinize the label. A 1mended to soothe diaper rash, but the FDA year-old infant with cow milk allergy develhas not approved labeling of colloidal oatoped anaphylaxis twice after topical applicameal for use on diaper rash (Marvin G. Partion of a diaper rash cream containing caker, MD, s. C. Johnson and Son, personal sein.22 communication, 1994). Irritant contact dermaTopical steroids are another commonly titis has been reported from overuse of acid used therapy. Concentrations over 1%are prepH cleanser^.^^ scription only, but more potent products may be used if available. The occlusion of the wet diaper raises the absorption of the topical D-Diaper steroid and may lead to purple diaper-area nodules termed granuloma gluteale infant~rn.~~ The diaper itself can be therapeutic, both in preventing and ameliorating diaper rash. Potent topical steroid use, even in the hands
TREATMENT OF DIAPER DERMATITIS
Infants in diapers with absorbent gel lining had fewer diaper rashes of less severity than children in cloth or nongel-lined diapers. The diaper may also be therapeutic for atopic children, as the tropical environment may effectively rehydrate xerotic atopic skin.43 Diapers may also accentuate the eruption in two other forms of generalized infantile dermatitis: seborrheic dermatitis4*and psoriasiform napkin d e r m a t i t i ~ . ~ ~ E-Education
Although guiding caregivers through the realm of nonprescription topical therapy may seem like a daunting task, more is involved in diaper rash counseling than just selecting the correct topical treatment. Over-thecounter products may be inadequate therapy in certain cases. Some substances may be toxic when applied under moist occlusion or "under-wraps." The diaper rash itself may represent a serious illness. In summary, treatment of diaper rash is successful when it achieves the "bottom line": a comfortable infant and a confident, wellinformed caregiver. Brochures on diaper rash are available from the American Academy of Pediatrics (Diaper Rash: Guidelines for parents. American Academy of Pediatrics, Division of Publications, 141 Northwest Point Boulevard, P.O. Box 927, Elk Grove Village, IL 60009-0927.) On the internet, the Group Health Cooperative of Puget Sound has an excellent discussion of treatment suggestions as well as a detailed list of reasons to call the doctor.20 References 1. Abdel-Magid EHM, Ahmed F-R EA: Salicylate intoxication in an infant with ichthyosis transmitted through skin ointment - A case report. Pediatrics 94939, 1994 2. Aberer W Topical mercury should be banned - Dangerous, outmoded but still popular. J Am Acad Dermatol 24150, 1991 3. Agren MS: Percutaneous absorption of zinc from zinc oxide applied topically to intact skin in man. Dermatologica 180:36, 1990 4. American Academy of Pediatrics, Committee on Drugs: Clioquinol (iodohydroxychloroquin, vioform and iodoquinol (diiodohydroxyquin): Blindness and neuropathy. Pediatrics 86:797, 1990 5. Arnsmeier SL, Paller AS: Getting to the bottom of diaper dermatitis. Contemp Pediatr 14:115, 1997 6. Berg RW Etiology and pathophysiology of diaper dermatitis. Adv Dermatol 3:75, 1988
239
7. Boiko S Diapers and diaper rashes. Dermatology Nursing 9:33, 1997 8. Bosch-Banyeras JM, Catala M, Mas P, et al: Diaper dermatitis: Value of vitamin A topically applied. Clin Pediatr 27448, 1988 9. Collipp PJ: Effect of oral zinc supplements on diaper rash in normal infants. J Med Assoc Ga 78:621, 1989 10. Federal Register: External analgesic drug products for over-the-counter human use: Diaper rash labeling claims. Final rule. 5760426, 1992 11. Federal Register: Skin protectant drug products for over-the-counter human use: Proposed rulemaking for diaper rash drug products. 55:25204, 1990 12. Federal Register: Topical antifungal drug products for over-the-counter human use: Diaper rash labeling claims. Final rule. 5760430, 1992 13. Gaunder BN, Plummer E: Diaper rash: Managing and controlling a common problem in infants and toddlers. J Pediatr Health Care 1:26, 1987 14. Ghadially R, Halkier-Sorensen L, Elias PM: Effects of petrolatum on the stratum corneum structure and function. J Am Acad Dermatol 26:387, 1992 15. Goldberg NS, Esterly NB, Rothman KF, et al: Perianal pseudoverrucous papules and nodules in children. Arch Dermatol 128:240, 1992 16. Gonzalez J, Hogg RJ: Metabolic alkalosis secondary to baking soda treatment of a diaper rash. Pediatrics 67820, 1981 17. Hansen RM: Dermatitis and nutritional deficiency. Another acrodermatitis enteropathica-like eruption. AJDC 147940, 1993 18. Honig PJ, Gribetz B, Leyden JJ, et al: Amoxicillin and diaper dermatitis. J Am Acad Dermatol 19:275, 1988 19. Hoppe JE: Treatment of oropharyngeal candidiasis and candidal diaper dermatitis in neonates and infants: review and reappraisal. Pediatr Infect Dis J 16:885, 1997 20. http: / / www.ghc.org/health-info/self/children/ dia-rash.htm1 21. http:// www.onhealth.com/harts/ailments/htm/diaper.htm 22. Jarmoc LM, Primack WA: Anaphylaxis to cutaneous exposure to milk protein in a diaper rash ointment. Clin Pediatr 26:154, 1987 23. Jordan WE, Lawson KD, Berg RW, et al: Diaper dermatitis: Frequency and severity among a general infant population. Pediatr Dermatol 3:198, 1986 24. Koblenzer PJ: Diaper dermatitis - An overview. Clin Pediatr 12:386, 1973 25. Konya J, Gow E: Granuloma gluteale infantum. Australas J Dermatol 3757, 1996 26. Kramer D, Honig PJ: Diaper dermatitis in the hospitalized child. Journal of Enterostomal Therapy 15:167, 1988 27. Leyden JJ: Diaper dermatitis. Dermatol Clin 4:23, 1986 28. Parra CA, Smalik AV Percutaneous absorption of zinc in acrodermatitis enteropathica. Dermatologica 163:413, 1981 29. Patrizi A, Neri I, Marzaduri S, et al: Pigmented and hyperkeratotic napkin dermatitis: A liquid detergent irritant dermatitis. Dermatology 193:36, 1996 30. Philipp R, Hughes A, Golding J, et al: Getting to the bottom of nappy rash. Br J Gen Pract 47493, 1997 31. Rabinowitz LG, Esterly NB: Diaper dermatitis. In Demis DJ (ed): Clinical Dermatology. Philadelphia, Lippincott-Raven, 1995, pp 1-8 32. Rasmussen JE: Classification of diaper dermatitis: An overview. Pediatrician 14(Suppl 1):6, 1987
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BOIKO
33. Rattet JP, Headley JL, Barr RJ: Diaper dermatitis with psoriasiform id eruption. Int J Dermatol20:122, 1981 34. Siegel E, Wason S Boric acid toxicity. Pediatr Clin North Am 33363, 1986 35. Siegel E, Wason S: Camphor toxicity. Pediatr Clin North Am 33:375, 1986 36. SingalavanijaS, Frieden IJ: Diaper dermatitis. Pediatr Rev 16:142, 1995 37. Stoppoloni G, Prisco F, Santinelli R, et al: Potential hazards of topical steroid therapy. Am J Dis Child 1371130, 1983 38. Tush GM, Kuhn RJ: Methemoglobinemia induced by an over-the-counter medication. Ann Pharmacother 30:1251, 1996
39. Van D The herbal medicine boom: Understanding what patients are taking. Cleve Clin J Med 65129,1998 40. Vivier PM, Lewander WJ, Martin HB, et al: Isopropyl alcohol intoxication in a neonate through chronic dermal exposure: A complication of a culturallybased umbilical care practice. 10:91, 1994 41. White CM, Gailey RA, Lippe S: Cholestyramine ointment to treat buttocks rash and anal excoriation in an infant. Ann Pharmacother 30954, 1996 42. Williams ML: Differential diagnosis of seborrheic dermatitis. Pediatrics in review 7204, 1986 43. Wong DL, Brantly, Clutter LB, et al: Diapering choices: A critical review of the issues. Pediatr Nurs 18:41, 1992
Address reprint requests to Susan Boiko, MD Department of Dermatology Kaiser Permanente 780 Shadowridge Drive Vista, CA 92083 e-mail: susan.x.boikoQkp.org
0733-8635/99 $8.00
+ .OO
Bruce H. Thiers, Consulting Editor
TREATMENT OF DIAPER DERMATITIS Susan Boiko, MD
Diaper rash commonly affects infants. The largest reported group survey of diaper rash incidence recently took place in Great BritTwelve thousand parents of newborns were queried for a period of 4 weeks after their child’s birth. In this survey, 25% of parents noted diaper (nappy) rash at this early age, in contrast to previous studies describing diaper rash incidence at its peak in the range of ages 8 to 12 month^.'^,*^ Although many cases of diaper rash are transient, last 1 day, and resolve without treatment,13 caregiver concern about diaper rash is reflected by (1) the ever-increasing array of over-the-counter products promising rapid diaper rash relief, (2) a burgeoning of internet sites devoted to diaper rash, and (3) a multitude of visits to nurse practitioners, family practitioners, pediatricians, and dermatologists for diagnosis and treatment of diaper rash. This article discusses common and rare causes of diaper rash, suggests an approach to the infant or toddler with diaper rash, describes helpful treatments for diaper rash, and reviews hazardous or questionable treatments and practices. Several sources for reputable medical information are provided.
Dr. Boiko has been a paid consultant to the Procter and Gamble Company, Cincinnati, Ohio.
DIAPER RASH
As in real estate, the three tenets in making a diagnosis of diaper rash are ”location, location, location.” In this case, location refers to the cutaneous topography covered by the diaper. The specific boundaries are superiorly circumferenced around the abdomen and lumbar back at about the level of the umbilicus, and inferiorly, around the upper thighs, encompassing the genitalia, perineum, and buttocks. Diaper rash is a geographic diagnosis.6 It occurs in persons of any age who wear diapers, but the age range discussed in this article will be limited to infants and toddlers. Although diaper rash is most commonly caused or accentuated by wearing a diaper, cutaneous eruptions may occur independent of diaper wear.24Because of their location in the diaper area, these rashes must be recognized or treatment may be fruitless, and diagnosis of a systemic illness may be de1a~ed.I~ THE DIAPER AS A CAUSE OF DIAPER RASH
The climate in the diaper area may be described as tropical: warm and humid. There are two types of diapering systems in use in the United States today: reusable, employing
From the Southern California Permanente Medical Group, San Diego, California
DERMATOLOGIC CLINICS
-
VOLUME 17 NUMBER 1 *JANUARY1999
235
236
BOIKO
washable cotton cloth against the skin, and disposable, with a nonwoven water-permeable top sheet overlying an absorbent lining of wood pulp and polyacrylase gel. Both reusable and disposable diapers trap urine and feces against the skin surface. If the infant is not changed immediately when wet or soiled, the diaper becomes the container for a complex series of interactions between the covered skin, its cutaneous and gut flora, excreta, and the diaper itself (Display Box 1).
Display Box 1. Factors Contributing to Generic Diaper Rash
I
Friction: skin-to-skin and skin-to-diaper contact Urine: stratum corneum superhydration urease enzyme liberates ammonia from cutaneous bacteria; ammonia causes weak irritant effect on nonintact skin. Feces: digestive enzymes (lipases and proteases) mix with urine on nonintact skin; attack epidermis, raise surface pH to alkaline range
child develops diaper dermatitis. Problems such as diarrhea, neurogenic bowel or bladder, urinary incontinence, or ileostomy or colostomy closure may cause perianal dermatitis.26 Candida Diaper Dermatitis
A disrupted epidermal barrier is fertile ground for cutaneous Cundidu infection. Clinically characterized by early maceration of the anal mucosa and perianal skin, Cundidu infection progresses over days to confluent diaper area tomato-red plaques, papules, pustules, and satellite papules. The more distant satellite lesions are most likely to culture positive for Cundidu. Potassium hydroxide preparation should be made from satellite lesions rather than the larger plaques or eroded area. Cundidu may be introduced to the diaper area from the upper gastrointestinal (GI) tract via an intraoral Cundidu infection (thrush) with white plaques on the buccal mucosa, tongue, and gingivae. Lower GI tract colonization or infection from a caregiver’s hands are other sources of diaper area Cundidu expos~re.’~
Generic Diaper Rash
Miliaria Rubra
Disruption of the epidermal barrier results in a dermatitis, termed generic diaper rush by Rasmussen, and is categorized as a chafing rash, or irritant contact d e r m a t i t i ~Clinically, .~~ generic diaper rash appears as erythematous, often shiny patches over the convex surfaces of the diaper area with relative sparing, or in some cases, maceration of the skin folds (mild intertrigo). The infant may be asymptomatic. Generic diaper rash may resolve spontaneously but is commonly treated by caregivers and health care providers with barrier creams, topical cortisones, and topical antifungal preparations. The epidermal barrier may be further disrupted by aggravating factors. For example, diarrhea, specifically more than three unformed stools a day, is associated with an increased incidence of generic diaper rash,’3, 30, 32 as well as Cundidu diaper dermatitis.18 With constant urinary dribbling owing to congenital malformations, pseudoverrucous perianal papules and nodules of the diaper area have been reported, which resolve with cessation of,the incessant flow of urine.15There are special considerations when a hospitalized
Miliaria rubra, otherwise known as prickly heat or heat rush, clinically appears as tiny red papules and papulovesicles, sometimes pruritic. It is commonly seen in infants wearing disposable diapers, where the plastic outer covering is separated from the diaper by the nonwoven diaper liner, without intervening polyacrylase gel or wood pulp fluff. This usually occurs at the elasticized openings of the diaper and at the superolateral abdomen, where the diaper tapes attach to the front panel of the diaper (Susan Boiko, MD, unpublished observation, 1998).Miliaria rubra is caused by eccrine sweat duct occlusion and may also be found in overlapping skin folds in the infant, especially neck and axillary folds. DIAGNOSTIC APPROACH TO “GENERIC” DIAPER DERMATITIS Even before the diaper area is examined, a directed medical history will provide valuable clues as to whether the diaper rash is generic, whether the child’s life is in immedi-
TREATMENT OF DIAPER DERMATITIS
ate danger, and whether the examination may be limited to the diaper area, or will need to be more generalized. Clues that the diaper rash is not generic diaper dermatitis but is dermatitis of immediate serious concern include: Acute onset History of toxic substance applied to the diaper area (Table 1) Fever Systemic symptoms including severe vomiting, diarrhea, lethargy Rapid progression (spread, vesiculation) of lesions in minutes to hours Pain on palpation or with voiding (defecation) Entire diaper area involved Deep ulceration Signs of abuse or neglect (e.g., cutaneous wasting, poor hygiene, lacerations, bruising) Congenital abnormalities of the urinary or lower GI tract Systemic illness or immunodeficiency The differential diagnosis of such eruptions is extensive and is reviewed in several recent articles and textbook chapter^."^, 27, 31,36
237
A-Air A time-honored prescription is to remove the diaper so that the source of occlusion is removed. An adjunct to air is sunlight. In the late 1940s, my Aunt Mildred was arrested because of her daughter’s diaper rash. A physician advised her to take the 9-month-old infant to a local beach in New Jersey and expose the child’s diaper rash to the sunshine. At the beach, a woman was offended and insisted my aunt be arrested for indecent exposure of a child. Upon arriving at the police station, the charges were immediately dismissed (Mildred Boiko, personal communication, 1992).More than 50 years later, a greater concern would be for the long-term effects of ultraviolet light exposure on nonexposed skin. Alternatives to removing the diaper temporarily have included recommendations for drying of the buttocks skin with a hair dryer, which may cause chapping and severe burns even on the lowest setting, or exposure to the infrared rays of a gooseneck lamp, which may also provide a burn hazard. Air is the permanent cure, as children who no longer wear diapers can no longer get diaper rash. B-Barriers
THERAPY OF GENERIC DIAPER DERMATITIS Treatment of generic diaper rash can be summarized as air (A), barriers (B), cleansing (C), diaper (D), and education (E). This approach (A-E) is mainly empiric because there are few double-blind placebo-controlled studies to determine efficacy of topical diaper rash therapy.
Barriers and other topical products are the mainstay of generic diaper dermatitis therapy. The Food and Drug Administration (FDA) stringently regulates products labeled for infant use that are classified as ”over-thecounter” and prescription drugslo,ll; however, herbal preparations are sold over-the-counter with few instructions and no regulation as to purity or potential One internet site
Table 1. AVOID THESE TOXIC SUBSTANCES IN DIAPER AREA
Toxin
Effect
Baking soda (sodium bicarbonate) Benzocaine and resorcinol Boric acid Camphor Iodohydroxyquin, diiodohydroxyquin Isopropyl alcohol Naphthalene mothballs (diapers stored with) Potent topical steroids Salicylates
Hypokalemic metabolic alkalosis16 Methern~globinemia~~ Erythrcderma, GI, CNS toxicity” Seizures35 Blindness, neuropathy4 Hypotonia, lethargy, seizures, dehydration, hypoxia40 Fatal hemolytic anemia35 Cushing’s syndrome, cutaneous atrophy37 Salicylate intoxication with fever, vomiting, diarrhea, dehydration, metabolic acidosis’ Erythroderma, neurologic and renal toxicity2
Topical mercurials
Adaptedfrorn Boiko S Diapers and diaper rashes. Dermatology Nursing 9:33, 1997; with permission.
238
BOX0
of a dermatologist, should be limited to a recommends herbs such as oils of (1)sandalcourse of a few days and a small quantity wood, peppermint, and lavender mixed tod i ~ p e n s e dCombination .~~ topical steroid/angether, (2) calendula cream, or (3) chickweed tifungal creams should be avoided in the leaves, powdered marshmallow root, powdiaper area. Although betamethasone diprodered chickweed root, powdered comfrey prionate/clotrimazole cream (Lotrisone, root, goldenseal root powder, sweet almond Schering Corporation, Madison, NJ) is speoil, and beeswax to be heated in a cast-iron cifically noted as ”not recommended” for diapan and strained through cheesecloth before per dermatitis in the 1998 edition of the Phyapplying to the diaper rash.21 sicians Desk Reference, it has caused The most common ingredients in over-thegranuloma gluteale infantum and cutaneous counter diaper rash products are zinc oxide atrophy in a diaper-wearing t ~ d d l e r . ~ and petrolatum. Zinc oxide cream, ointment, For treatment of Candida dermatitis, topical or paste is commonly applied as a waterover-the-counter antifungal preparations (miimpermeable barrier. Percutaneous absorpconazole cream, clotrimazole cream) may be tion of zinc oxide has raised serum zinc levels used although these products are not labeled in normal adults: and in a child with acroderfor diaper rash therapy.12 They may be more matitis enteropathica where the compound effective than prescription topical nystatin was applied to the diaper area.28A 10-mg and should be applied at least 3 times a day dosage of zinc gluconate was orally adminisuntil the rash has cleared. It is not clear tered in a double-blind, placebo-controlled whether oral antifungal administration is study during the first 4 months .of infancy helpful in the absence of oral Candidiasis with a reported decrease in incidence of dia(thrush).19 per rash for those infants receiving zinc; howInnovative topical preparations have also ever, serum zinc levels were not mea~ured.~ been reported. A compounded preparation Petrolatum is a mixture of long-chain aliof 5% cholestyramine in Aquaphor has been phatic hydrocarbons. Until 1992 it was applied to the diaper or stoma area in situathought to act as an impermeable barrier betions in which there was high stool output, tween the epidermis and water. It is now with rash resolution reported in an infant and known to travel through the interstitial spaces some children.4I of the stratum comeum, aiding in barrier recover~.‘~ Combined with zinc oxide paste and aluminum acetate solution, it is a constituent C-Cleansing of the Diaper Rash of 1-2-3 Paste and is especially useful for diaper rash associated with diarrhea or increased Procter and Gamble (Cincinnati, Ohio) stool output.26Although vitamins are popular manufactures a baby wipe called “Rash additives to diaper rash products, one study Care,” but this product is actually meant to found no advantage to a vitamin A-fortified prevent diaper rash. Most wipes recommend cream compared to zinc oxide, lanolin, and that use be discontinued if the skin is broken. petrolatum Physicians may recommend aluminum aceZinc oxide and petrolatum are the prime tate (Domeboro soaks, Bayer Corporation, ingredients in most commercial diaper rash West Haven, CT) as an astringent, but there preparations, but they are not the sole conare no studies comparing this treatment to tents. If there is a concern that the child may soaking with tap water alone. Anecdotally, be developing a reaction to one of these prodoilated oatmeal baths have been recomucts, it is essential to scrutinize the label. A 1mended to soothe diaper rash, but the FDA year-old infant with cow milk allergy develhas not approved labeling of colloidal oatoped anaphylaxis twice after topical applicameal for use on diaper rash (Marvin G. Partion of a diaper rash cream containing caker, MD, s. C. Johnson and Son, personal sein.22 communication, 1994). Irritant contact dermaTopical steroids are another commonly titis has been reported from overuse of acid used therapy. Concentrations over 1%are prepH cleanser^.^^ scription only, but more potent products may be used if available. The occlusion of the wet diaper raises the absorption of the topical D-Diaper steroid and may lead to purple diaper-area nodules termed granuloma gluteale infant~rn.~~ The diaper itself can be therapeutic, both in preventing and ameliorating diaper rash. Potent topical steroid use, even in the hands
TREATMENT OF DIAPER DERMATITIS
Infants in diapers with absorbent gel lining had fewer diaper rashes of less severity than children in cloth or nongel-lined diapers. The diaper may also be therapeutic for atopic children, as the tropical environment may effectively rehydrate xerotic atopic skin.43 Diapers may also accentuate the eruption in two other forms of generalized infantile dermatitis: seborrheic dermatitis4*and psoriasiform napkin d e r m a t i t i ~ . ~ ~ E-Education
Although guiding caregivers through the realm of nonprescription topical therapy may seem like a daunting task, more is involved in diaper rash counseling than just selecting the correct topical treatment. Over-thecounter products may be inadequate therapy in certain cases. Some substances may be toxic when applied under moist occlusion or "under-wraps." The diaper rash itself may represent a serious illness. In summary, treatment of diaper rash is successful when it achieves the "bottom line": a comfortable infant and a confident, wellinformed caregiver. Brochures on diaper rash are available from the American Academy of Pediatrics (Diaper Rash: Guidelines for parents. American Academy of Pediatrics, Division of Publications, 141 Northwest Point Boulevard, P.O. Box 927, Elk Grove Village, IL 60009-0927.) On the internet, the Group Health Cooperative of Puget Sound has an excellent discussion of treatment suggestions as well as a detailed list of reasons to call the doctor.20 References 1. Abdel-Magid EHM, Ahmed F-R EA: Salicylate intoxication in an infant with ichthyosis transmitted through skin ointment - A case report. Pediatrics 94939, 1994 2. Aberer W Topical mercury should be banned - Dangerous, outmoded but still popular. J Am Acad Dermatol 24150, 1991 3. Agren MS: Percutaneous absorption of zinc from zinc oxide applied topically to intact skin in man. Dermatologica 180:36, 1990 4. American Academy of Pediatrics, Committee on Drugs: Clioquinol (iodohydroxychloroquin, vioform and iodoquinol (diiodohydroxyquin): Blindness and neuropathy. Pediatrics 86:797, 1990 5. Arnsmeier SL, Paller AS: Getting to the bottom of diaper dermatitis. Contemp Pediatr 14:115, 1997 6. Berg RW Etiology and pathophysiology of diaper dermatitis. Adv Dermatol 3:75, 1988
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7. Boiko S Diapers and diaper rashes. Dermatology Nursing 9:33, 1997 8. Bosch-Banyeras JM, Catala M, Mas P, et al: Diaper dermatitis: Value of vitamin A topically applied. Clin Pediatr 27448, 1988 9. Collipp PJ: Effect of oral zinc supplements on diaper rash in normal infants. J Med Assoc Ga 78:621, 1989 10. Federal Register: External analgesic drug products for over-the-counter human use: Diaper rash labeling claims. Final rule. 5760426, 1992 11. Federal Register: Skin protectant drug products for over-the-counter human use: Proposed rulemaking for diaper rash drug products. 55:25204, 1990 12. Federal Register: Topical antifungal drug products for over-the-counter human use: Diaper rash labeling claims. Final rule. 5760430, 1992 13. Gaunder BN, Plummer E: Diaper rash: Managing and controlling a common problem in infants and toddlers. J Pediatr Health Care 1:26, 1987 14. Ghadially R, Halkier-Sorensen L, Elias PM: Effects of petrolatum on the stratum corneum structure and function. J Am Acad Dermatol 26:387, 1992 15. Goldberg NS, Esterly NB, Rothman KF, et al: Perianal pseudoverrucous papules and nodules in children. Arch Dermatol 128:240, 1992 16. Gonzalez J, Hogg RJ: Metabolic alkalosis secondary to baking soda treatment of a diaper rash. Pediatrics 67820, 1981 17. Hansen RM: Dermatitis and nutritional deficiency. Another acrodermatitis enteropathica-like eruption. AJDC 147940, 1993 18. Honig PJ, Gribetz B, Leyden JJ, et al: Amoxicillin and diaper dermatitis. J Am Acad Dermatol 19:275, 1988 19. Hoppe JE: Treatment of oropharyngeal candidiasis and candidal diaper dermatitis in neonates and infants: review and reappraisal. Pediatr Infect Dis J 16:885, 1997 20. http: / / www.ghc.org/health-info/self/children/ dia-rash.htm1 21. http:// www.onhealth.com/harts/ailments/htm/diaper.htm 22. Jarmoc LM, Primack WA: Anaphylaxis to cutaneous exposure to milk protein in a diaper rash ointment. Clin Pediatr 26:154, 1987 23. Jordan WE, Lawson KD, Berg RW, et al: Diaper dermatitis: Frequency and severity among a general infant population. Pediatr Dermatol 3:198, 1986 24. Koblenzer PJ: Diaper dermatitis - An overview. Clin Pediatr 12:386, 1973 25. Konya J, Gow E: Granuloma gluteale infantum. Australas J Dermatol 3757, 1996 26. Kramer D, Honig PJ: Diaper dermatitis in the hospitalized child. Journal of Enterostomal Therapy 15:167, 1988 27. Leyden JJ: Diaper dermatitis. Dermatol Clin 4:23, 1986 28. Parra CA, Smalik AV Percutaneous absorption of zinc in acrodermatitis enteropathica. Dermatologica 163:413, 1981 29. Patrizi A, Neri I, Marzaduri S, et al: Pigmented and hyperkeratotic napkin dermatitis: A liquid detergent irritant dermatitis. Dermatology 193:36, 1996 30. Philipp R, Hughes A, Golding J, et al: Getting to the bottom of nappy rash. Br J Gen Pract 47493, 1997 31. Rabinowitz LG, Esterly NB: Diaper dermatitis. In Demis DJ (ed): Clinical Dermatology. Philadelphia, Lippincott-Raven, 1995, pp 1-8 32. Rasmussen JE: Classification of diaper dermatitis: An overview. Pediatrician 14(Suppl 1):6, 1987
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33. Rattet JP, Headley JL, Barr RJ: Diaper dermatitis with psoriasiform id eruption. Int J Dermatol20:122, 1981 34. Siegel E, Wason S Boric acid toxicity. Pediatr Clin North Am 33363, 1986 35. Siegel E, Wason S: Camphor toxicity. Pediatr Clin North Am 33:375, 1986 36. SingalavanijaS, Frieden IJ: Diaper dermatitis. Pediatr Rev 16:142, 1995 37. Stoppoloni G, Prisco F, Santinelli R, et al: Potential hazards of topical steroid therapy. Am J Dis Child 1371130, 1983 38. Tush GM, Kuhn RJ: Methemoglobinemia induced by an over-the-counter medication. Ann Pharmacother 30:1251, 1996
39. Van D The herbal medicine boom: Understanding what patients are taking. Cleve Clin J Med 65129,1998 40. Vivier PM, Lewander WJ, Martin HB, et al: Isopropyl alcohol intoxication in a neonate through chronic dermal exposure: A complication of a culturallybased umbilical care practice. 10:91, 1994 41. White CM, Gailey RA, Lippe S: Cholestyramine ointment to treat buttocks rash and anal excoriation in an infant. Ann Pharmacother 30954, 1996 42. Williams ML: Differential diagnosis of seborrheic dermatitis. Pediatrics in review 7204, 1986 43. Wong DL, Brantly, Clutter LB, et al: Diapering choices: A critical review of the issues. Pediatr Nurs 18:41, 1992
Address reprint requests to Susan Boiko, MD Department of Dermatology Kaiser Permanente 780 Shadowridge Drive Vista, CA 92083 e-mail: susan.x.boikoQkp.org