Preventive measures help to manage diaper dermatitis

Toronto - Both common and uncommon causes of diaper dermatitis have to be recognized in order to develop an effective plan to treat diaper dermatitis, a condition that is highly frequent in infants, according to a staff physician in pediatric dermatology at the Hospital for Sick Children, Toronto. 

“Sometimes you have to recognize that there may be something else going on,” says Miriam Weinstein, M.D., F.R.C.P.C., associate professor, department of pediatrics, Faculty of Medicine, University of Toronto. “There can be uncommon causes.”

Speaking here at the inaugural pediatric woundcare symposium organized by the Hospital for Sick Children, Dr. Weinstein notes there are generalized diseases that affect the diaper area, and there are diseases that are specific to the diaper area.

Conditions such as eczema, seborrheic dermatitis and psoriasis are skin diseases that can affect the diaper area. Infections such as Candida or Staph and/or strep can elicit or contribute to diaper rash, too.

“Candida in the diaper area tends to be related to the diapering process,” Dr. Weinstein says. “As soon as kids are out of diapers, we don’t typically see this (infection).”

Finding the cause

In some instances, a biopsy may be required to determine the underlying condition that is triggering diaper dermatitis, she says.

One of the rare conditions that leads to diaper dermatitis includes Langerhans cells histiocytosis, a condition where there is also scalp involvement. Other rare conditions that trigger diaper dermatitis include zinc deficiency, malabsorption syndromes, and granular parakeratosis. Babies typically respond quickly to treatment when zinc deficiency has been diagnosed, Dr. Weinstein says.

Dermatitis that is widespread can be characteristic of malabsorption syndromes, she says, with associated signs being edema, diarrhea and irritability.

“The malabsorption syndromes usually go well beyond the diaper area,” Dr. Weinstein says.

The etiology of granular parakeratosis is unknown, but some measures can prevent it from occurring.

“We don’t know what causes granular parakeratosis, but we know that it may be linked to overuse of steroids or topical products,” Dr. Weinstein says. “You have to consider this diagnosis if too many products are being used, and there is a scaly eruption that is non-responsive to other treatments.”

Treating ICD

Irritant contact dermatitis (ICD) in the diaper area is specific to the diaper milieu and diapering/cleaning process, she says.

The presentation of ICD affects sites such as the inner and upper thighs and buttocks, but spares skin creases, Dr. Weinstein explains.

“It tends to be sharply demarcated, it can be glazed, and there can be erosions,” she says.

Numerous factors contribute to ICD including irritation from urine and stool, friction owing to a wet diaper rubbing on the skin, friction and irritation from diaper wipes, and candida, according to Dr. Weinstein.

In addition, occlusive diapering overhydrates the skin, making it more prone to friction, Dr. Weinstein notes. Diapered skin has an elevated pH level, and this elevation triggers enzymes that damage the epidermis. The presence of diarrhea also worsens the ICD, for the content and consistency of feces may further irritate the skin.

Treating ICD involves frequent diaper changes, gentle cleansing such as sitz baths, the avoidance of harsh rubbing, and the liberal use of barrier creams like zinc oxide with every diaper change.

“Put on the zinc oxide in a thick fashion, like you would frosting,” Dr. Weinstein says, adding that barrier creams should be routinely applied if the baby is at high-risk of recurrence of diaper dermatitis.

When hemangiomas are present, treatment with beta-blockers should be initiated, Dr. Weinstein advises. Presentations like ulcers have to heal. If antimicrobial agents or topical corticosteroids are being applied, a cream base will more easily permit the application of zinc oxide on top of these agents.

Clinicians should exercise caution when using combination products such as mixtures of cortisones and steroids. They should pay attention to the different types and strengths of medications in a combination product.

“Sometimes we use ointment bases, and you aren’t able to place zinc oxide on top of these bases,” Dr. Weinstein says.

Healing skin should not come into contact with urine or feces, and the choice of cleansers should be at the discretion of parents, she says.

Disclosures: Dr. Weinstein reports no relevant financial interests.