The Bottom Line – Managing Diaper Dermatitis

S. Humphrey, MD; J. N. Bergman, MD, FRCPC;
S. Au, MD, FRCPC
Department of Dermatology and Skin Science, University of British Columbia, Vancouver, Canada

Irritant Diaper Dermatitis (IDD)

Irritant diaper dermatitis (IDD) is a common inflammatory eruption of the skin in the diaper area, seen in 25% of children wearing diapers. [Ward DB, et al. Arch Pediatr Adolesc Med 154:943-6 (2000).]

IDD is caused by the presence of moisture, warmth, urine, feces, and friction. It is difficult to completely eradicate these predisposing factors in a diapered child. Thus, IDD presents an ongoing therapeutic challenge for parents, family physicians, pediatricians, and dermatologists.

Pathogenesis

Four key factors contribute to the development of IDD:

Wetness

• Wet diapers result in excess hydration and maceration of the stratum corneum, leading to impaired barrier function, enhanced epidermal penetration by irritants and microbes, and susceptibility to frictional trauma.

Friction

• IDD is most commonly distributed in areas with greatest skin-to-diaper contact.
• Friction disrupts the macerated stratum corneum, exacerbating barrier dysfunction.

Urine and Feces

• The interaction of urine and feces is key to the pathogenesis of IDD. Bacterial ureases in the stool degrade the urea that is found in urine causing ammonia to be released and local pH to increase.
• Fecal lipases and proteases are activated by the increased pH, causing skin irritation and disruption of the epidermal barrier.
• Ammonia does not directly irritate intact skin; it is thought to mediate irritation by contributing to the high local pH.

Microorganisms

• Candida albicans and Staphylococcus aureus (less common) infections are associated with IDD; the increased humidity and pH in the diaper provide the ideal milieu for microbial proliferation.

Clinical Features

• Localized asymptomatic erythema can progress to widespread painful erythema with maceration, erosions, and frank ulceration.
• IDD commonly spares the skin folds and affects convex skin surfaces in close contact with the diaper, including the buttocks, genitalia, lower abdomen, and upper thighs.
• Severe variants can occur, which include:
• Jacquet erosive diaper dermatitis: associated with diarrhea, poor hygiene, infrequent diaper changes, and plastic diapers
• Granuloma gluteale infantum: associated with topical steroid use, candida infection, and plastic diaper covers.

Always consider other conditions that may occur in the diaper area when assessing a patient with possible IDD. See Table 1.

Risk Factors

• Fecal incontinence and diarrhea
• e.g., Hirschsprung’s disease, fecal impaction and overflow, and anogenital malformations.
• Increased bile acids in stool
• e.g., short-gut syndrome and conjugated hyperbilirubinemia
• Atopic dermatitis
• increased sensitivity to irritants and susceptibility to secondary infection.

Treatment

Barriers

• Pastes are the most hardy and desirable barriers, followed by ointments.
• Choose pastes with >10% of a fine powder such as zinc oxide or titanium dioxide.
• Creams and lotions are not appropriate barriers as they are poorly adherent, minimally occlusive, and contain preservatives.
• Barrier should be applied thickly to diaper area like “icing on a cake” after each diaper change.
• Cover barrier with petroleum jelly to prevent it from sticking to diaper.
• Avoid barriers with potentially harmful ingredients such as camphor, phenol, boric acid, and salicylates.

Cleansing

• Bathe daily in a lukewarm bath using irritant and fragrance-free soap.
• Gently pat dry with a towel to avoid any undue friction.
• Do not attempt to remove all the adherent barrier paste when wiping off urine/ feces.
• Mineral oil can help remove residual barrier when necessary.
• Unscented and alcohol-free diaper wipes are appropriate for patients with IDD. They restore normal pH balance and prevent skin breakdown.

Diapers

• Maximizing “diaper-free” time is a widely recommended preventative strategy, but not very practical.
• Change diapers as soon as they are wet or soiled (at least every 3–4 hours, more often in neonates).
• Do not use tight-fitting diapers; looser diapers can minimize contact between skin and urine/ feces.
• Cloth diapers are not recommended for patients with IDD; they increase skin wetness, promote mixing of urine and feces, and are associated with Jacquet erosive diaper dermatitis.
• Common IDD should resolve when children become toilet trained.

Disposable Diapers

“Breathable” superabsorbent disposable diapers (e.g., Pampers^®, Procter & Gamble; Huggies^®, Kimberly-Clark) are the diapers of choice in IDD:

• They contain a polyacrylate polymer core that forms a gel when hydrated and traps moisture away from the skin surface; the gel controls pH by its buffering capacity and by separating urine from feces.
• “Breathable” backsheet (outer cover) prevents excess humidity but still protects against leaks; it feels like cloth rather than plastic, and is readily identifiable in the office.
• Polyacrylate gel core diapers are associated with reduced skin wetness, superior pH control, and less IDD compared with cellulose core disposable and cloth diapers [Campbell RL, et al. J Am Acad Dermatol 17:978-87 (1987)].
• They have been shown to reduce the prevalence of severe IDD by up to 50%. [Akin F, et al. Pediatr Dermatol 18:282-90 (2000)].
• Most conventional diapers now use the breathable polyacrylate gel core technology.

Corticosteroids

• A short course of a mild topical corticosteroid is frequently necessary in moderate-to-severe IDD.
• Hydrocortisone 1% ointment can be applied to affected areas twice daily for a limited duration.
• Mid-to-high potency corticosteroids should never be used in the diaper area (risk of atrophy, systemic absorption, candidiasis, granuloma gluteale infantum).
• Avoid combination antifungal-corticosteroid products that often contain mid-to-high potency steroids.

Infection

• Candida infection is often associated with moderate-to-severe cases of IDD and presents with beefy red erythema and satellite papules and pustules; the skin folds may be involved.
• The azoles, nystatin, and ciclopirox are all appropriate topical anticandidal agents; twice-daily application is recommended until resolution.
• Mupirocin is also effective in the treatment of IDD superinfected with Candida.

Remember the ABCDEs of Diaper Dermatitis

Conclusion

IDD is a common dermatosis afflicting diapered children. It is caused by wetness, friction, urine, stool, and microorganisms. A proactive approach targeting predisposing factors is the best defense against IDD.

• Table of Contents
• The Bottom Line – Managing Diaper Dermatitis
• Treatment of Head Lice
• Common Bacterial Skin Infections