CHAPTER 20

Diaper dermatitis is an eczematization of the areas covered by diaper. Continuous occlusion , moisture and maceration of the diaper area may cause non-physiological state, where skin cannot tolerate that indefinitely. Fermentation of the secretions and liberation of ammonia plays also an important factor. Obese well-fed infants are more predisposed to have diaper dermatitis .

Etiology

Inspite that different physiological and pathological factors that play an important role in the etiology, yet the allergens that can cause the skin lesions in one infant may be not the same as that in another infant.

Predisposing Factors

1. Maceration of the crural area: This will lead to changing the optimum physiological status of the crural area.

2. Occlusion of the Crural Area: Prolonged occlusion of the skin can itself produce erythema due to increasel sweating and accumulation of debris on the crural area.

3. Water: Water is an important irritating factor especially when their contents of salts or chlorine are higher than the standard or using polluted water.
   Hydration and friction may be responsible for many cases of napkin dermatitis making the skin more susceptible to irritants. It has been suggested that prolonged contact with water alone can provoke dermatitis.
   Maceration of the stratum corneum by water may be an important predisposing factor, which increases transepidermal permeability, friction and infections .

4. Urine
   The role of urine in precipitating the skin lesions may be due to increased pH or higher contents of ammonia .
   Ureas are produced by a variety of fecal bacteria, which will have the effect of increasing the pH when mixed with urine.
   This may explain the findings that breast fed infants are less liable to diaper dermatitis than those fed on cows‘ milk , since the feces of the former group have been shown to be less heavily colonized by urease-products .
   In addition, urine appears to increase trans-epidermal permeability more effectively than water alone .

5. Feces
   Human feces have an irritant effect on skin . Infants feces contain substantial amounts of pancreatic protease and lipase. Similar enzymes appear to be produced within the gut by a variety of bacteria causing irritation and leading to higher pH of feces.
   One of the factors that have been shown to affect fecal pH is the infant‘s diet. Higher pH being found in the cows‘ milk formula-fed infant .

6. Friction
   It seems likely that friction between the skin and the fabric of the nappy plays at least some part in the etiology .

7. Micro-organisms
   The use of broad-spectrum oral antibiotics increases the recovery of Candida albicans from the rectum and skin. These may aggravate primary irritant napkin dermatitis.

8. Chemical irritants
   Soaps, detergents and antiseptics used to clean washable napkins have often been incriminated in the initiation and aggravation of primary irritant napkin dermatitis.

9. Obese infants are mor susceptible to diaper dermatitis.

We found that diaper dermatitis is more common in female infants. This may be related to different mode of urine voiding, ano-genital secreations, concentrated urine, more susceptable to Candidiasis or due to other factors.

Clinical Features

The onset is most often during the second and third month .

Skin lesions :

Confluent erythema of the areas in contact with the diapers i.e. the buttocks, the genitalia, the lower abdomen, pubic area and the upper thighs. In some infants, the eruption is more or less confined to the margins of the napkin area. Napkin dermatitis may present with different clinical manifestations.

Acute lesions: the erythema may have a glazed appearance, where later , there may be exfoliation of the affected areas of the skin.

Chronic cases show finer scaling .

Erythematous type : Intensely red confluent erythema of the entire perineal area including the depths of the flexural folds. Skin lesions present with erythema and slightly elevated margins. Within the marginal area small pustules may involve the periphery of the erythema - so-called ‘satellite‘ lesions.

This clinical type is associated with more intense proliferation of Candida albicans and is invariably associated with fecal carriage of this organism .

Psoriasiform type : the erythematous areas are similarly well marginated but have a psoriasiform aspect with prominent scaling. The onset of this eruption is commonly termed ‘napkin psoriasis‘ that may be quite sudden and its extension is rapid.

Herpetiform type : This takes the form of an eruption of vesicles and pustules followed by shallow erosions, and closely resembling herpes simplex clinically, but showing no evidence of this infection pathologically.

Granulomatous type : This rare type manifests with a dome shape , reddish-brown or purple nodules. The lesions are usually known as infantile gluteal granuloma .

Extensive type : The lesion extends peripherally to include the lower abdomen and back which may reach the axillary folds. Some believes that such type is a manifestation of infantile seborrheic dermatitis .

Hypopigmented type:

Post-inflammatory hypopigmentation may be a striking feature in racially pigmented infants.

The author found that the hypo pigmentation was mainly more in infants treated with topical steroids .

Erosive type of primary irritant napkin dermatitis is seen, in which small vesicles and erosions may develop into rather characteristic shallow round ulcers with raised crater-like edge.

Involvement of the genitalia may lead to dysurea, if the glans penis is severely affected, male infants may experience acute retention of urine .

Differential Diagnosis

Candidiasis

Candidiasis has characteristic clinical features in infants. Skin lesions of candidiasis are confluent glistening, sharply marginated erythematous with peripheral desquamation which may be accompanied by pustulation. Satellite pustules besides oral candidiasis are commn.

In neonatal Candidiasis, a superficial candida infection is transmitted to the baby during birth . The rash normally appears during the second week of life.

Congenital syphilis

Congenital syphilis has to be considered in infants with a dermatitis in the napkin area.

Clinical Features

The lesions of congenital syphilis appear as reddish-brown macules, sometimes slightly raised which appear principally on the extremities including the palms , soles, and on the face mainly around the mouth. The napkin area is also frequently affected.

Diagnoses

Serological tests (VDRL , Treponema palladium immobilization test (TPI) are positive .

The Fluorescent Treponemal Antibody Absorption test ( FTA-ABS ) is a confirmatory test in cases of false positive and false negative tests .

This test gives positive result in almost every case of syphilis .

Zinc deficiency

Zinc deficiency must be considered in any infant with a napkin dermatitis, which fails to respond to appropriate treatment. A history of prematurity should increase one‘s suspicion, and a normal plasma zinc level does not rule out the diagnosis.

Clinical feutures of zinc deficiency dermatitis

Infants with napkin eruptions caused by zinc deficiency present with:

Concurrent facial dermatitis extending from the perioral area.

An erosive paronychia.

Erosions of palmer creases of the hands.

Histiocytosis

Napkin dermatitis is one of the most common skin lesions of Langerhan's cell histiocytosis in infants .

Dermatophytes infections: Tinea cruris can be differentiated by the active raised edges, central clearing of lesions and by detecting of the causative organism.

Herpes simplex virus infection The eruption is acute, has characteristic painful grouped vesicular lesions on an erythematous base and is accompanied by constitutional manifestations such as fever .

Treatment of Napkin Dermatitis

Successful treatment of napkin dermatitis depends mainly on detection of the predisposing factors. The application of topical medications alone without correction of the predisposing factors, usually is rewarded with a therapeutic failure.

1- General measures

1. Washable diapers : When disposable diapers are not available due to economical or other reasons , the washable diapers can be used and they are preferred . Care should be taken concerning the washable diapers in order to give the best results . These include :

   Type of cloth : the cloth should be made of soft cotton that can easily absorb excretions and should be free from polyesters .

   Absorbency of napkins. The absorbency of the napkin is another important factor.

   Washable cloth napkins have the advantage of allowing two or more layers to be worn at once in order to increase the volume of urine that can be effectively absorbed. As the baby becomes older, though the frequency of urination falls, the volume voided on each occasion rises.

   New diapers should be washed before using for the first time to sweep away any chemicals .

   Washing of the diapers with mild soap and there should be good rinsing to remove any remnants of detergents .

   It is preferred that diapers are soaked after washing. Few drops of lemon juice or white vinegar are added to the soaked diapers and left for an hour or more and then washed under the tap water , rinsed and dried . Diapers should be made of soft cotton cloth . Harsh and stiff cloth may cause chaffing to the area.

   Diaper should not be too tight , too loose on the skin surface , should not be kept for a long time and should be changed immediately after wetting .

2. Disposable diapers are available in the market of different types and with different efficiency . The mother should use a good quality, which can absorb easily . She has to take care of the inner lining of the diaper to be free from plastic or polyester inner lining , which comes in contact with the skin of the infant. Suitable size of diapens according to the age of infant should be used in order not to compress the skin of thighs and abdomen.

Care of the napkins 

The use of antiseptic solutions for the storage of napkins prior to washing is more or less universal. These may be safe as long as suitable agents are used besides washing and rinsing procedures are adequate. Toxicity of infants by antiseptics used in the laundery washing of napkins is well documented or due to ink marking used or related to some detergents ,antiseptics and preservatives as phenol .

The quaternary ammonium compounds are now regarded as the best choice, of which benzalkonium chloride is perhaps the most widely employed. Antiseptics should never be used during the rinsing process.

Marking inks of the washable napkins have caused aniline poisoning. These may cause methaemoglobinaemia when the napkins have not subsequently been washed before use .

Storage of napkins in mothballs containing naphthalene has caused hemolytic anemia and fatal cases among infants .

The mother should pay more care and attention to her infant . Babies under the care of housemaids who usually neglect changing the diapers are more susceptible to develop diaper dermatitis .

Change of  diapers 

The frequency of napkin changes is almost certainly more important than either the type of napkin or the wearing of occlusive pants.

A reasonable plan is a routine changing or at least checking the napkin for wetting or soiling at regular periods .

2- Preventive measures

Effective treatment is directed mainly to prevent the irritating agent and directed towards the predisposing factors .

Avoid using tissue paper for cleaning the skin especially those soaked with alcohol, antiseptics or perfume.

Gentle cleaning of the diaper area is very important. Mothers should use very mild , non-irritating soap and non-perfumed .

Meticulous cleaning will do more harm .Rubbing the area with a sponge or other harsh sponges should be avoided .Cleaning by a mild soap and a cotton texture sponge is that all needed .

At each napkin change, an emollient such as white soft paraffin, or a half-and-half mixture of white soft paraffin and liquid paraffin, or zinc and castor oil cream BP should be applied if the napkin has not been wetted or soiled.

If the napkin has been wetted or soiled, the area should be cleansed with water and a water-miscible emollient application such as emulsifying ointment BP, aqueous cream and dried before applying a water-repellent emollient.

During remission, the baby should be bathed with dispersible bath oil added to the water, e.g. Alpha Keri, Oileatum or Balneum, and emulsifying ointment BP, aqueous cream BP or Unguentum Merck should be used . While the eruption is under treatment, such baths should ideally be given daily.

The use of talc and over-the-counter preparations containing potential irritants should be discouraged.

Cleaning of infants

The ideal cleanser for new born and infants should have the following features:

Must contain delicate tensides.

Must be physio-chemically stable.

Must not contain perfumes.

Must not contain alcohol.

Must not contain substances cross-reactive with other allergens.

Must not contain substances that can be metabolized by cutaneous microflora.

It is important that the napkin area is left exposed and free for sometime daily without diapers for aeration .

Rubber plastic panties worn over the napkin should be avoided or used with care since these may cause more occlusion.

Powders such as talcum powder should be avoided if the napkin area is macerated as that may be is abrasive and may cause more irritation.

3- Active treatment

Non-steroidal topical preperations : are the first line of treatment    

 Corticosteroids should be reserved for the most severe,reluctant types of atopic dermatitis when the non-steroidal preperation fail to clear the lesions.

The most effective and safe antisteroidal topical preperations are " Pufexamac "

( Droxaryl or Flogocid ) and "Tacrolimus " (Protopic cream).

Fluorinated or potent steroids should be avoided.

Topical antihitamines should not be used.

Treatment depends on the type of the lesion of the diaper area .

Oozing lesion: Potassium permanganate 1: 9000 compresses are used to dry the lesion . Clean or sterile gauze immersed in Potassium permanganate is used as compresses applied gently to the oozing surface for one minute, and this can be used frequently.

The physician should be very careful in choosing the topical preparations because of the possibility of local sensitization by some creams or lotions containing sensitizers such as neomycin, local anesthetics ,antibiotics , antihistamine preparations and others. The area is scalded and the possibility of rapid absorption of toxins and others as potent corticosteroids may endanger the life of the infant.

Topical corticosteroids

Although some  physicians use corticosteroids frequetly , even in the mildest cases , my experience is that corticosteroids topically and systemically are not always routinely indicated in napkin dermatitis .

                                                                                                         Fig. 176cMisuse of topical corticosteroids

                                                                                                                                                 (Hypopigmentation and skin rash )

I treat napkin dermatitis as follows:

1. Wet and macerated diaper area

   I instruct the mother to use:

   Potassium permanganate compresses 1:9000 twice daily to clean the area from debris and exudate.

   Non-steroid cream, containing mild antiseptic such as Pufexamac (Flogocid cream) is applied after the permanganate compresses.

   Gauze, either the dry one or with olive oil or with non sensitizing antibiotic such as" Sofratulle or Fucidin " is applied above the cream. The idea of this is to cut short the viscous circle and prevents contact of the plastic diaper with the infant‘s skin to minimize irritation and occlusion.

2. The dry type: gentle cleaning of the area ,ointment such as ( Flogocid) ointment and gauze under the diaper.

   In severe dry cases: emollient can be used and very mild steroid ointment such as( Elocom or Eumovate ) ointment is used just for

    a few days and the mother should be instructed to stop the ointment and not to use it more than one week.

3. Secondarily infected lesions 

   Topical anti-bacterial cream such as Mupricine (Bactropan ) applied  once daily and systemic antibiotic such as erythrocin can be used. 

4. Complicated lesions: Candidiasis can be treated by mild topical preparation as " Flogocid ointment " which is a non-steroid anti-inflammatory, antifungal and anti-bacterial preparation. This is a safe preparation and causes rapid clearing of the skin lesions. We found that most new born and young children cannot tolerate the topical azoles, where the delicate and usually abraded napkin area becomes more irritated.

N.B. : Antifungal preparations especially those combined with steroid should be better avoided and if there is strong indications for their use ,these should be used cautiously and for a short period . Other Antifungal preparations may cause severe local reaction with more erythema and irritation to the crural areas especially antifungal lotions such as (Canstene ) . This reaction may be due to the vehicle causing more irritation to the macerated sensitive skin of the crural area and the genitalia in particular .

It must be borne in mind that the abraded skin will considerably enhance the rate of percutaneous absorption of corticosteroid from topical application in the napkin area or occlusive conditions found at this site.

Corticosteroid absorption may cause hazardous side effects such as interference with the descent of the testis especially in premature babies.

REFERENCES

1. Herpetiform napkin dermatitis: napkin dermatitis simulating an acute herpes simplex infection. Br J Dermatol 1986;114: 746-7.

2. Keswick BH, Seymour JL, Milligan MC. Diaper area skin microflora of normal children and children with atopic dermatitis. J Clin Microbiol 1987; 25: 216-21.

3. Zimmerer RE, Lawson KD, Calvert CJ. The effects of wearing diapers on skin.Pediatr Dermatol 1986; 3: 95-101.

4. Stein H. Incidence of diaper rash when using cloth and disposable diapers. J Pediatr 1982; 101: 720-3.

5. Buckingham KW, Berg RW. Etiologic factors in diaper dermatitis: the role of feces. Pediatr Dermatol 1986; 3: 107-12.

6. Jordan WE, Lawson KD, Berg RW et al. Diaper dermatitis: frequency and severity among a general infant population. Pediatr Dermatol 1986; 3: 198-207.

7. Munz D, Powell KR, Pai CH. Treatment of candidal diaper dermatitis: a double blind controlled comparison of topical nystatin with topical plus oral nystatin. J Pediatr 1982; 101: 1022-5.

8. Berg RW, Buckingham KW, Stewart RL. Etiologic factors in diaper dermatitis: The role of urine. Pediatr Dermatol 1986; 3: 102-6.

9. Buckingham KW, Berg RW. Etiologic factors in diaper dermatitis: The role of feces. Pediatr Dermatol 1986; 3: 107-12.

10. Campbell RL, Bartlett AV, Sarbargh FC et al. Effect of diaper types on diaper dermatitis associated with diarrhoea and antibiotic use in children and day-care centres. Pediatr Dermatol 1988; 5: 83-7.

11. Jordan WE, Lawson KD, Stewart R et al. Diaper dermatitis: Frequency and severity among a general infant population. Pediatr Dermatol 1986; 3: 198-207.

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