Diaper dermatitis

Last updated: February 14, 2023

Summary

Diaper dermatitis refers to various rashes affecting the perineal and perianal areas during diaper use. The most common cause is irritant contact dermatitis, which typically manifests with papules, plaques, and patches, sometimes with maceration or erosion. Other common causes included allergic contact dermatitis and infection. Diagnosis is initially based on clinical evaluation, and treatment of the suspected underlying cause can usually be initiated without further diagnostics. If symptoms worsen despite initial therapy, further diagnostics (e.g., bacterial culture, skin biopsy) guided by history and physical examination findings should be performed.

Epidemiology

Typically seen in infants
Peak incidence: 9–12 months of age ^[1]

Epidemiological data refers to the US, unless otherwise specified.

Overview

Overview of diaper dermatitis
Condition			Etiology	Characteristics of the rash	Treatment
Diaper-related	Irritant contact dermatitis (most common cause) ^[1]		Increased moisture Irritation due to prolonged exposure to urine and feces Diaper soaps, detergents Lower stool pH (e.g., in nonbreastfed infants)	Acute: pruritic and/or painful erythema, edema, and vesicular rash Chronic: pruritic and/or painful xerosis, scaling, lichenification, hyperkeratosis, and fissuring Well-defined borders	ABCDE approach ^[1] Air: diaper-free periods to dry the skin Barrier: cream or ointment (e.g., zinc oxide, lanolin) to protect the skin Clean: keep the skin clean Diaper: frequent diaper changes to maintain dryness Education: explain the treatment plan to caregivers Low-potency topical corticosteroids for persistent symptoms
	Allergic contact dermatitis		Personal care products (e.g., perfumes, soaps, cosmetics)	Intensely pruritic erythematous papules, vesicles with serous oozing Ill-defined borders	Allergen avoidance Cool compresses, calamine lotion, wet dressings Mid-potency topical corticosteroids for localized dermatitis
	Candidiasis		Candida albicans (most common)	Scaly, erythematous, deep red plaques and satellite papules	Topical antifungal agents (e.g., clotrimazole, ketoconazole, nystatin)
Non-diaper-related	Seborrheic dermatitis		Unknown; may be associated with Malassezia spp.	Erythematous plaques with patchy scaling, greasy yellow crusts Well-defined borders	First-line therapy: topical antifungals (ketoconazole) Topical corticosteroids (for severe acute flares) Exposure to sunlight Creams and shampoos containing selenium sulfide, zinc pyrithione, salicylic acid, tar, or sulfur
	Bacterial infection	Perianal streptococcal dermatitis	Group A Streptococcus (S. pyogenes)	Pruritic erythematous rash with purulent exudate, crusting, and/or superficial fissures or cracks Well-defined borders Rectal pain and blood-streaked stools	Adults: penicillin Children: oral amoxicillin
	Bacterial infection	Impetigo	Staphylococcus aureus	Small vesicles, pustules, and/or honey-colored crusts on an erythematous base	Mild nonbullous: topical antibiotics (mupirocin) Bullous impetigo, ecthyma, or severe nonbullous impetigo: first-generation cephalosporins (e.g., cephalexin) or dicloxacillin
	Enterobiasis		Corynebacterium minutissimum	Severely pruritic (especially at night) Excoriations and/or bacterial superinfections, perianal cellulitis	Bendazoles Pyrantel pamoate
	Psoriasis		Infections (e.g., β-hemolytic streptococci, staphylococcal infections, HIV) Mechanical irritation Drugs (e.g., beta blockers)	Pruritic erythematous plaques and papules with silvery scaling Well-defined borders Koebner phenomenon and Auspitz sign	See “Approach to patients with psoriasis.”

Diagnostics

General

The diagnosis of diaper dermatitis is based on clinical evaluation.

Obtain a comprehensive clinical history.
Assess characteristics of the rash (i.e., presence of papules, vesicles, nodules) affecting the perianal and perineal areas.

In most patients, the rash is caused by irritant contact dermatitis resulting from the moist environment in the diaper area, and treatment can be initiated without further diagnostics.

Further diagnostics

If symptoms persist or worsen despite initial treatment, or if the patient has symptoms that suggest a different condition, further diagnostics guided by history and physical examination findings are appropriate.

Candidiasis: KOH preparation, fungal culture of the skin
Bacterial infection: bacterial culture for S. aureus or group A Streptococcus
Skin biopsy: atypical rashes and/or those that do not respond to conventional therapy

Chronic candidal diaper dermatitis in children should raise suspicion for diabetes mellitus type 1. In the absence of diabetes mellitus type 1, chronic and/or severe diaper dermatitis should raise suspicion for child neglect or abuse.

Differential diagnoses

References

Klunk C, Domingues E, Wiss K. An update on diaper dermatitis.. Clin Dermatol. 2014; 32 (4): p.477-87.doi: 10.1016/j.clindermatol.2014.02.003 . | Open in Read by QxMD

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