Diaper Dermatitis

Key Points

Diaper dermatitis, also known as diaper rash, is a frequently encountered benign skin rash corresponding to the area covered by a diaper
- Usually a form of irritant contact dermatitis, but allergic contact dermatitis also may contribute
Infants or incontinent adults with frequent stooling or diarrhea and infrequent diaper changes are more likely to develop diaper rash
Prevention includes bathing infant twice weekly, ¹ cleansing diaper area, changing diapers frequently (as often as every 2 hours ² or as needed), using highly absorbent diapers, and applying barrier agents based on zinc oxide or petroleum jelly
Treatment focuses on increasing the frequency of diaper changes, using superabsorbent diapers and barrier creams if not already used, allowing periodic diaper-free time, and topically applying solutions such as aluminum/magnesium antacid or sucralfate
If rash involves inguinal folds or satellite lesions, suspect candidal infection, which is a frequent complication

Pitfalls

Failure to consider a more severe disease, such as zinc deficiency, in a child with oral and mucous membrane involvement

What's on this Page

Terminology

Clinical Clarification

Diaper dermatitis, also known as diaper rash, involves skin inflammation within the area covered by a diaper
- Usually a form of irritant contact dermatitis, but allergic contact dermatitis also may contribute
Affects premature and full-term neonates, infants, and children, as well as adults with urinary or fecal incontinence
- Difficult to maintain skin integrity, especially in older adults and those with medical or surgical comorbidities (eg, with dementia, during postoperative period) and in premature infants who have a thinner, immature skin barrier that is easily damaged. ³ ⁴
- Among people living in assisted living communities, an estimated 39% of residents are incontinent (36% urinary, 20% bowel) ⁵
- Among hospitalized neonates, 25% to 65% have diaper dermatitis ⁶
- Over 80% of neonates with opioid withdrawal syndrome are affected ⁶

Diagnosis

Clinical Presentation

Common presentation of diaper dermatitis.From Chayavichitsilp P et al: Diaper dermatitis. In: Lebwohl MG et al, eds: Treatment of Skin Disease: Comprehensive Therapeutic Strategies. 4th ed. Philadelphia, PA: Elsevier; 2014:188-9, Figure 1.
Typical findings of zinc deficiency. – In this patient, the zinc deficiency was caused by low levels of zinc in breast milk.From Krol AL et al: Diaper area eruptions. In: Eichenfield LF et al, eds: Neonatal and Infant Dermatology. 3rd ed. Philadelphia, PA: Elsevier;2015:245-64.e2, Figure 17.19B.
Presentation of excoriated and bleeding skin of a premature infant. – Image courtesy Marty O. Visscher, PhD.From Visscher MO et al: Factors Impacting Skin Integrity in NICU Patients. 37th Annual Conference, virtual poster presentation, National Association of Neonatal Nurses, September 13-15, 2020.

History

Rash in diaper area reported by parent or caretaker
Irritability or fussiness (in neonates and infants)
Diarrhea may precede rash or may exacerbate existing rash
Other contributing factors may be elicited in the history:
- Use of diapers that do not have enhanced absorbency, including cloth diapers
- Frequent stooling events per day (in neonates and infants) ⁷
- Prolonged exposure to feces and urine because of infrequent diaper changes
- Infrequent use of or ineffective protective treatments or creams
- Multiple food allergies resulting in more frequent stools and persistent rash over the entire perineum ⁸

Physical examination

Examination reveals erythematous patches that may include raised regions and/or papules corresponding to areas in direct contact with the diaper (eg, convexities of vulva or scrotum, buttocks, upper thighs, lower abdomen); there may be associated maceration, excoriation, weeping, bleeding, or peeling of the skin
- Jacquet erosive diaper dermatitis, a severe form usually associated with chronic diarrhea, is characterized by erythematous nodules with an eroded surface ⁹
Skin folds and inguinal creases may be affected, particularly as infants gain weight and the areas are in constant contact (ie, intertrigo)
The gluteal cleft can be involved, particularly in premature infants, when fecal matter is trapped and in constant contact; excoriation and bleeding may be observed.

Causes and Risk Factors

Causes

Prolonged exposure to moisture and occlusion makes the skin more susceptible to damage caused by friction from the diaper surface during movement, exposure to local irritants, and increased skin permeability due to increased hydration ¹⁰
- Urine and feces are both skin irritants; alone or in combination they increase local pH and exacerbate damage caused by moisture and friction ¹¹

Risk factors and/or associations

Age

In children, peak incidence is age 9 to 12 months ¹²
In hospitalized premature and full-term infants, it may begin within days of birth ⁶
Incontinent adults who require diapers or incontinence pads are also at risk (approximately 25 million people in the United States are affected by incontinence) ¹³

Other risk factors/associations

Frequent stooling ⁶ ¹⁴
Infrequent diaper changes ¹⁴
Diapers without enhanced absorbency (eg, cloth) ⁹
Diarrhea ¹⁴
Oral thrush ¹⁴
Comorbidities (eg, short gut syndrome, receiving chemotherapy in infancy)
In infants, consumption of nutrition other than breast milk ⁹ ¹⁵

Risk factors for recurrent episodes ¹⁴

Infrequent or ineffective use of skin protectants (eg, barrier cream)
Infrequent diaper changes
Underlying medical condition (eg, chronic diarrhea, multiple food allergies) ⁸
Associated with Candida infection

Diagnostic Procedures

Primary diagnostic tools

Usually, diagnosis is based on history and physical examination

Differential Diagnosis

Candidal diaper dermatitis.From Morrell DS et al: Fungal infections, infestations, and parasitic infections in neonates and infants. In: Eichenfield LF et al, eds: Neonatal and Infant Dermatology. 3rd ed. Philadelphia, PA: Elsevier; 2015:198-215.e3, Figure 14.8.
Perianal streptococcal dermatitis with guttate psoriasis.From Krol AL et al: Diaper area eruptions. In: Eichenfield LF et al, eds: Neonatal and Infant Dermatology. 3rd ed. Philadelphia, PA: Elsevier; 2015:245-64.e2, Figure 17.14A.
Group A streptococcal infection involving perianal area. – Moist erythema of the folds is characteristic.From Krol AL et al: Diaper area eruptions. In: Eichenfield LF et al, eds: Neonatal and Infant Dermatology. 3rd ed. Philadelphia, PA: Elsevier; 2015:245-64.e2, Figure 17.14Biv.
Allergic contact diaper dermatitis. – Allergic contact dermatitis from disposable diaper components. Called “Lucky Luke dermatitis” by the authors after a cartoon character who carries his holster in the same area.From Krol AL et al: Diaper area eruptions. In: Eichenfield LF et al, eds: Neonatal and Infant Dermatology. 3rd ed. Philadelphia, PA: Elsevier; 2015:245-64.e2, Figure 17.11.
Seborrheic dermatitis. – A cause of diaper rash in young infants, seborrheic dermatitis is difficult to distinguish clinically from infantile psoriasis but tends to be less erythematous, to have thinner scaling, and to respond more quickly to topical anti-inflammatory medications.From Paller AS et al: Eczematous eruptions in children. In: Paller AS et al, eds: Hurwitz Clinical Pediatric Dermatology. 5th ed. Philadelphia, PA: Elsevier; 2016:38-72.e7, Figure 3-38.
Typical diaper involvement of psoriasis.From Krol AL et al: Diaper area eruptions. In: Eichenfield LF et al, eds: Neonatal and Infant Dermatology. 3rd ed. Philadelphia, PA: Elsevier;2015:245-64.e2, Figure 17.9A.
Typical diaper involvement of psoriasis.From Krol AL et al: Diaper area eruptions. In: Eichenfield LF et al, eds: Neonatal and Infant Dermatology. 3rd ed. Philadelphia, PA: Elsevier;2015:245-64.e2, Figure 17.9B.
Perianal psoriasis in a toddler.From Krol AL et al: Diaper area eruptions. In: Eichenfield LF et al, eds: Neonatal and Infant Dermatology. 3rd ed. Philadelphia, PA: Elsevier;2015:245-64.e2, Figure 17.9C.
Vulvar psoriasis in a toddler.From Krol AL et al: Diaper area eruptions. In: Eichenfield LF et al, eds: Neonatal and Infant Dermatology. 3rd ed. Philadelphia, PA: Elsevier;2015:245-64.e2, Figure 17.9D.
Miliaria rubra. – Multiple, erythematous, pinpoint macules and papules in an infant with atopic dermatitis who was being treated with overapplication of greasy emollients.From Paller AS et al: Cutaneous disorders of the newborn. In: Paller AS et al, eds: Hurwitz Clinical Pediatric Dermatology. 5th ed. Philadelphia, PA: Elsevier; 2016:11-37.e4, Figure 2-8.
Staphylococcal infection with both pustules and bullae in an 11-day-old infant.From Krol AL et al: Diaper area eruptions. In: Eichenfield LF et al, eds: Neonatal and Infant Dermatology. 3rd ed. Philadelphia, PA: Elsevier;2015:245-64.e2, Figure 17.13A.
Staphylococcal scalded skin syndrome in a neonate.From Krol AL et al: Diaper area eruptions. In: Eichenfield LF et al, eds: Neonatal and Infant Dermatology. 3rd ed. Philadelphia, PA: Elsevier;2015:245-64.e2, Figure 17.13B.
Scabies. – Erythematous papules with crusting in an infested infant.From Paller AS et al: Infestations, bites, and stings. In: Paller AS et al, eds: Hurwitz Clinical Pediatric Dermatology. 5th ed. Philadelphia, PA: Elsevier; 2016:428-47, Figure 18-1.
Langerhans cell histiocytosis. – Extensive eruption resembles severe Candida infection, but purpuric papules near the umbilicus are typical of Langerhans cell histiocytosis.From Krol AL et al: Diaper area eruptions. In: Eichenfield LF et al, eds: Neonatal and Infant Dermatology. 3rd ed. Philadelphia, PA: Elsevier;2015:245-64.e2, Figure 17.20A.
Langerhans cell histiocytosis. – Langerhans cell histiocytosis with ulceration in the inguinal crease.From Krol AL et al: Diaper area eruptions. In: Eichenfield LF et al, eds: Neonatal and Infant Dermatology. 3rd ed. Philadelphia, PA: Elsevier;2015:245-64.e2, Figure 17.20B.

Most common

Candidal diaper dermatitis⁹
- May occur as a secondary infection exacerbating irritant diaper dermatitis or may occur on its own after antibiotic exposure
- Most common diaper area infection in children (80% of infections) ¹⁶ ¹⁷
- Rarely associated with diabetes
- Typically presents as bright, beefy red patches with satellite macules or pustules with small collarettes
- Rash is often accentuated in skin folds, and in males it can involve the scrotum; but it may be generalized throughout the diaper area in infants
- Differentiate based on physical examination and laboratory test results
  - Candida infection often involves inguinal folds and gluteal cleft with satellite lesions
  - Potassium hydroxide preparation will demonstrate yeast
Perianal streptococcal infection ¹⁸
- Caused by group A β-hemolytic Streptococcus (Streptococcus pyogenes)
- Characterized by bright red perianal patches, fiery red erythema, and maceration in the intertriginous folds; satellite lesions are not present
- Pain, low-grade fever, and malaise may accompany this infection
- May be misdiagnosed as irritant contact dermatitis, allergic dermatitis, pinworm, or child abuse
- More common in children; 80% of cases occur in males aged 1 to 7 years ¹⁸
- Differentiate based on physical examination and laboratory test results
  - Itch and rectal bleeding may occur, neck and axillary area may be involved, and systemic symptoms may be present
  - Group A Streptococcus isolated from rectal swab (rapid test) has positive predictive value of 80% and negative predictive value of 96% ¹⁸
Allergic contact dermatitis
- Allergy to dyes, adhesives, rubber, and other components of disposable diapers ²
- Sensitivity or allergy to products used to clean diaper area (eg, soaps, shampoos, disposable wipes) ²
- Rash is typically isolated to areas the allergen touches; for example, there may be a line of pink patches or plaques corresponding to areas of skin touching elastic diaper components (typically waistline and upper thighs)
- Differentiate by eliminating exposure to putative agent, allowing rash to clear completely, and reassessing with reexposure
Seborrheic dermatitis ¹⁹²⁰
- Consists of erythematous patches that are usually well demarcated, with inguinal fold involvement but without the degree of scaling seen on seborrheic lesions of the scalp (cradle cap)
- Malassezia (yeast) is believed to be involved
- Usually resolves by age 6 to 9 months
- Use physical examination results to differentiate
  - Commonly associated with white to yellow scaling seborrhea on the scalp
  - Difficult to differentiate from infantile psoriasis, but it tends to be less erythematous and to have thinner scaling
Psoriasis⁹
- Well-defined patches of erythema, often but not invariably with silvery scales
- May present as an unusually persistent diaper rash
- Typically involves skin folds and often the gluteal cleft
- Use history and physical examination results to differentiate
  - May have a positive family history
  - Usually has a characteristic scaly plaquelike appearance and may involve skin folds
- Lack of complete response to low-potency steroids also may suggest the diagnosis
Miliaria rubra (heat rash)
- Caused by retention of sweat in the eccrine sweat duct, secondary to blockage of the duct associated with warmth and humidity in the diaper area
- Appears as erythematous papules and small pustules; may be pruritic
- Use history and physical examination results to differentiate
  - Usually occurs in hot, humid weather
  - May involve other parts of the body
Staphylococcus aureus infection ⁹
- May occur in newborns from colonization of umbilical stump
- Typically, small papules and pustules are present
  - If toxin-producing bacteria are present, larger fragile blisters of bullous impetigo may extend from umbilical stump
- Folliculitis or, much less commonly, furuncles or abscesses also may occur
- Differentiate based on history and physical examination results
  - Fever may be present; presence of bullae or purulence suggests bacterial infection
Scabies
- In infants, appears as inflammatory nodules, bullae, and pustules, which may evolve to scale or crust
- May include genital area, but usually is not confined to that region; commonly involves scalp, neck, chest, palms, and soles of feet in infants
- Household members with more typical scabies rash, including classic burrows, provide a clue to diagnosis
- Confirm diagnosis by demonstrating mite on microscopic examination of skin scrapings

Less common

Langerhans cell histiocytosis ⁹
- Extreme eruptions in diaper area
- Symptoms include scale, crusting, and barely palpable hemorrhagic papules resembling petechiae, often involving inguinal creases; atrophy and deep ulcerations may be present
- Use physical examination and skin biopsy results to differentiate
  - Often involves scalp, ears, oral mucosa, and inguinal creases; hemorrhagic papules are characteristic
Zinc and biotin deficiency ⁹²¹
- Symptoms may include erythematous plaques, erosions, and pustules in diaper area; severe cases may be infected ²²²³
  - May involve other mucocutaneous areas (eg, perioral)
- Dermatitis due to zinc deficiency may not respond to antibiotics with systemic effects and/or topical agents (eg, nystatin/zinc oxide)
- May appear after breastfeeding has stopped because zinc availability in cow’s milk is different from breast milk
- Occurs because of zinc deficiency resulting from autosomal recessive disorder in zinc absorption (acrodermatitis enteropathica) ²⁴
- Dermatitis due to zinc deficiency is typically associated with severe deficiency ²⁵
- Differentiate based on physical examination and laboratory results demonstrating deficiency

Treatment Goals

Eliminate precipitating factors and allow skin to heal
- Reduce length of skin exposure to excessive moisture
- Reduce prolonged contact with feces and urine
Relieve discomfort
Base treatment on type and degree of skin breakdown: ²⁶
- Irritant contact dermatitis
  - Protect all diaper-covered skin by applying barrier cream or paste
  - Consider applying a thin layer of petroleum jelly to the cream or the diaper to prevent it from sticking to the barrier cream/paste
  - At each diaper change, gently clean the area, removing and replacing only soiled portions of barrier cream

Disposition

Recommendations for specialist referral

Refer to dermatologist for refractory rash that does not respond to usual treatment

Treatment Options

First, perform a focused skin assessment of perianal area using a valid and reliable tool

Neonates and infants; options include: ²⁶
- Validated, widely used scale with scores derived from assessment of both area of involvement and severity ²⁷
- Perineal Skin Care Guidelines for Diapered/Incontinent Patients, adapted from Children’s Hospital of Philadelphia by the Association of Women’s Health, Obstetric and Neonatal Nurses ²⁶
- Neonatal Skin Condition Score, which was not designed for diaper area but has been used for this purpose ²⁸
Adults ¹³
- Can use a continence assessment or evaluation tool (eg, those used when admitting residents to an assisted living facility) ¹³
- Must distinguish incontinence-associated dermatitis from pressure ulcers and other dermatoses ²⁹

Encourage breastfeeding ²⁶

Urine and stools of breastfed infants have lower pH and enzyme levels than formula-fed infants

Optimize skin care to decrease irritation ²

Use superabsorbent diapers if not already using ²⁶ ³⁰
Consider using dye-free diapers to avoid allergens ²⁶
Frequently check for wet or soiled diapers and change them: ²⁶
- With feedings (healthy infants)
- With clustered caregiving (hospitalized neonates)
Gently clean skin; blot, avoid wiping or rubbing ²⁶
- Neonates: base technique on gestational age
  - Use soft cloth and sterile water for premature infants younger than 28 weeks gestational age until 1 week old
  - Otherwise, use soft cloth, water, and cleanser that is free of irritating ingredients and allergens ³¹
  - Use disposable baby wipes based on a robust buffering system, to create an acidic pH skin surface and to remove feces and deactivate fecal enzymes ³²
- Adults ³³
  - Skin should be cleansed with a pH-balanced cleanser to maintain the acid mantle
  - A pH-balanced cleanser that leaves the skin with a slightly acidic pH reduces skin irritation and dryness, which helps maintain skin integrity
Use ointments or skin barrier creams containing zinc oxide at every diaper change in infants at risk for developing diaper dermatitis ²⁶
- Give preference to formulations with fewer additives
- Select barrier creams that are not removed by stool
Use alcohol-free liquid barrier skin protectants as a barrier on dry skin beneath the barrier cream in infants older than 28 days ²⁶
Allow diaper-free time when possible

In cases that do not improve despite consistent treatment, topical medications may reduce inflammation and relieve discomfort

Low-potency corticosteroid creams ³⁴
- High-potency creams have been associated with iatrogenic Cushing syndrome
- Higher potency preparations also may cause thinning of skin; should be used sparingly until improvement is noted and nondrug therapy can be resumed
- May use occlusive dressings to manage refractory conditions; however, this can increase systemic absorption and the risk of adverse reactions. Advise caregivers to avoid use of tight-fitting diapers or plastic pants in patients being treated in the diaper area as these may act as an occlusive dressing
Other agents that are widely used but not well studied include sucralfate and magnesium/aluminum antacid solution ² ³⁵ ³⁶ ³⁷

Drug therapy

Hydrocortisone ointment 0.5% to 2.5% ³⁴
- Hydrocortisone Topical cream; Infants, Children, and Adolescents: Apply a thin layer topically to the affected area(s) 2 to 4 times daily for up to 2 weeks.
- Hydrocortisone Topical cream; Adults: Apply a thin layer topically to the affected area(s) 2 to 4 times daily for up to 2 weeks.
Sucralfate cream 4%
- Requires extemporaneous compounding
- Sucralfate Topical cream; Adults, Adolescents, Children, and Infants: Apply a visible layer topically to the affected area(s) every 4 to 6 hours. ³⁶ ³⁷

Nondrug and supportive care

Superabsorbent diapers ²
- Multilayered and designed to wick moisture and feces away from skin and prevent rewetting
- Contain a superabsorbent material, such as a gel, that helps maintain a dry environment
Barrier creams
- Apply a protective barrier agent (cream or paste) (eg, zinc oxide) at every diaper change ³⁴
- Consider also applying petroleum jelly to the diaper, to keep it from sticking to the skin ²⁶
  - However, overuse of petroleum jelly may reduce diaper absorbency
- For areas of excoriation and/or bleeding, consider using a crusting technique to create a thick barrier: ²⁶
  - Apply stoma powder to excoriated, wet regions, and remove excess
  - Apply antifungal powder if yeast infection is suspected
  - Seal powder with a skin protectant, such as a liquid barrier film, creating a crust
  - Apply thick layer of zinc oxide–containing cream
Skin cleansing ¹
- Use cleansers that are free of known irritants or allergens, or diaper wipes with an effective buffer system (pH 4-5.5), which create an acidic skin surface pH, remove feces, and deactivate fecal enzymes

Complications and Prognosis

Complications

Secondary infection
- Candidal diaper dermatitis
- Bacterial infection, usually staphylococcal or streptococcal

Prognosis

Typically benign conditions that resolve within several days without complication ³⁴

Screening

At-risk populations

Anyone in diapers with any of the following:
- Frequent loose stools (eg, short gut syndrome, infectious diarrhea)
- Taking antibiotics
- Undergoing opioid withdrawal
- Abnormal rectal sphincter tone (eg, exstrophy of bladder, spina bifida)
- Allergies
- Undergoing chemotherapy treatment

Prevention

Change diaper as often as necessary to keep area clean and dry
- Carefully and gently cleanse diaper area using cotton balls/squares or washcloth and water alone or using specifically designed baby wipes, pat dry, and avoid friction ¹
  - Baby wipes are designed to provide an optimum, acidic skin surface pH ¹
Use diapers designed for optimal dryness (superabsorbent, breathable) ⁹
- Their use does not obviate need for frequent diaper changes and for prompt change after defecation
Applying ointments that contain zinc oxide or petroleum with or without vitamin A may prevent or mitigate severity of diaper rash ¹²
Bathe infant twice weekly, and use liquid baby cleanser based on gentle ingredients or water alone ¹
- Synthetic detergent or water alone is preferable to soap (cleanser made from fatty acid) ¹
In adults, cleanse skin with a cleansing product that maintains an acidic skin surface pH ³³
If diaper area is soiled, clean before bathing ¹²
In incontinent adults, try to avoid soap-based cleansers; use moisturizer and/or skin protectant ³⁸
Consider applying emollient or protective ointment to dry skin ¹