ANDREW

Dermatitis of the diaper

area in infants is a common cutaneous disorder.The highest prevalence occurs between 6
and 12 months of age. Diaper
dermatitis is also seen in adults with urinary or fecal
incontinence.
Irritant diaper dermatitis is an erythematous dermatitis
limited to exposed surfaces. The folds remain unaffected,
in contrast to intertrigo, inverse psoriasis, and candidiasis
where the folds are frequently involved. In severe cases of
irritant dermatitis there may be superficial erosion or even
ulceration. The tip of the penis may become irritated and
crusted, with the result illat the baby urinates frequently and
spots of blood appear on the diapex
Complications of diaper dermatitis include punched-out
ulcers or erosions with elevated borders (Jacquet erosive
diaper dermatitis); pseudoverrucous papules and nodules;
and violaceous plaques and nodules (granuloma gluteale
infantum).
The importance of ammonia in common diaper dermatitis
has been overstated, but constant maceration of the skin is
critical.The absence of diaper dermatitis in societies in which
children do not wear diapeis clearly implicates the diaper
environment as the cause of the eruption. Moist skin is more
easily abraded by friction of the diaper as the child moves.
Wet skin is more permeable to irritants. Skin wetness also
allows the growth of bacteria and yeast. Bacteria increase
the local pH, increasing the activity of fecal lipases and
pioteases. C ~ n d i d nnlbicnns is frequently a secondary
invader and when present produces typical satellite erythematous lesions or pustules at the
periphery as the dermatitis
spreads.
Napkin psoriasis (Fig. 5-11), seborrheic dermatitis, atopic
dermatitis, Langerhans cell histiocytosis, tinea cruris, allergic
contact dermatitis, acrodermatitis enteropathica, aminoacidurias, biotin deficiency, and
congenital syphilis should be
included in the differential diagnosis.
Prevention is the best treatment. Diapers that contain
superabsorbent gel have been proved effective in preventing
diaper dermatitis in both neonates and infants.They work by
absorbing the wetness away from the skin and by buffering
the pH. Cloth diapers and regular disposable diapers are
equal to each other in their propensity to cause diaper
dermatitis and are inferior to the superabsorbent gel diapers.
The frequent changing o i diapers is also critical.
Protecting the skin of the diaper area is of great benefit in
all forms of diaper dermatitis. Zinc oxide paste is excellent.
The application of a mlxture of equal parts Nystatin
olntment and 1% hydrocortisone ointment at each diaper
change offers both anticand~dalact~vityand an occlusive
protective barrier from wine and stool.