Education

Oxford, UK
International
IJD
Blackwell
1365-4632
45 Publishing,
Publishing
Journal Ltd,
of
Ltd.
Dermatology
2004

Management of diaper dermatitis

Gupta and
Review of the
Skinner
management of diaper dermatitis

Aditya K. Gupta, MD, PhD, FRCP(C)1, and Alayne R. Skinner, HBSc2

From 1the Division of Dermatology,

Department of Medicine, Sunnybrook and
Women’s College Health Sciences Center
(Sunnybrook site) and 2the University of
Toronto, Toronto, and Mediprobe Research
Inc., London, Ontario, Canada

Correspondence
Aditya K. Gupta, MD, PhD, FRCP(C)
490 Wonderland Road South, Suite 6, London
Ont. N6K 1L6
Canada
E-mail: agupta@execulink.com

Drug names
ciclopirox: Loprox
clotrimazole: Canesten Topical
clotrimazole–betamethasone dipropionate:
Lotriderm
hydrocortisone: Cortate
ketoconazole: Nizoral
miconazole: Micatin
mupirocin: Bactroban
nystatin: Mycostatin
nystatin–triamcinolone: Kenacomb
triamcinolone: Triaderm

Introduction Etiology

Diaper dermatitis (DD) is a general term used to explain
inflammatory processes within the diaper area. DD is one of
the most common disorders in neonates and infants, with up
to 35% of infants affected at any given time.1 The incidence
of DD is highest in those between 8 and 12 months of age.1
There are no differences in the prevalence between genders
or race,2 although breastfed babies may have a reduced risk.3,4
In an American study, of approximately 8.2 million visits,
there was a one in four chance of an infant being diagnosed
with DD.2
The treatment of DD includes anti-inflammatory and anti-
microbial agents, frequent diaper changing, and parent
education. Although mild forms of DD may clear spontane-
ously, more severe forms, especially those with secondary
infection, require medical attention. Current medications
used in the treatment of DD, such as nystatin and hydro-
cortisone, do not encompass all aspects of the disorder and are
830 therefore not always effective.
Neonate skin goes through many changes within the first
weeks of birth, which creates an opportunity for skin break-
down and the development of a rash.5 In an open study
involving 31 neonates, rash severity increased over the first
few weeks after birth, with a significant increase from the first
week up to the fourth week (P < 0.05).6,7 Infant skin is thinner
than that of adults, produces fewer secretions, and is more
susceptible to irritation and infection.3
The critical step in the development of DD is the occlusion
of the skin under the diaper.8 Infrequent diaper changes create
overhydration and maceration of the stratum corneum,
which makes the skin more sensitive to friction; this may
interfere with the protective barrier function, allowing for
the exposure of the lower layers to irritants.9 Digestive stool
enzymes (e.g. trypsin and lipase) may play a role in the
development of DD, with hydration and alkaline pH increas-
ing the activity of these enzymes.9,10 Aggravating factors in
DD include poor skin care, microorganisms, urinary tract

International Journal of Dermatology 2004, 43, 830 –834 © 2004 The International Society of Dermatology
Gupta and Skinner
abnormalities, diarrhea, and the use of broad-spectrum
antibiotics.9
Baby Wipes
Previously, baby wipes that contained alcohol, perfumes, and
other irritating substances were often associated with the
induction and exacerbation of DD.11 In a double-blind study,
baby wipes containing a water-based, alcohol-free lotion on
a nonwoven cloth-like substrate with a pH of 5.5 were found
to have significantly lower rash scores in the intertriginous
areas compared with water and cleansing materials (P < 0.05).12
Baby wipes that have been developed more recently are more
suitable for daily use on infant skin, even in those with sensitive
skin.11,12
Presentation
The development of dry, flaky skin is one of the first signs of
dermatitis.6 The generic form is characterized by erythema
on the convex surfaces with the skin folds spared.8 Clinical
variants include Jacquet’s form (erosive variant), which is
usually seen in children with persistent diarrhea; psoriasiform,
characterized by erythema, silvery surface scale, and spared
skin folds; and napkin psoriasis, characterized as psoriasiform,
but with scaly erythematous papules and plaques on the
trunk, limbs, face, and scalp.8 A new presentation has been
suggested that involves asymmetric lesions in the areas in
which the skin is in contact with the securing components
of the diaper.13,14
More severe forms of DD may occur where there is second-
ary infection. Candida DD often presents as a red erythemat-
ous rash, with satellite pustules or papules.3,8 Secondary
bacterial infection involves superficial erosions with a yellow
serum crust and, sometimes, bullae.15 The differential
diagnoses of DD are listed in Table 1.3,9,16,17
Secondary Infections
Inflammation produced by irritation increases the perme-
ability and susceptibility of the skin to secondary infection.8
In cases in which DD has been present for three or more
days, Candida albicans has been isolated in up to 80% of
infants.1,3,18 An open study compared 28 infants with DD
and 48 infants with healthy skin. Colonization by Candida
species was significantly greater in those children with DD
(P < 0.0003),10 and there was a significant correlation between
Candida infection and increased severity of DD (P <
0.0001).10 This has also been noted elsewhere.19
Children with oropharyngeal candidiasis often have
candidal DD due to excretion of C. albicans in the feces.20 In
the diaper area of healthy infants, C. albicans has been found
in very few cases (< 4%).18 When secondary infection involves
© 2004 The International Society of Dermatology
Review of the management of diaper dermatitis Education 831
3,9,16,17
Table 1 Differential diagnoses of diaper dermatitis
Allergic contact dermatitis
Atopic dermatitis
Biotin deficiency
Child abuse
Chronic bullous dermatitis
Condyloma acuminatum
Congenital syphilis
Dermatophyte infections
Granuloma gluteale infantum
Herpes simplex
Histiocytosis-X
Impetigo
Intertrigo
Milaria rubra
Molluscum contagiosum
Noduloulcerative eruption
Psoriasis
Streptococcal and staphylococcal dermatitis
Seborrheic dermatitis
Staphylococcal folliculitis
Zinc deficiency
C. albicans and bacteria, such as Escherichia coli, there is a
synergistic effect that creates increased cell adhesion of the
pathogens.21
Bacterial organisms may also be isolated from the diaper
area of infants with DD.21 In a study involving 58 infants (age
range, 2 weeks to 21 months) with clinical signs of secondarily
infected DD, bacterial cultures were taken to determine the
microflora in the diaper region.22 Staphylococcus aureus was
most common, and was a single isolate in 18 of 32 infants.
Other common bacterial isolates found were Streptococcus,
E. coli, Peptostreptococcus, and Bacteroides. There were
some cases of mixed infection (26 out of 58), but no pattern
or correlation was found.22
Management of Diaper Dermatitis
The management of DD encompasses numerous approaches.
The physician must have an understanding of the etiology of
DD for correct diagnosis and proper treatment.2 Another
important factor in the prevention and treatment of DD is
parent education and support.3 Simply eliminating the causes
of DD and using barrier creams may be enough to cure mild
forms.1,3 For the best therapeutic approach, fungal and bac-
terial investigation should be undertaken when suspected.21
Different presentations of DD may require different treat-
ment strategies. For example, the erosive variant (Jacquet’s)
may not respond to hydrocortisone and/or antifungal creams
and should be treated with stomahesive powder.8 In addition,
refractory psoriasiform and napkin psoriasis may be treated
with tar cream therapy.8 If the infant does not respond to
International Journal of Dermatology 2004, 43, 830 –834
832 Education Review of the management of diaper dermatitis
therapy, it may be due to poor compliance, failure to correct
the aggravating factors, or the diagnosis may have been
incorrect.9
Diapers
Frequent diaper changing is one of the most important factors
in curing and preventing DD.8,23 Changing the diaper every
hour for neonates and every 3–4 h throughout infancy is
recommended, and infants should be kept out of diapers as
much as possible.1 Advancements in diaper technology have
reduced the frequency and severity of DD, and may also
normalize pH.9 An important advancement in diapers is the
use of sodium polyacrylate polymers in the diaper core that
form a gel when hydrated to keep liquid away from the skin.11
In North American and Western European trials, infants
using diapers made from such materials have a significantly
decreased incidence and severity of DD compared with those
using cloth diapers or other disposable diapers.11
Another advancement in diapers is the use of a “breathable
backsheet” that allows water vapor to flow out of the diaper
by means of microporous membranes, without leaking
liquids.11,19 In a study evaluating the effects of breathable
diapers on C. albicans infection on the forearm skin of adults,
infection was reduced by 62% under breathable diaper
patches compared with nonbreathable diaper patches.19 In a
single-blind clinical study comparing the use of diapers with
a breathable cover to those without (controls), diapers were
randomly assigned to between 230 and 260 infants between
3 and 15 months of age.19 Infants wore the diapers for
7 weeks. The prevalence of DD in infants wearing the control
diaper was almost 33%, with 2–6% of infants having a
moderate to severe rash. In the breathable diaper group, there
were 50% fewer cases of severe DD and these infants had
fewer signs of irritation.19
A novel diaper has been developed that incorporates a zinc
oxide/petroleum and steryl alcohol formulation top sheet that
lines the inside of the diaper.24 This formulation effectively
transfers to the skin, with nondetectable amounts of zinc
oxide in the skin 2 days after the cessation of use.24 A ran-
domized, double-blind trial compared diapers containing the
zinc oxide formulation with normal diapers (n = 304).24 After
1 week of all infants wearing normal diapers, half began to
wear test diapers for 4 weeks, whilst the others continued to
use normal diapers. A significant reduction in DD, and in the
proportion of visits in which there was no erythema or diaper
eruption, was found in those children using the test diaper
compared with those using the normal diaper (P < 0.05).24
Treatment
Records from the National Ambulatory Care Survey (1990–
97) were employed to find the top 10 most used agents to
International Journal of Dermatology 2004, 43, 830 –834
Gupta and Skinner
treat DD in the USA; these were nystatin (27%), clotrimazole
(16%), nystatin–triamcinolone (16%), hydrocortisone
(8.3%), clotrimazole–betamethasone dipropionate (6.2%),
ketoconazole (4.0%), triamcinolone (2.1%), zinc oxide
(2.1%), miconazole (1.7%), and triple antibiotic (1.6%).2
Barrier creams
In the prevention and treatment of mild DD, topical barrier
creams containing active ingredients, such as zinc oxide, petro-
latum, cod liver oil, dimethicone, or lanolin, are all useful.2
These agents should be applied at each diaper change to
create a drier environment under the diaper, and to prevent
damage and infection of the skin.1 It should be noted that
when DD with secondary Candida infection is covered with
a petroleum- or zinc oxide-based ointment, the condition may
worsen.5 Once DD eruption has ceased, a protective barrier
should be used to minimize recurrence.8
Corticosteroids
A short duration of mild steroid ointments (maximum of
2 weeks) may be useful in moderate to severe cases of DD that
have not responded to other topical agents.3 Nothing stronger
than hydrocortisone 1% should be considered,9 and this
should only be applied until the eruption has cleared.8
Although mid- and high-potency corticosteroids are not
indicated for use in DD, they are some of the most prescribed
creams (i.e. nystatin–triamcinolone and clotrimazole–
betamethasone dipropionate).2,25 Stronger corticosteroids may
cause serious side-effects, such as skin atrophy, striae, and
tachyphylaxis, as well as hypothalamus–pituitary–adrenal
axis suppression, Cushing’s syndrome, intracranial hyper-
tension, growth delay, and other side-effects, in the pediatric
patient due to the increased skin surface area to body weight
ratio compared with adults.25 The inappropriate overuse of
combination agents and the misuse of high-potency corticos-
teroids for DD need to be addressed.2
Antifungal agents
As candidal infection is quite common in more severe cases of
DD, antifungal agents are often prescribed. Nystatin is effect-
ive against C. albicans, but has no activity against bacteria,21
nor does it exhibit anti-inflammatory activity. Relapse of DD
with secondary infection after treatment with nystatin is
common because of failure to eradicate concomitant bacterial
infections, recolonization from reservoir sites, and occasional
resistance to antifungal agents.21 If nystatin does not result
in improvement within 1–2 days, a different agent should be
considered.5
Other creams and ointments used in the treatment of DD
include clotrimazole and miconazole. Studies have shown that
both of these agents result in a clinical cure rate of approxim-
ately 80%.20 In a placebo-controlled, randomized, double-
blind trial, infants aged 2–13 months with DD were treated
© 2004 The International Society of Dermatology
Gupta and Skinner
with either miconazole nitrate 0.25% in a zinc oxide-based
ointment (n = 101), or with the zinc oxide ointment alone
(n = 101), for 7 days.26 Those in the miconazole group had
significantly fewer rash sites and lower mean total rash
scores on days 5 and 7 (P < 0.001). In the miconazole group,
58% of infants cleared completely, compared with 33% in
the placebo group (P < 0.001). Of those patients who were
positive for C. albicans at baseline, the yeasts were absent in
96% of those treated with miconazole, compared with 4% of
placebo patients (P < 0.001).26
Ciclopirox is a broad-spectrum agent that may be useful in
the treatment of DD, although no studies have been performed
for this indication. Ciclopirox has been used safely and effect-
ively in children;27 however, it is not indicated for use in the
pediatric population. Ciclopirox appears to exhibit activities
that would encompass all aspects of the treatment of DD in
one agent instead of using combination agents. Ciclopirox has
antifungal activity against C. albicans and dermatophytes, as
well as some dermatophyte molds.28 Antibacterial activity has
been reported against S. aureus, as well as other bacterial
organisms not as commonly isolated in DD.29–31 Another
advantage to ciclopirox is that it offers anti-inflammatory
properties that are similar to those of a mild corticosteroid, but
without the unwanted side-effects associated with the latter.32
Antibacterial agents
The efficacy of mupirocin 2% ointment (n = 10) compared
with nystatin cream (n = 10) was assessed in the treatment of
moderate to severe candidal DD in a randomized study lasting
7 days.21 Mupirocin eradicated C. albicans in 2–6 days (mean,
2.6 days) in all patients, while nystatin cleared C. albicans
within 5 days (mean, 2.8 days) in all patients. Mupirocin
healed all wounds within the study duration, with the mean
being 4.7 days, while nystatin only healed three wounds
within the 7 days. With regard to Gram-positive and
Gram-negative organisms, mupirocin reduced these, but did
not eradicate them, and nystatin had no effect on bacteria.21
Conclusions
DD is a common problem in infants that requires medical
attention if the condition persists for more than a few days.
Frequent diaper changing and advancements in diaper
technology are important as they help prevent and reduce
the severity of DD. Nystatin, clotrimazole, miconazole,
ciclopirox, and mupirocin have been used with good efficacy
in the treatment of DD.
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© 2004 The International Society of Dermatology