C L I N I C A L A N D LA B O R A T O R Y I N V E S T I G A T I O N S DOI 10.1111/j.1365-2133.2006.07423.

Prospective aetiological study of diaper dermatitis in the

elderly
N. Foureur, B. Vanzo, S. Meaume and P. Senet
Service de Gérontologie V et Consultation de Dermatologie, Hôpital Charles Foix, 7 avenue de la République, 94205 Ivry sur Seine, France

Summary

Correspondence Background The different causes of diaper dermatitis (DD) in the elderly are not
Patricia Senet well known and the treatment is often empirical.
E-mail: patricia.senet@cfx.ap-hop-paris.fr Objectives To determine the causes of DD in the elderly and to evaluate the efficacy
of antifungal treatments in this indication.
Accepted for publication
30 March 2006
Methods Consecutive patients presenting with DD were included. Clinical evalua-
tion, skin swabs for bacterial and mycological cultures, patch testing and skin
Key words biopsy were performed at inclusion. This was followed by 1 month of topical
antifungal treatment, diaper dermatitis, elderly antifungal cream and, if needed, by oral fluconazole for the second month.
Results Forty-six patients were included (mean age 85 years). Causes of DD were
Conflicts of interest
established for 38 patients: 24 had candidiasis (63%), six irritant dermatitis
None declared.
(16%), four eczema (11%) and four psoriasis (11%). After 2 months of treat-
ment, 27 of 37 (73%) patients were cured and five of 37 were improved.
Conclusions Mycoses and irritant dermatitis are the main causes of DD in the
elderly, and emollient skin care and topical antifungal treatment can be consid-
ered a first-line therapy for this indication.

Diaper dermatitis (DD) is a common skin disorder of the

elderly and a frequent cause of dermatological consultation for
bedridden patients.
In infants, the pathophysiology and evaluation of the differ-
ent aetiologies of DD have been well reported. Irritant DD
may be the most common form of diaper rash,1 and is due to
the interaction between the skin and several local factors such
as dampness, maceration, irritant topical preparations, fric-
tional damage and faecal enzymes.2 Secondary infection by
Candida may occur particularly following systemic antibiotic
treatment.3 A characteristic DD of infancy named ‘Lucky Luke’
dermatitis has also been reported, and is related to sensitiza-
tion to rubber components of the diaper.4,5
In the elderly, several common skin diseases may be locali-
zed under the diaper including psoriasis, contact dermatitis,
pemphigoid and infectious diseases. Despite its frequency, the
different causes of DD in the elderly are poorly understood
and their respective frequencies have not been studied. DD
treatment is a real challenge as patients with long-standing DD
are at greater risk for pressure ulcers.6,7 Treatment is often
empirical in the absence of a systematic diagnostic approach,
and is based on antifungal treatments and emollient skin care.
The main objective of this study was to determine the cau-
ses of DD in the elderly. The secondary objective was to evalu-
ate the efficacy of routine skin care and of antifungal
treatments that are usually prescribed for elderly patients pre-
senting with DD.
Patients and methods
This prospective observational study included all consecutive
patients aged over 70 years who presented to the dermatologi-
cal department between March 2003 and July 2004 with DD.
All patients were hospitalized in rehabilitation and long-term
care units at Charles Foix University Geriatric Hospital. DD
was defined as the presence of a rash localized under the dia-
per. The study included an initial evaluation and two follow-
up visits.
The initial clinical evaluation included a careful history
based on a standardized questionnaire (Fig. 1), a complete
physical examination, with detailed study of clinical features
of the eruption (e.g. erythema, ulcerations, necrosis, pus-
tules, vesicles, scaling, localization on the convex surfaces of
the skin beneath the diaper, and involvement of inguinal
creases) and a photograph of the eruption for the final
blind assessment at the end of the study (see below). Any
relevant historical information was noted, including underly-
ing diseases, systemic and local treatments with emphasis
on antibiotics, level of dependence, presence of diarrhoea,
number of diapers changed per day, and date of onset of
eruption.
A presumptive initial diagnosis of irritant dermatitis was
made in the presence of erythema, with or without scaling or
erosive lesions, that involved the convex surfaces of the skin in
contact with the diaper, and spared the inguinal creases.

 2006 British Association of Dermatologists • British Journal of Dermatology 2006 155, pp941–946 941
942 Causes of diaper dermatitis in the elderly, N. Foureur et al.

First Consultation Second Consultation (at one month)

Date: Date:

Patient’s status (name, sex and Patient’s status (name, sex and
age) age)
Hospital’s department New disease or medical
Weight and height problem?
Historical informations New treatment?
Underlying diseases

Treatments

Level of dependence Bedridden Yes No

Seated all the day Yes No Presence of diarrhoea Yes No
Walk is possible Yes No From how long ?
Presence of diarrhoea Yes No Aetiology :
For how long ? Specific treatments for the Number of diapers changed per day:
Aetiology : diaper dermatitis from the last Local antiseptic/Topical/antifungal/Topical steroids
Date of onset of eruption consultation Systemic treatment :
Hypoallergenic disposable diapers : Yes No
Specific treatments for the Number of diapers changed per day:
diaper dermatitis before Local antiseptic / Local antifungal Clinical outcome Cure Improvement Failure
inclusion Local steroids / Systemic treatment
Hypoallergenic disposable diapers : Yes No

Results of bacterial cultures

Presumptive initial diagnosis Results of mycological cultures

Swabs for bacterial cultures Number/Localizations : Results of patch tests
Swabs for mycological cultures Number/Localizations : Results of histopathological
examination and periodic acid–
Patch tests Yes No Schiff
Skin biopsy Yes No Treatment
Treatment Bifonazole cream once a day/Routine skin care Date of the next consultation
Date of the next consultation

Third Consultation (at two months)

Date
Patient’s status (name,
sex and age)
New disease or
medical problem?
New treatment?

Presence of diarrhoea Yes No

For how long ?
Aetiology :
Specific treatments Number of diapers changed per day:
for the diaper Topical antiseptic/Topical antifungal
dermatitis from the last Local steroids/Systemic treatment :
consultation Hypoallergenic disposable diapers : Yes No

Clinical outcome Cure Improvement Failure

Clinical features of the

eruption

Localization of the
eruption

Final diagnosis

Treatment

Fig 1. Standardized study questionnaire.

A presumptive initial diagnosis of candidiasis was made when
the rash involved the inguinal creases or when beefy red
plaques with satellite pustules were present. A presumptive ini-
tial diagnosis of eczema was made in the presence of red plaques
with vesicles or peripheral scales, without pustules, that spared
the inguinal creases. A presumptive initial diagnosis of psoriasis
was made in the presence of well-circumscribed, erythematous,
thick, scaly or brilliant plaques, with a personal or family history
of psoriasis. After the first visit, all patients were treated for
1 month with bifonazole cream once a day and routine skin
care while awaiting the mycological culture results, as irritant
dermatitis with a high probability of superinfection by Candida is

 2006 British Association of Dermatologists • British Journal of Dermatology 2006 155, pp941–946

thought to be the most frequent cause of DD.8 Routine skin care
included increased frequency of diaper changes, exclusive use
of warm water and mild soap for cleaning, drying without rub-
bing, and barrier ointment.
Laboratory studies were performed at the first visit. They
included skin swabs for bacterial and mycological cultures. A
skin biopsy for periodic acid–Schiff (PAS) staining and histo-
pathological examination was performed and analysed blind.
Patch tests (European standard series and rubber series) were
performed at the first visit and read 48 h later.
The follow-up visits at 1 and 2 months included a complete
physical examination with emphasis on clinical outcome, sys-
temic and/or local treatments, and skin care compliance. The
clinical efficacy of the first-line treatment was defined as ‘cure’
(disappearance of all baseline signs and symptoms), ‘improve-
ment’ or ‘failure’ (no change or worsening of the signs and
symptoms). At 1 month, the treatment was adapted for
patients who were not cured according to the results of the
laboratory investigations and the clinical outcome. Oral fluc-
onazole 100 mg daily for 1 month was prescribed with con-
tinuation of routine skin care for patients with a positive
mycological scraping and/or positive PAS staining. Oral fluc-
onazole was also prescribed for patients who improved with
topical fungal treatment but without achieving complete cure,
as fluconazole is a safe and effective alternative to topical
agents in cases of extensive cutaneous candidiasis,9,10 and may
eradicate the candidal colonization of the gastrointestinal tract.
In cases of unchanged or worsened DD with negative myco-
logical culture and PAS staining, betamethasone dipropionate
0Æ05% cream was prescribed as second-line therapy with pro-
gressive tapering over 30 days. This strength of steroid was
chosen because most of the patients have an intense eruption,
related to the delay between diagnosis and treatment. More-
over, as routine skin care included increased frequency of skin
cleaning, topical steroids did not stay in contact with the skin
for a long time.
At the end of the study, all medical records and the photo-
graphs were reviewed blind by two of us (N.F., P.S.) for
final diagnosis assessment. Irritant dermatitis was diagnosed
in cases of suggestive initial symptoms, particularly when
inguinal creases were spared, with negative mycological cul-
ture, negative PAS staining and favourable course (complete
cure or improvement) after routine skin care associated with
local or general antifungal treatment. Candidiasis was diag-
nosed in cases of suggestive initial symptoms, with positive
mycological cultures and/or positive PAS staining, and a
favourable course after topical or general antifungal treat-
ment. The diagnosis of candidiasis was also considered prob-
able in cases of suggestive initial symptoms, particularly
when inguinal creases were involved, and when complete
cure occurred after antifungal treatment, even if mycological
cultures or PAS staining were negative. The diagnosis of
eczema and psoriasis was made in cases of suggestive initial
symptoms and histopathological data, associated with failure
of antifungal treatment.
 2006 British Association of Dermatologists • British Journal of Dermatology 2006 155, pp941–946
Causes of diaper dermatitis in the elderly, N. Foureur et al. 943
Results
Epidemiological data
Forty-six consecutive elderly patients with DD were included
in this study (10 men and 36 women). The mean age was
85 years (range 72–100). Seventy-five per cent of patients
were very dependent and unable to walk. Diarrhoea was noted
for five (11%). Diapers were changed from two to five times
per day in 86% of the patients. Thirteen patients (28%) were
included < 15 days after the onset of DD, and 21 (46%) after
the 15th day of onset. Date of onset was not available for 12
(26%) patients. Thirty-six patients had been treated before the
first visit, 25 (54%) with topical antifungal cream, nine
(20%) with topical steroids, and two with an antiseptic
solution.
Laboratory investigations
In 45 cases, cutaneous swab cultures revealed polymicrobial
growth including methicillin-resistant Staphylococcus in 11 cases.
Seventeen mycological cultures were positive for C. albicans,
and eight of 17 were associated with a positive PAS staining
on biopsy. Thirteen of them occurred in patients with a final
diagnosis of candidiasis. Skin biopsies were performed in all
patients. Histological examination revealed psoriasis in four
cases, eczema in six, and nonspecific or psoriasiform dermati-
tis in 21 cases. The histological diagnoses were candidiasis
(characterized by subcorneal pustules) in 14 cases; all of them
were positive for PAS staining and nine of them had a positive
mycological scraping. The histological diagnosis correlated
with the initial clinical diagnosis in 13 of 14 cases for candidi-
asis, three of four for psoriasis, and three of six for eczema.
Nonspecific or psoriasiform histological data correlated with
the final diagnosis of irritant DD in four of 21 cases, candidia-
sis in 11 of 21, and eczema or psoriasis in two of 21. Sixty
per cent of the initial diagnoses of candidiasis were confirmed
by mycological swab cultures or histological examination.
Patch testing was performed in 41 of 46 patients. Nine
patients had positive reactions to allergens tested using the
European standard battery: balsam of Peru (four cases), cobalt
chloride (four cases), paraphenylenediamine (four cases), fra-
grance mix (two cases), formaldehyde (one case), nickel sul-
phate 5% (one case), potassium dichromate (one case) and
paraben mix (one case). No positive test was relevant clinic-
ally. No patient had a positive reaction to the rubber series.
Cause
At 1 month, follow-up information was obtained from 41 of
46 patients. Five of 46 patients died before attending the sec-
ond visit. In all cases, the cause of death was unrelated to the
DD. Three of these patients had nonspecific laboratory findings
and two had positive PAS staining and/or positive mycological
cultures. At 2 months, four other patients were lost to follow-up
944 Causes of diaper dermatitis in the elderly, N. Foureur et al.

(one died and three were discharged from the hospital). Only
one patient had sufficient information recorded for final analy-
sis. A final aetiological diagnosis of DD was established for 38
patients: 24 had candidiasis (63%), six irritant dermatitis
(16%), four eczema (11%) and four psoriasis (11%). Among
patients with a final diagnosis of candidiasis, 17 of 24 had
positive cultures or PAS staining, and 13 of 24 had a charac-
teristic histology of candidiasis. Two of the five patients who
had diarrhoea were positive for cutaneous mycological
cultures. Only four of 24 patients with candidiasis as final
diagnosis received oral antibiotics before the eruption.
Respectively, six of 24 patients with a final diagnosis of
candidiasis and two of six with irritant dermatitis received a
topical antifungal treatment before the first consultation (not
significantly different). One patient with psoriasis and one
with eczema had positive mycological cultures but these were
considered as superinfections because of the clinical and histo-
logical data.
Treatment and course
Data are summarized in Tables 1 and 2. Follow-up informa-
tion was obtained for 41 of 46 patients at 1 month. After
1 month of topical antifungal treatment, 13 of 41 patients
(32%) were cured (eight with candidiasis and five with irrit-
ant dermatitis) and 23 of 41 (56%) were improved. Five
patients (12%) had an unchanged or worsened eruption.
Three of them (one with eczema and two with psoriasis) were
treated thereafter with topical steroids and were cured in
1 month. The two others had positive mycological cultures
and positive PAS staining. Oral fluconazole 100 mg day)1 for
1 month was prescribed with continuation of routine skin
care for patients with positive mycological cultures and/or
positive PAS staining, and for patients who improved with
topical fungal treatment without complete cure. Follow-up
information was obtained for 21 of 25 patients who received
1 month of oral fluconazole: 14 of 21 patients (67%; 13 with
candidiasis and one with irritant dermatitis) were cured and
five of 21 (24%; three with candidiasis, one with psoriasis
and one with eczema) improved. Two of 21 patients (9%),
both with eczema, had an unchanged or worsened eruption.
Concerning patients with candidiasis under the diaper (n ¼
24), eight (33%) were cured after 1 month of local treatment,
three (12Æ5%) improved, and 13 (54%) were cured after addi-
tion of oral fluconazole. Concerning irritant dermatitis (n ¼
6), five patients were cured with local antifungal treatment.
Overall, routine skin care and antifungal treatment for 1 or
2 months cured 73% of all patients. No patients with DD relat-
ed to eczema or psoriasis (n ¼ 8) were cured with routine
skin care and topical or oral antifungal treatment.

Table 1 Characteristics of patients with a final diagnosis of candidiasis

Previous treatment Clinical outcome Clinical outcome

Sex/age Mycological PAS Pathological after 1 month of after 1 month of
1 2 3
(years) cultures staining examination bifonazole fluconazole
M/91 ) + ) Negative Negative Nonspecific Improved Cured
F/92 + ) + Negative Positive Candidiasis Improved Improved
M/91 ) + ) Positive Negative Nonspecific Improved Improved
F/72 ) + ) Negative Negative Nonspecific Cured
F/73 ) ) + Positive Positive Candidiasis Worsened Cured
F/92 ) ) ) Negative Negative Psoriasis Cured
M/79 NP NP NP Negative Positive Candidiasis Cured
F/90 ) + + Positive Positive Candidiasis Improved Cured
F/82 ) + + Positive Positive Candidiasis Improved Cured
F/80 ) ) ) Negative Positive Candidiasis Improved Cured
F/91 ) + + Negative Negative Nonspecific Cured
F/77 ) ) ) Positive Negative Psoriasis Cured
F/79 ) ) ) Negative Positive Candidiasis Improved Cured
M/77 ) ) ) Negative Negative Nonspecific Cured
M/77 ) ) ) Positive Positive Candidiasis Improved Cured
F/85 ) ) ) Negative NP NP Improved Cured
M/92 ) ) ) Positive Positive Candidiasis Improved Cured
F/91 ) ) ) Positive Negative Nonspecific Improved Cured
F/90 ) ) ) Negative Negative Nonspecific Cured
F/78 + ) ) Positive Positive Candidiasis Improved Cured
F/72 ) ) ) Positive Positive Candidiasis Improved Cured
F/94 ) ) ) Positive Negative Nonspecific Improved Cured
F/87 ) ) ) Positive Positive Candidiasis Cured
F/83 ) ) ) Positive Positive Candidiasis Improved Improved

Previous treatment: 1, antiseptic; 2, antifungal; 3, dermocorticoids. PAS, Periodic acid–Schiff; NP, not performed.

 2006 British Association of Dermatologists • British Journal of Dermatology 2006 155, pp941–946
 Causes of diaper dermatitis in the elderly, N. Foureur et al. 945

Table 2 Characteristics of patients without candidiasis as final diagnosis

Previous treatment Clinical outcome Clinical

Sex/age Mycological PAS Pathological after 1 month of outcome Final
1 2 3
(years) cultures staining examination bifonazole at final visit diagnosis
F/100 ) ) ) Negative Negative Eczema Cured Irritant dermatitis
F/79 ) ) ) Negative Negative Nonspecific Cured Irritant dermatitis
F/77 NP NP NP Negative Negative Nonspecific Cured Irritant dermatitis
F/90 ) + ) Negative Negative Eczema Improved Cured (fluco) Irritant dermatitis
F/82 ) + + Negative Negative Psoriasis Cured Irritant dermatitis
F/90 ) ) ) Negative Negative Nonspecific Cured Irritant dermatitis
F/77 ) + + Negative Negative Nonspecific Worsened Cured (steroids) Psoriasis
M/87 ) ) ) Negative Negative Psoriasis Improved Lost to follow-up Psoriasis
F/100 ) ) ) Positive Negative Psoriasis Unchanged Cured (steroids) Psoriasis
F/87 ) + ) Negative Negative Psoriasis Improved Improved (fluco) Psoriasis
M/88 ) + ) Negative Negative Nonspecific Improved Unchanged (fluco) Eczema
F/88 ) + ) Negative Negative Eczema Unchanged Cured (steroids) Eczema
F/81 ) ) ) Positive Negative Eczema Improved Improved (fluco) Eczema
F/78 ) + ) Negative Negative Eczema Improved Unchanged (fluco) Eczema

Previous treatment: 1, antiseptic; 2, antifungal; 3, dermocorticoids. PAS, Periodic acid–Schiff; NP, not performed; fluco, oral fluconazole for
1 month; steroids, topical steroids for 1 month.

tional protection at the level of the fasteners that restricts

Discussion
This was a prospective observational study to assess the cause
of DD in the elderly and the efficacy of the routine skin care
and antifungal treatments that are usually prescribed for elderly
patients presenting with DD. A high prevalence of candidiasis
(63%) was observed compared with that of irritant dermatitis
(16%), eczema (11%) and psoriasis (11%). The careful initial
clinical examination was effective as 65% of the initial clinical
diagnoses were confirmed by laboratory findings. Histological
examination did not contribute to the diagnosis as 48% of the
findings were nonspecific. No laboratory investigations seemed
necessary except for mycological swab cultures. Routine skin
care associated with antifungal treatment cured 73% of the
patients, indicating that antifungal treatment may be consid-
ered a first-line therapy for DD in the elderly.
In this study, candidal infection appeared to be the main
cause of DD in the elderly but may have been overestimated.
In fact, it has been demonstrated in children that warmth and
moisture occurring under occlusive diapers can facilitate infil-
tration of the stratum corneum by Candida species.11 In this
study, many cases of candidiasis may have been irritant der-
matitis associated with a secondary candidal infection, as anti-
fungal treatment was given concomitantly with routine skin
care. On the other hand, 54% of the patients had received
topical antifungal treatment before inclusion in this study.
Therefore, the prevalence of positive mycological culture may
have been underestimated.
Although care givers frequently relate DD to contact derma-
titis or irritation, this diagnosis may have been underestimated
in our study. In cases of DD in the elderly, care givers spontan-
eously use hypoallergenic disposable diapers or superabsorbent
night diapers. Hypoallergenic diapers, like standard diapers,
are manufactured with polyethylene, but they have an addi-
maceration. However, minimizing skin wetness by superab-
sorbent and/or hypoallergenic diapers decreases the prevalence
and the severity of DD.11 Thus, patients who were cured by
routine skin care, an increased frequency of diaper changes or
the use of hypoallergenic diapers were probably not addressed
in consultation for inclusion, and this may represent a selec-
tion bias. Unfortunately, the kind of diaper that was used for
each patient was not mentioned in the medical record and
was not assessable.
We diagnosed 11% of patients to have contact dermatitis
under the diaper, although we were unable to determine
which allergen was causing the sensitization. In all these cases,
the eruption was localized to the outer buttocks or the hips.
In the literature, a similar localization of contact dermatitis
due to diapers has been reported in children. This contact der-
matitis is a particular pattern of diaper dermatitis, that is bilat-
eral and localized on the outer buttocks and hips (Fig. 2). In
small series of children, this particular contact dermatitis was
related to positive patch tests for rubber components (mer-
captobenzothiazole), glues (p-tertiary-butylphenol-formaldehyde
resin)4,5 and cyclohexylthiophthalimide, a retarder of vulcan-
ization,12 that are present in diapers. However, other paedi-
atric series have reported negative patch tests for diaper
components.4,13
Biopsy and histopathological examination at the first consul-
tation did not contribute usefully to the diagnosis in most
cases, as histological examinations were often nonspecific,
even in cases of psoriasis or eczema. Superinfection or infec-
tion by C. albicans seems so frequent that it may be reasonable
to propose a biopsy only when antifungal treatment and rout-
ine skin care fail.
This study supports the efficacy of antifungal treatment in
elderly patients affected with DD. Severe diaper rash correlates

 2006 British Association of Dermatologists • British Journal of Dermatology 2006 155, pp941–946
946 Causes of diaper dermatitis in the elderly, N. Foureur et al.
Fig 2. Bilateral contact dermatitis due to diaper, localized on the
outer buttocks and hips.
strongly with the presence of C. albicans.14 It has already been
reported that routine skin care alone cannot cure DD,15 espe-
cially in cases of long-lasting eruption,1,11 justifying the use
of antifungal treatment.8,14
Although superficial candidal infections of the skin often
respond to topical agents, systemic therapy is sometimes
required.10 Fluconazole diffuses rapidly and extensively into
the skin10 and is effective in cases of extensive candidiasis.9 In
this study oral antifungal treatment seemed more effective
than topical treatment, probably because oral treatment is eas-
ier to administer than local treatment in a geriatric hospital.
On the other hand, the clinical outcome after treatment was
not blindly evaluated in this study and this study did not
include statistical analysis because of the small number of
enrolled patients.
In summary, this study supports the high prevalence of
candidiasis (63%) and irritant dermatitis (16%) causing DD
in elderly hospitalized patients. In most cases, laboratory
investigations are not necessary, except for mycological cul-
tures of cutaneous swabs. Routine skin care and topical
antifungal treatment result in cure or improvement in most
patients. Oral antifungal treatment may be required in cases
of extensive candidiasis that respond poorly to topical treat-
ment.
 2006 British Association of Dermatologists • British Journal of Dermatology 2006 155, pp941–946
Acknowledgments
We thank Christine Khavas for helping us with the monitoring
of the patients.
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