Diaper Dermatitis (Nappy Rash)

Last updated 20.09.12

 

 

Definition

-  Inflammatory skin eruption in the diaper covered region

 

Features

-  Caused by numerous skin conditions

-  Peak incidence 9 to 12 months

-  Can effect anyone who wears a nappy

-  One of most common skin disorders in children

-  Can be broadly divided into

-  Rash w or worse w diaper use

-  Rash regardless of diaper use

-  Loss of epidermal barrier from friction, chemical irritation & overhydration

-  Aggravating factors

-  Diarrhoea, chronic stooling

-  Formula feeds

-  Broad spectrum Abx

 

Causes

-  Diaper associated

-  Irritant dermatitis

-  Candida

-  Allergic dermatitis: response to actual diaper

-  Nondiaper associated

-  Seborrhoiec dermatitis

-  Atopic dermatitis

-  Staph: folliculitis, impetigo

-  Strep (GAS)

-  HSV

-  Psoriasis

-  Scabies

-  Langerhans cell histiocytosis

-  Congenital syphilis

-  Miliaria

-  Tinea

-  Gluteal granuloma

-  Zinc deficiency (acrodermatitis anteropathica)

-  Kawasaki disease

 

Associated S/S

-  Hx

-  Diaper use, type, changes, ?cloth

-  Cleaning of diaper area

-  Irritant dermatitis

-  Asymptomatic erythema --> painful scaling papules + superficial erosions

-  Convex skin surfaces in direct contact with nappy

-   Bottocks, lower abdomen, genitals, upper thighs

-  Skin fold spared

-  If left untreated for >3/7 --> candida

-  Candidal dermatitis

-  Beefy red plaques, satellite papules, superficial pustules

-  Often involve skin folds

-  Hx of oral thrush, Abx use, diarrhoea

-  If persistant ? DM type 1 or immunodeficiency

-  Colonises most forms of diaper dermatitis if prolonged

-  Allergic dermatitis

-  Well demarcated papules, erythema, vesicles or erosions

-  Often in districution of dye in nappy

-  Seborrhoiec dermatitis

-  Well demarcated erythema, papules, plaques w greast yellow scales

-  Prominence in skin folds

-  Rarely isolated to nappy area, usually + scalp (cradle cap)

-  Atopic dermatitis

-  Typically spares nappy region

-  Effects other areas of body

-  Family Hx atopy

-  Bacterial infection

-  Must exlude sepsis

-  Impetigo

-   1-2mm pustules + honey crusted erosions

-   --> bullous impetigo

-  GAS

-   Bright red, sharply demarcated perianal/perineal rash

-   +/- blood streaked stools, fissures, pruritus, pain on defecation

-  HSV

-  Vesicular, papular or pustular lesions

-  Should consider child abuse

-  Psoriasis

-  Any age

-  Sharply demarcated erythematous scaly papules + plaques

-  Family Hx

-  Scabies

-  Erythematous papules, nodules, excoriations

-  Family members effected

-  Langerhans histiocytosis

-  Potentially life threatening

-  Severe recalcitrant diaper dermatitis

-  Red/orange or yellow/brown scaly papules, erosions or petechiae

-  DDx Seborrhoiec dermatitis by color

-  Lymphadenopathy, hepatosplenomegaly, anaemia

-  Congenital syphilis

-  Copper colored scaly macules & papules

-  Moist erosions

-  +/- perianal papular lesions (condylomata lata)

-  Symetric desquamation of palms + soles

-  Anaemia, hepatosplenomegaly, jaundice

 

Ix

-  Irritant dermatits +/- candida clinical Dx

-  If recalcitrant or atypical features Ix further

-  +/- KOH for candida

-  +/- fungal culture

-  +/- gram stain + culture: if suspecting bacterial

-  +/- scraping for scabies

-  +/- skin biopsy for Langerhans histiocytosis

-  +/- syphilis serology + dark field microscopy

 

Mx

-  Prevention

-  Cleaning w warm water & soft cloth

-  Avoid baby wipes & soap

-  Eliminate direct skin contact with urine & faeces ie: frequent nappy changes, rest time between

-  Topical barriers at each nappy change

-  Zinc, castor oil cream, liquid paraffin 10% in zinc..

-  Irritant dermatitis

-  If severe Hydrocortisone 1% ointment topical BD-TDS until resolution

-   Briefly & sparingly, 3-5/7

-   Max BD 1/52

-  For prolonged irritant dermatitis & candida

-  Nystatin 100,000 units/g cream topical TDS

-  OR Miconazole 2% cream topical BD

-  Suspected bacterial

-  Impetigo

-   Mupirocin 2% ointment topical BD 7/7

-   If widespread: Flucloxacillin 12.5mg/kg PO QID 7/7

-   If penicillin sensitive: Cephalexin 25mg/kg PO BD 7/7

-   If penicillin anaphylaxis: Roxithromycin 4mg/g PO BD 7/7

-  GAS

-   Phenoxymethylpenicillin 12.5mg/kg PO QID 10/7

-   If penicillin sensitive: Cephalexin 12.5mg/kg BD 10/7

-   If penicillin anaphylaxis: Roxithromycin 4mg/g PO BD 10/7

-  HSV: IV Acyclovir if severe + ulceration or urinary retention

-  Mx as per other underlying causes

-   Scabies, Psoriasis..

 

 

 

References

 

eTG – Nappy Rash – 2009

UpToDate – Overview of Diaper Dermatitis in Infats & Chilldren – 2010