06/04/2019

Diaper dermatitis: don’t make a rash decision

By Nardine Nakhla

CASE

LL is an afebrile 26-month-old female who presents with “diaper rash,” which she has had for approximately 10 days. Her mother asks for assistance in choosing a product, as LL’s symptoms are now disrupting her sleep. Upon further investigation, you discover that LL has been given Ex-lax chocolate pieces daily for the past week to treat minor constipation. Skin examination reveals a well-demarcated area of erythema with small blistering on the bilateral buttocks. The perianal skin and genitalia are unaffected.

BACKGROUND

Diaper dermatitis (DD)—diaper rash—is the most common skin eruption in infants and toddlers, but can occur in any person with incontinence.(1,2) This condition arises when the normal skin barrier is impaired due to prolonged exposure to moisture (urine and feces) and destructive fecal enzymes (urease, protease, lipase) become activated in the alkaline environment of the diaper area.(3,4) Mechanical friction produced by diaper wearing further perpetuates skin damage.(4)

Irritant DD is a nonimmunologic reaction triggered by irritants in the diaper area. Convex skin surfaces in direct contact with irritants are affected, while those areas not exposed (e.g., skin folds) are typically spared. Irritant DD often begins as acute erythema, but may progress to an intensely erythematous rash affecting the groin creases and perianal area. The presence of satellite pustules on nearby skin (e.g., thighs or abdomen) is often indicative of a yeast infection. Candida albicans is isolated in up to 80% of infants with perineal skin irritation that persists for three days or longer.(5)

Senna, a plant-based cathartic, is a common ingredient in over-the-counter laxatives (e.g., Ex-lax chocolate pieces) and has been implicated in cases of contact dermatitis in the diaper region.(4,6-9) This type of erosive dermatitis has been observed with a range of senna doses, including therapeutically appropriate doses.

ASSESSMENT AND THE PHARMACIST’S ROLE

While most rashes in the diaper region are simple cases of irritant contact or candidal DD, it is important to recognize that eruptions in this area may reflect an exacerbation of a more diffuse dermatologic condition, or be related to a condition that has coincidently manifested in the diaper area but is otherwise unrelated.(10) Because of the often sharp borders and blistering, irritant DD can be confused with abusive scald burns. A thorough history is important to ensure the correct diagnosis is made. This includes gathering information the rash has been present, exposure to potential irritants (e.g., detergents, medications) and other information (e.g., type of diaper used, frequency of diaper changes), as pertinent. A visual inspection of the rash may be appropriate in certain circumstances. If inspection is inappropriate, the pharmacist should use open-ended questions to gain a description of the rash. DD that lasts three or more days is usually sufficient to confirm a secondary yeast infection. Patients presenting with a rash in the diaper area should be referred when red flags are identified (Table 1). If the dermatitis is deemed to be irritant DD with or without Candida infection, self-care recommendations can be made.

TABLE 1: Diaper Dermatitis Red Flags⁽¹³⁾

Acute onset with oozing, pus, vesicles or ulceration at lesion site(s)
Frequent recurrences, especially with no rash-free period
Moderate/severe presentation with or without systemic signs and symptoms (e.g., fever, nausea, vomiting)
Rash or skin lesions present outside the diaper area
Symptoms are part of, or caused by, another disease state
Complicated secondary infection or comorbid urinary tract infection
Significant behavioural change in patient (e.g., incessant crying, lethargy, sleep)
Signs of abuse or neglect
Patient is immunocompromised
Symptoms fail to improve despite 7 days of appropriate treatment, or fail to resolve after 14 days

MANAGEMENT STRATEGIES

Primary goals for DD management include relieving symptoms, resolving the dermatitis and preventing recurrence. There is no evidence that any single method is effective alone.(11) Combination methods, including nonpharmacologic and pharmacologic measures, should address all causative factors according to the ABCDE mnemonic (Figure 1).(12) Discontinuation of aggravating factors is a critical first step in DD management;(13) however, the best management of DD is prevention.(11,14)

Irritant DD responds well to a topical barrier applied liberally with each diaper change.(13) In moderate to severe cases, very-low-potency topical corticosteroids (e.g., hydrocortisone 0.5%–1%) may be recommended for a limited duration (1–2 weeks).(13) When candidiasis is suspected, a topical antifungal (e.g., clotrimazole 1%) should also be applied twice daily for one to two weeks, before the barrier product.(13)

PHARMACIST’S RECOMMENDATION

A thorough history reveals well-demarcated borders restricted to the diaper area and sparing of the gluteal folds, suggesting that LL has irritant DD. The senna-containing laxative used to manage constipation may be causing or exacerbating LL’s condition, as sennosides are an established skin irritant when held in the diaper area. The senna-containing laxative should be discontinued and alternatives for managing LL’s constipation (e.g., increasing dietary fibre) should be discussed. Application of a topical barrier cream, such as zinc oxide 40%, should also be encouraged to facilitate skin healing. If senna-containing laxatives are used again in the future, administration should be timed such that bowel movements occur during the day and diapers can be changed promptly to reduce exposure time. Other nonpharmacologic strategies for managing DD described in the ABCDE mnemonic (Figure 1) should also be promoted. If LL’s condition fails to improve within seven days of implementing nonpharmacologic strategies and applying a topical barrier cream, referral for further evaluation is necessary.

Figure 1: Evidence-based Measures to Manage Diaper Dermatitis⁽¹²⁾
A (air, absorptives, antifungals, anti-inflammatories)	Encourage air-drying (by leaving diaper off intermittently)to diminish damaging effects of occlusion and maceration Avoid use of plastic underpants that fit over the diaper area Use topical absorptives (e.g., zinc oxide), antifungals (e.g., clotrimazole 1%, miconazole 2%, nystatin) and anti-inflammatories (e.g., 0.5–1% hydrocortisone up to tid for ≤ 2 weeks) as appropriate
B (barriers)	Avoid powders due to risk of inadvertent inhalation Use barrier products: Zinc oxide 10%–40% Petrolatum Silicone-based products (dimethicone or dimethylpolysiloxane) Ceramides-based protectants
C (cleansing, compresses)	Cleansing should occur after urination or defecation using a soft cloth or hypoallergenic baby wipe: Rinsing with water is sufficient to remove urine Mild soaps should be used for feces removal Area should be blotted dry Avoid diaper wipes containing chemicals or fragrances; wipes without sensitizers are as well-tolerated as water in the daily cleansing of infants with atopic dermatitis(15) Wet compresses or oatmeal baths may be recommended if there is oozing and crusting with acute inflammation
D (diapers)	Use super-absorbent disposable diapers Change diapers frequently to decrease occlusion, mechanical irritation, risk of secondary infection, and contact time with urine and feces Never use the apparently unsoiled part of a diaper to wipe/clean the diaper area, to avoid risk of infection with invisible contaminents
E (education)	Educate parents and caregivers to ensure they understand

REFERENCES

1. Foureur N, Vanzo B, Meaume S, et al. Prospective aetiological study of diaper dermatitis in the elderly. Br J Dermatol 2006;155:941-6.

2. Ward DB, Fleischer AB Jr, Feldman SR, et al. Characterization of diaper dermatitis in the United States. Arch Pediatr Adolesc Med 2000;154:943-6.

3. Shin HT. Diagnosis and management of diaper dermatitis. Pediatr Clin North Am 2014;61:367-82.

4. Nield LS, Kamat D. Prevention, diagnosis, and management of diaper dermatitis. Clin Pediatr 2007;46:480-6.

5. Gupta AK, Skinner AR. Management of diaper dermatitis. Int J Dermatol 2004;43:830-4.

6. Melvin JE, Hickey RW. Laxative-induced contact dermatitis. Pediatr Emerg Care 2018 May 9. [Epub ahead of print].

7. Cogley K, Echevarria A, Correa C, et al. Contact burn with blister formation in children treated with sennosides. Pediatr Dermatol 2017;34:e85-8.

8. Smith WA, Taintor AR, Kos L, et al. Senna-containing laxative inducing blistering dermatitis in toddlers. Arch Dermatol 2012;148:402-4.

9. Leventhal JM, Griffin D, Duncan KO, et al. Laxative-induced dermatitis of the buttocks incorrectly suspected to be abusive burns. Pediatrics 2001;107:178-9.

10. Klunk C, Domingues E, Wiss K. An update on diaper dermatitis. Clin Dermatol 2014;32:477-87.

11. Blume-Peytavi U, Hauser M, Lunnemann L, et al. Prevention of diaper dermatitis in infants—a literature review. Pediatr Dermatol 2014;31:413-29.

12. Boiko S. Treatment of diaper dermatitis. Dermatol Clin 1999;17:235-40.

13. Nakhla N, Butt K. Diaper dermatitis. In: Jovaisas B, ed. Compendium of therapeutics for minor ailments. 3rd ed. Ottawa, ON: CPhA; In Print.

14. Sikic Pogacar M, Maver U, Marcun Varda N, et al. Diagnosis and management of diaper dermatitis in infants with emphasis on skin microbiota in the diaper area. Int J Dermatol 2018;57:265-75.

15. Ehretsmann C, Schaefer P, Adam R. Cutaneous tolerance of baby wipes by infants with atopic dermatitis, and comparison of the mildness of baby wipe and water in infant skin. J Eur Acad Dermatol Venereol 2001;15(suppl 1):16-21.

TABLE 1: Diaper Dermatitis Red Flags(13)

Figure 1: Evidence-based Measures to Manage Diaper Dermatitis(12)

TABLE 1: Diaper Dermatitis Red Flags⁽¹³⁾

Figure 1: Evidence-based Measures to Manage Diaper Dermatitis⁽¹²⁾