Topic: Allergic dermatitis, scabies, eczema, vitiligo
Question: Following an acute episode of diarrhoea a 3 month old infant wearing diaper daily develops rash on skin surfaces that are in direct contact with diaper. ① What is your diagnosis? Describe clinical picture of this disorder. ② How do you treat skin condition of this child?
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The diagnosis is diaper dermatitis, also known as diaper rash. It presents as an erythematous rash in the diaper area, including buttocks, perineum and upper thighs.
Diaper dermatitis, also known as diaper rash, is an inflammatory skin condition in the diaper area in infants. It is very common, affecting about 50% of babies at some point. The warm, moist, acidic environment under the diaper, combined with friction from the diaper material leads to skin barrier disruption and inflammation. Additional contributing factors include:
• Fecal enzymes like lipases and proteases that irritate the skin, especially after loose stools. Ammonia from urine also raises skin pH.
• Overgrowth of Candida albicans, which naturally inhabits the GI and skin in about 50% of babies. Candida infection is more likely with prolonged wetness, use of antibiotics, infant formula feeding etc.
• Sensitivity or allergy to diaper materials, baby wipes, lotions etc. Disposable diapers, though convenient, create an occlusive environment and may contain potential sensitizers.
• Chafing and skin trauma from tight-fitting or ill-fitting diapers.
Clinically, the rash presents as erythematous macules, papules, vesicles and bullae confined to the area covered by diaper. There may be satellite lesions from Candida overgrowth. The lesions are often symmetrical and spares the skin creases like popliteal fossa. The rash may be scaly or moist, and can range from minor inflammation to severe ulceration in some cases.
Treatment involves both medical therapy and proper skin care:
• Remove wet diapers promptly and allow air drying of skin as much as possible. Gently cleanse with lukewarm water and mild baby shampoo. Pat dry instead of rubbing.
• Apply barrier paste with zinc oxide, petroleum jelly or silicone-based ointment with each diaper change. This protects from moisture and friction.
• Use low-potency hydrocortisone cream (0.5-1%) for inflammation for 3-5 days. For secondary candidal infection, apply nystatin, clotrimazole or miconazole cream 2-3 times a day for at least 7 days. For severe infection, oral fluconazole may be needed.
• Avoid baby wipes, fragrances and new diaper brands. Use hypoallergenic unscented diapers.
• If rash worsens or persists beyond a week, other diagnoses like allergic contact dermatitis, psoriasis and Langerhans cell histiocytosis need to be considered. Skin biopsy and patch testing may be required for diagnosis.
• Probiotics and breastfeeding may help in prevention. Keep the baby well hydrated and nourished. Follow up with a pediatric dermatologist if needed.
Most cases of diaper dermatitis can be managed at home with the measures described above. However, contact your baby’s doctor right away if there are signs of infection like pus, fever or severe pain, or if the rash is not improving with treatment or is worsening.
