Managing Diaper Dermatitis

Diaper dermatitis (DD) is the most common skin condition in infancy¹ with an estimated 50-65 percent of infants having had at least one occurrence.^2-4 DD has no race or gender predilection³ and incidence peaks between nine and 24 months of age.^2,5,6 Most cases are mild, last for two to three days per episode,⁶ and are typically managed by pediatricians and family physicians. Although the term “diaper dermatitis” loosely refers to any type of dermatitis in the diaper area, it has traditionally been used to refer to an irritant dermatitis. Irritant DD occurs on the convex surfaces of the groin that contact the diaper and classically spares the skin folds.¹ This condition can range from mild disease with asymptomatic erythematous papules to severe disease presenting with painful eroded plaques and punched-out erosions, i.e., Jacquet’s erosive diaper dermatitis.¹ DD resolves when the patient no longer uses diapers and is fully toilet trained.¹ Severe or refractory cases should be further evaluated for secondary or alternate diagnoses, including infections, nutritional deficiency, seborrheic dermatitis, psoriasis, Langerhans cell histiocytosis, and child abuse.¹

Multifactorial Etiology

DD is a multifactorial condition involving impairment of the skin barrier leading to irritant contact dermatitis (Fig. 1).^1,7-9 Newborn skin, particularly in the diaper area, is more susceptible to skin barrier disruption compared to more mature skin.¹⁰ Causative factors include excessive moisture (e.g., from incomplete drying or perspiration), friction, and exposure, to caustic substances, such as urine and feces.¹ Friction and excessive moisture even without urine or feces breaks down the stratum corneum and increases permeability to potential irritants.^8,11 Urine increases moisture and raises pH. Urine pH ranges from 4.6 to 8; however, the pH increases when urine urea is broken down by fecal urease.¹² Fecal pH is 6.5 to 7.5 and normal buttock skin pH is 5.5.^13,14 Alkaline pH changes the microbial colonization and activates fecal enzymes to degrade the stratum corneum.¹⁵ Severity of DD has been correlated with elevated pH in the diaper area.^13,16 DD has also been correlated with frequency and consistency of bowel movements with risk factors including viral gastroenteritis, constipation with fecal incontinence, underlying gastrointestinal disorders, and dietary changes.^2,5 Breastfeeding has been shown to be protective for moderate to severe DD, possibly due to the significantly lower pH of feces from exclusively breastfed infants with less enzymatic activity.^5,17-19

Multi-faceted Treatment Approach

As irritant DD has a multifactorial etiology, a multifaceted treatment approach addressing the various risk factors can be beneficial (Fig. 1). The first step is to obtain a detailed history including bathing and cleansing routines, product ingredient review, frequency and description of urination and defecation, and diet.¹ The development of superabsorbent, disposable, and breathable diapers instead of cloth diapers has greatly decreased the incidence and severity of DD;^11,20-22 however, soiled diapers should still be removed as soon as possible.¹ Diapers should be loosely fitting.¹ Excessive scrubbing and use of alcohol wipes should be avoided.

When using a disposable diaper, the genital area does not need to be cleansed with a detergent/soap after urination. A water rinse followed by a short air-dry period prior to replacing the diaper is recommended. Following fecal exposure, the area can be cleansed with a gentle water rinse, mild soap, and patted dry. Pre-moistened wipes have been shown to be as mild as water;²³ however, a significant number of available wipes contain preservative and fragrance chemicals that can irritate and potentially cause contact sensitization, and therefore should not be used on broken skin.^1,24

Restoration of the acid mantle (pH restore) with acidification sprays, soaks, or pH buffers in baby wipes may assist in reversing the alkaline pH.^8,25 These soaks and sprays are formulated by adding a tincture of white or apple cider vinegar to a water bath or spray bottle (~1:100). The pH restore solution can be used with every diaper change and does not need to be rinsed but should be patted dry and further allowed to air-dry if time permits. Liberal use of barrier creams such as zinc oxide and petrolatum create an occlusive layer, which aids in decreasing contact with irritants and decreasing transepidermal water loss (TEWL). Barrier creams can be reapplied with each diaper change and should be applied in a thick layer often likened to “frosting on a cake.”¹ Cornstarch powder absorbs moisture and reduces friction.¹ While talcum powder is a common ingredient in baby powders, cornstarch is considered to be a safer alternative as it has not been previously associated with ovarian cancer or found to contain asbestos contamination.^26,27 A new cream-to-powder product using corn starch and other natural ingredients is suggested to be safe and effective for preventing DD.²⁸

In more severe conditions, additional treatments may be necessary. If there are erosions, mineral oil can be used to soften and gently remove dried feces.¹ Wet compresses (with water or pH restore solution) may be used prior to medications and barrier creams if exudate or crusting is noted.¹ Low-potency topical steroids may be used for short periods of time to calm inflammation.¹ If a stinging sensation is noted with bath water, addition of ¼ cup of salt or baking soda may minimize discomfort as well as reduce infection.^1,29

For secondary bacterial infections, topical antimicrobials are often prescribed. For candida infection, nystatin is the most commonly prescribed topical agent;³ however, other agents such as ketoconazole, can also be used. Refractory cases may require systemic treatment.¹ Decreased microbial colonization including methicillin-resistant Staphylococcus aureus (MRSA) can be achieved with dilute sodium hypochlorite (bleach) baths (e.g., 0.125-0.5 cups per full tub or one to two teaspoons of bleach per gallon of water) twice a week and mupirocin twice a day to nares for five days as a first step.^30,31 Alternative decolonization protocols can be performed if needed and call for mupirocin application to additional body sites and at monthly intervals. While dilute bleach baths have antimicrobial activity³² and baking soda eases pain, they both increase the skin’s pH. Thus, it is important to pH restore after these baths; the natural acidic milieu allows the healthy microbiota of the diaper area to thrive and produce innate antimicrobial agents against invasive pathogens.^7,33

Patient Education

Irritant DD is a common skin condition that can cause patient discomfort as well as caregiver anxiety. Parent education of the risk factors and multifactorial treatment approach is imperative for prevention and management. The mainstays of DD treatment include measures aimed at decreasing moisture, friction, pH, and contact with irritants. In severe and refractory cases, a variety of secondary and differential diagnoses can be considered.

The authors have no relevant disclosures.

1. Shin HT. Diagnosis and management of diaper dermatitis. Pediatric clinics of North America. Apr 2014;61(2):367-382.

2. Adalat S, Wall D, Goodyear H. Diaper dermatitis-frequency and contributory factors in hospital attending children. Pediatr Dermatol. Sep-Oct 2007;24(5):483-488.

3. Ward DB, Fleischer AB, Jr., Feldman SR, Krowchuk DP. Characterization of diaper dermatitis in the United States. Archives of pediatrics & adolescent medicine. Sep 2000;154(9):943-946.

4. Blume-Peytavi U, Hauser M, Lunnemann L, Stamatas GN, Kottner J, Garcia Bartels N. Prevention of diaper dermatitis in infants--a literature review. Pediatr Dermatol. Jul-Aug 2014;31(4):413-429.

5. Jordan WE, Lawson KD, Berg RW, Franxman JJ, Marrer AM. Diaper dermatitis: frequency and severity among a general infant population. Pediatr Dermatol. Jun 1986;3(3):198-207.

6. Benjamin L. Clinical correlates with diaper dermatitis. Pediatrician. 1987;14 Suppl 1:21-26.

7. Atherton DJ. A review of the pathophysiology, prevention and treatment of irritant diaper dermatitis. Current medical research and opinion. May 2004;20(5):645-649.

8. Atherton DJ. Understanding irritant napkin dermatitis. International journal of dermatology. Jul 2016;55 Suppl 1:7-9.

9. Merrill L. Prevention, Treatment and Parent Education for Diaper Dermatitis. Nursing for women’s health. Aug-Sep 2015;19(4):324-336; quiz 337.

10. Ludriksone L, Garcia Bartels N, Kanti V, Blume-Peytavi U, Kottner J. Skin barrier function in infancy: a systematic review. Archives of dermatological research. Sep 2014;306(7):591-599.

11. Odio M, Thaman L. Diapering, diaper technology, and diaper area skin health. Pediatr Dermatol. Nov 2014;31 Suppl 1:9-14.

12. Berg RW, Buckingham KW, Stewart RL. Etiologic factors in diaper dermatitis: the role of urine. Pediatr Dermatol. Feb 1986;3(2):102-106.

13. Hoeger PH, Enzmann CC. Skin physiology of the neonate and young infant: a prospective study of functional skin parameters during early infancy. Pediatr Dermatol. May-Jun 2002;19(3):256-262.

14. Visscher MO, Adam R, Brink S, Odio M. Newborn infant skin: physiology, development, and care. Clinics in dermatology. May-Jun 2015;33(3):271-280.

15. Gozen D, Caglar S, Bayraktar S, Atici F. Diaper dermatitis care of newborns human breast milk or barrier cream. Journal of clinical nursing. Feb 2014;23(3-4):515-523.

16. Schmid-Wendtner MH, Korting HC. The pH of the skin surface and its impact on the barrier function. Skin pharmacology and physiology. 2006;19(6):296-302.

17. Pratt AG, Read WT, Jr. Influence of type of feeding on pH of stool, pH of skin, and incidence of perianal dermatitis in the newborn infant. The Journal of pediatrics. May 1955;46(5):539-543.

18. Stamatas GN, Tierney NK. Diaper dermatitis: etiology, manifestations, prevention, and management. Pediatr Dermatol. Jan-Feb 2014;31(1):1-7.

19. Shin HT. Diaper dermatitis that does not quit. Dermatol Ther. Mar-Apr 2005;18(2):124-135.

20. Akin F, Spraker M, Aly R, Leyden J, Raynor W, Landin W. Effects of breathable disposable diapers: reduced prevalence of Candida and common diaper dermatitis. Pediatr Dermatol. Jul-Aug 2001;18(4):282-290.

21. Davis JA, Leyden JJ, Grove GL, Raynor WJ. Comparison of disposable diapers with fluff absorbent and fluff plus absorbent polymers: effects on skin hydration, skin pH, and diaper dermatitis. Pediatr Dermatol. Jun 1989;6(2):102-108.

22. Clark-Greuel JN, Helmes CT, Lawrence A, Odio M, White JC. Setting the Record Straight on Diaper Rash and Disposable Diapers. Clinical pediatrics. Aug 2014;53(9 suppl):23S-26S.

23. 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. Journal of the European Academy of Dermatology and Venereology : JEADV. Sep 2001;15 Suppl 1:16-21.

24. Manzini BM, Ferdani G, Simonetti V, Donini M, Seidenari S. Contact sensitization in children. Pediatr Dermatol. Jan-Feb 1998;15(1):12-17.

25. Blume-Peytavi U, Kanti V. Prevention and treatment of diaper dermatitis. Pediatr Dermatol. Mar 2018;35 Suppl 1:s19-s23.

26. Whysner J, Mohan M. Perineal application of talc and cornstarch powders: evaluation of ovarian cancer risk. American journal of obstetrics and gynecology. Mar 2000;182(3):720-724.

27. Rohl AN, Langer AM, Selikoff IJ, et al. Consumer talcums and powders: mineral and chemical characterization. Journal of toxicology and environmental health. Nov 1976;2(2):255-284.

28. Gunt HB, Levy SB, Lutrario CA. A Natural Cream-to-Powder Formulation Developed for the Prevention of Diaper Dermatitis in Diaper-Wearing Infants and Children: Barrier Property and In-Use Tolerance Studies. Journal of drugs in dermatology : JDD. May 1 2018;17(5):566-570.

29. Petersen BW, Arbuckle HA, Berman S. Effectiveness of saltwater baths in the treatment of epidermolysis bullosa. Pediatr Dermatol. Jan-Feb 2015;32(1):60-63.

30. Huang JT, Abrams M, Tlougan B, Rademaker A, Paller AS. Treatment of Staphylococcus aureus colonization in atopic dermatitis decreases disease severity. Pediatrics. May 2009;123(5):e808-814.

31. Fritz SA, Camins BC, Eisenstein KA, et al. Effectiveness of measures to eradicate Staphylococcus aureus carriage in patients with community-associated skin and soft-tissue infections: a randomized trial. Infection control and hospital epidemiology. Sep 2011;32(9):872-880.

32. Sassone LM, Fidel RA, Murad CF, Fidel SR, Hirata R, Jr. Antimicrobial activity of sodium hypochlorite and chlorhexidine by two different tests. Australian endodontic journal : the journal of the Australian Society of Endodontology Inc. Apr 2008;34(1):19-24.

33. Rippke F, Schreiner V, Schwanitz HJ. The acidic milieu of the horny layer: new findings on the physiology and pathophysiology of skin pH. Am J Clin Dermatol. 2002;3(4):261-272.