Diaper dermatitis

Napkin dermatitis results from prolonged skin contact with urine and faeces. Bacteria convert urea to ammonia which is an alkaline irritant

• friction, occlusion, and maceration all play important roles in the pathogenesis by impairing the skin's barrier function and increasing its susceptibility to irritants (1).

Presentation is with an erythematous, occasionally ulcerating, rash that spares the flexures. It may be complicated by candidiasis or seborrhoeic dermatitis.

Management:

• frequent nappy changes and careful washing with warm water at each change; clean the child's bottom to remove residual urine and faeces
• topical creams in napkin dermatitis
  • frequent application of protective creams, for example, zinc oxide creams or ointments; application of these creams with every nappy change is advised (2)
  • if eczema, seborrhoeic dermatitis or psoriasis present add topical 0.5-1.0% hydrocortisone
  • if candidasis then add topical nystatin or topical imidazole
  • if clinical differentiation of type of dermatitis (e.g. irritant napkin dermatitis, candidasis napkin dermatitis, seborrhoeic dermatitis) is not possible then empirical therapy with
    • a barrier cream (e.g. conotrane (R) or sudocrem (R)) plus
    • a combined topical steroid with antimicrobial preparation for 7 days e.g. timodine (R) cream (has antibiotic as well as antifungal properties) or daktacort (R) cream (hydrocortisone 1%, miconazole nitrate 2%)
• use disposable nappy liners
• avoid plastic and rubber pants - which increase the penetrance of irritants

Click here to link to images of napkin dermatitis

Notes:

• secondary bacterial infections may sometimes occur (particularly with S aureus and streptococcal spp.) and this should be managed with appropriate antibiotics (3)
  • secondary streptococcal infection can develop in the intertriginous folds of the napkin area, as well as the neck and axillae
    • this infection is associated with a bright red and moist appearance with sharply demarcated borders
  • bullous impetigo can also develop in the napkin area, and may occasionally be mistaken for candidiasis associated napkin dermatitis
  • S aureus folliculitis superimposed on napkin dermatitis is another bacterial infection that can involve the diaper area, and must be recognized so that appropriate antibiotic therapy can be instituted

Reference:

• (1) Davies MW et al. Topical Vitamin A, or its derivatives, for treating and preventing napkin dermatitis in infants. The Cochrane Database of Systematic Reviews 2005; 4:CD004300
• (2) Atherton D et al. What can be done to keep babies' skin healthy? RCM Midwives. 2004;7(7):288-90.
• (3) Friedlander SF et al; Contemporary Pediatrics (April 2009). Diaper dermatitis: appropriate evaluation & optimal management strategies