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On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.84 no.1 Rio de Janeiro Jan./Feb. 2009
Juliana Dumet FernandesI; Maria Cecília Rivitti MachadoII; Zilda Najjar Prado de OliveiraIIIICollaborating Physician, Department of Dermatology, Hospital das Clinicas, Medical School, Universidade de Sao Paulo (USP) - Sao Paulo (SP), Brazil
IISupervisor Physician, Department of Dermatology, Hospital das Clinicas, Medical School, Universidade de Sao Paulo (USP) - Sao Paulo (SP), Brazil
IIIPhysician, Director of Department of Dermatology, Hospital das Clinicas, Medical School, Universidade de Sao Paulo (USP) - Sao Paulo (SP), Brazil
Diaper irritant contact dermatitis is the most prevalent diaper dermatitis and, probably, the most common cause of cutaneous disease in infants. Wearing diapers causes over hydration and increase of local temperature and humidity. As a consequence, the skin becomes susceptible to friction from movement under the diaper. Occlusion, maceration and possibly Candida and bacteria may all play a role. Oils, soaps and powders can be irritant and aggravate the eruption. The best thing to do is prevention. Treatment is simple and depends on dermatitis type and severity.Keywords : HTLV-I infections; HTLV-I infections/complications; Human T-lymphotropic virus 1; Lymphoma, T-cell, cutaneous; Paraparesis, tropical spastic; Skin; Skin manifestations
Keywords:Candida albicans; Diaper rash; Diaper rash/therapy
As already approached by part I, previously published, diaper area dermatitis is a term that encompasses a set of inflammatory dermatoses that affect the region of the body covered by the diaper: perineum, buttocks, lower abdomen and thighs. The causes involved in diaper dermatitis are direct use of diaper, such as primary irritative diaper dermatitis (which is synonym to diaper dermatitis to some authors) and allergic contact dermatitis to plastic material of the diaper (very rare); dermatitis exacerbated by diaper use (such as psoriasis, atopical dermatitis, seborrheic dermatitis, miliaris, candidosis, allergic contact dermatitis); and those that are present in the region, but are not related to the use of diaper (enteropathic acrodermatitis, Langerhans cell histiocytosis, pediatric gluteal granuloma, perianal streptococcal dermatitis, bullous impetigo, scabies, congenital syphilis, AIDS). Thus, diaper area dermatitis should be interpreted not only as a specific diagnostic entity, but rather as a location diagnosis, which encompasses a group of dermatoses and results from the interaction of multiple factors.
Primary irritative diaper dermatitis is the most prevalent one 1. It is a contact dermatitis caused by primary irritation on the diaper region. The increase in temperature and local humidity cause skin maceration making it more susceptible to irritation caused by prolonged contact with urine and feces. The use of irritant powders, oils, soaps and ointments aggravate the clinical presentation. Moreover, the onset of secondary infection caused by Candida albicans or bacteria such as Bacillos faecallis, Proteus, Pseudomonas, Staphylococcus and Streptococcus is frequent.
It is known that susceptibility in atopical children with seborrheic dermatitis is much higher and concomitant onset of other entities may hinder differential diagnosis 2, 3, 4, 5. In addition, the involved genetic factors have not been fully understood yet.
There is no preference to gender, race or social level 6. Subjects from other age ranges may also develop the disease in special situations associated with urinary and fecal incontinence 7. The clinical presentation is similar, comprising the same complications and the same management approach.
In recent years, there has been a decrease in the frequency and severity of diaper dermatitis, especially owing to better quality of material used to manufacture them, which has significantly contributed to the advances of hygiene care.
CLINICAL PRESENTATION, DIAGNOSIS AND COMPLEMENTARY TESTS
1. Primary irritative diaper dermatitis
It is characterized by confluent and brilliant erythematous lesions that vary in intensity with time. It may be manifested through erythematous papules associated with edema and mild desquamation. It normally affects the regions of greater contact with the diaper and it is characteristically known as "dermatitis in W". Folds are normally spared and the most affected areas are convex surfaces of buttocks, thighs, lower portion of abdomen, pubic region, labia majora, and scrotum (Figure 1). Candidosis is considered the main complication of dermatitis and if they happen simultaneously, the erythema gets worse and there are satellite papular-pustulous lesions 8. When the erythema starts to improve, skin gets shrunk and has the aspect of a papyrus. In children below the age of four months, the first manifestation is mild perianal erythema.
The intensity of skin affection of diaper dermatitis range from mild to severe. pH affection of the skin may trigger the development of opportunistic infections of bacterial, fungal and viral nature. In more severe cases, eruption may affect areas not covered by the diaper. If there is no treatment, or if it gets infected, it may progress to maceration and exsudation, forming papules, vesicles or blisters, erosion or skin ulceration, infection of the penis, vulva or urinary tract. Moreover, there may be synechia or scaring of genital organs. If associated with diarrheic syndrome, the presentation has quick progression and is more severe 9.
There are two less frequent subtypes of primary irritative diaper dermatitis. One of them, known as Jacquet dermatitis, Jacquet pseudosyphilis, or syphiloid papuloerosive erythema, is an uncommon and severe form of diaper dermatitis that is developed by persistence and intensity of causing insult, associated with aggravating factors (topical irritant substances, fungi), and/or inappropriate management 1, 10, 1. It is characterized by firm and salient papules, of dark red or violaceus color, that appear before the vesicle-erosive-ulcerative stage. Ulcerations are oval or rounded, shallow and of crateriform aspect (Figure 2). If affects primarily the buttocks, upper thighs and sometimes the calves 12, 10. Upon regressing, this type of dermatitis may cause atrophy and hyperpigmentation. It normally affects children over the age of six months. However, Jacquet variant has already been described in adults as well 13. In boys, ulcers may affect the glans and urinary canal, leading to discomfort and dysuria 14. Another subtype, also known as "tide dermatitis" is characterized by erythema in bands, confined only to the diaper margins in the abdominal and thigh areas. This type of dermatitis results from constant friction with the diaper edge, aggravated by consecutive cycles of humidity and dryness.
Diagnosis of primary irritative diaper dermatitis is clinical and should be made by direct mycological analysis to determine the contamination by Candida when the erythema is intensified, showing satellite pustules or when there is slow resolution of the disease.
2. Other causes of diaper dermatitis
Proliferation of C. albicans is favored by the humid and warm environment produced by the diaper. It may penetrate into the stratum corneum, activate the alternate complement path and induce an inflammatory process 4. Candidosis in the diaper area is increasingly more common in children. It is probably due to frequent use of broad-spectrum oral antibiotics with subsequent diarrhea. Clinically, it is presented by erythematous plaques that may extend to the genitals, associated with peripheral desquamation and erythematous satellite pustules. It may also present small rosy papules covered by scales, which are coalescent in some areas (Figure 3). Anterior perineal and perianal regions and the folds are normally involved, which helps us differentiate candidosis from primary irritative diaper dermatitis (PIDD). In chronic or frequent recurrent presentations, it is important to investigate the infection of digestive tract by Candida (check oral cavity), vaginitis by Candida or maternal mastitis. Diagnosis is clinical and laboratorial using direct mycological analysis of the lesion, showing pseudo-hyphae (collected from the periphery of the erythema, papule or peripheral pustules) (Chart 1).
2.2- Allergic contact dermatitis
The true allergic diaper contact dermatitis may be complicated by another type of preexisting dermatitis or be on its own. It is characterized by mild erythema and desquamation, and sometimes there are vesicles and papules. It is uncommon in children below the age of two years. This condition should be suspected when there is not appropriate response to treatment options. Even though it is not common, it may happen after contact of the skin with some specific allergens such as paraben, lanoline, mercury compounds and neomycin, or substances found in disposal diapers (such as latex, for example), detergents or preparation of topical applications. Diagnosis is clinical and may be confirmed by contact tests (Chart 1).
2.3. Atopical dermatitis
Even though there is greater susceptibility of atopical people to irritative agents, in most cases atopical dermatitis normally tends to spare the diaper area. When it reaches it, it is manifested as PIDD. However, it tends to be chronic and relative resistant to treatment. There may be exsudate and crusts secondary to Staphylococcus aureus infection. There may be excoriation and liquenification owing to chronic pruritus. However, we should point out that indirect signs of pruritus, such as excoriation, are not manifested before the age of two years. Diagnosis is clinically-based (Chart 1).
2.4. Seborrheic dermatitis
It is a chronic inflammatory disease that frequently affects the diaper region. Its onset is normally between 3 and 12 weeks of life and it rarely appears after 6 months of age. Clinically, there are erythematous plaques with greasy scales on intertriginous lesions. Even though it preferably affects the folds, it has no satellite lesions, differently from candidosis. Diagnosis is clinical and there is normally spontaneous resolution between the ages of three and six months (Chart 1).
It is a rare disease in children, but when its onset is in the first year of life, it normally starts at the diaper region. This fact is probably due to Koebner phenomenon, that is, reproduction of the lesion in a traumatized area, secondary to diaper use. However, in most cases, it is not restricted to diaper area, extending characteristically to peri and umbilicar regions. Clinically it is presented by well-delimited lesions, such as thick and micaceous scales. Diagnosis is clinical. We should also investigate the typical lesions of psoriasis in other habitual locations of the disease, such as for example, the elbows, knees, face and scalp (Chart 1).
2.6. Enteropathic acrodermatitis
It is a rare disease, autosomal recessive, that is generated by serum zinc deficiency. It normally starts in infants when breastfeeding is replaced by regular cow milk or when the child is fed with regular milk since birth. It is suspected when there is persistent dermatitis and atypical presentation on the diaper area. The classical triad is acral and periorifice dermatitis, alopecia and diarrhea.
Acral dermatitis starts slowly with erythematous-desquamative plaques, well delimited and eczematous presentations on the face, scalp and anogenital areas, affecting also inguinal folds, periocular region, perinasal, perioral and distal extremities. Lesions progress and develop vesicle-bullous plaques, with multiple erosions and pustules. If the progression is chronic, there may be liquenification or psoriasiform plaques. Diagnosis is made by showing low level of plasma or serum zinc. Reduced dosage of alkaline phosphatase helps in the diagnosis, because this metalloenzyme is zinc-dependent (Chart 1).
2.7. Congenital syphilis
Lesions in congenital syphilis may be present since birth or within the first months of life. It may be manifested in the anogenital region as macules, papules, blisters, humid lesions, similar to warts (flat condyloma), associated with erosions. There may also be eruption such as syphilis secondary to erythema, papules and scales. In many cases, there are lesions on the palmar and plantar regions. Owing to increase in syphilis incidence, its congenital form should be included in differential diagnosis of diaper dermatitis. Diagnosis is clinical and laboratorial using serology tests (VDRL/TPHA or FTAAbs), cerebrospinal fluid analysis and radiographic studies (Chart 1).
2.8. Langerhans cell histiocytosis (Letterer-Siwe disease)
Langerhans cell histiocytosis is a rare and even fatal disease that may affect diaper region. Normally, its onset is in the first years of life, but it may also develop in children over the age of three years. It should be considered in the presence of dermatitis that at first is similar to difficult to treat seborrheic dermatitis. It is clinically presented by erythematous-brownish or purpuric papules, in addition to occasional hemorrhagic or ulcerated lesions. To diagnose it, it is necessary to have skin biopsy, comprising histopathology and immunohistochemical study (Chart 1).
2.9. Pediatric gluteal granuloma
It is a rare nodular dermatosis of unknown etiology, even though it may be present after topical treatment with powerful corticosteroids. It may also represent a localized cutaneous response to a prolonged inflammatory process that may occur in an area of preexisting primary irritative dermatitis or even after its resolution. There are no evidences of correlation between severity of diaper dermatitis and incidence of the eruption. It is believed that participation of Candida albicans is involved in the pathogenesis of the disease. It is clinically characterized by one or two oval nodules, erythematous purpuric nodules on the convex surfaces of the skin, sparing the flexures. Diagnosis is clinical or histopathological. There may be spontaneous resolution of some lesions (Chart 1).
2.10. Sexual abuse
It is suspected in cases of condyloma acuminatum or flat condyloma in children of any age. Owing to its legal implications, diagnosis should be carefully approached.
2.11. Bullous impetigo
The humid and warm environment of the diaper area is a predisposing factor to this Staphylococcus infection that is very frequent in newborns. It is caused by type II Staphylococcus aureus that produces the epidermolytic toxin responsible for separating the upper layers of the epidermis. It is presented as an erythematous macula that is transformed into vesicle-papule or purulent blister, flaccid, that is easily broken and form erosions. In general, diagnosis is clinically-based. In some special cases, bacterioscopic analysis and cultures may be used to identify the causing agent (Chart 1).
PREVENTION AND CARE
In babies with primary irritative diaper dermatitis, the most important element is prevention. Removal of occlusion is still the best way to prevent and to treat it. To that end, it is recommended to have a set of measures whose main objective is to maintain the area constantly dry. Thus, it is necessary to avoid irritation and maceration, limit the mixture and dispersion of urine and feces, reduce their contact with the skin, which helps us preserve the skin barrier function, and maintain, if possible, acid pH 14-16. By doing that we can eliminate or minimize all factors implied in the etiopathogenesis of the disease. There are five key aspects in prevention of diaper dermatitis as follows.
Frequency of diaper change
Urine diapers should be frequently changed so that the absorption capacity is not exceeded, avoiding contact of the urine with the skin. Diapers with feces should be immediately changed. In newborns, the change should be every hour, whereas in older children it can have a 3-4 hour interval 6.
Diaper absorption capability
Currently most commonly sold diapers contain superabsorbent acrylic gel material, effective to maintain the diaper area dry and in an acid media. Some modern diapers include substances capable of sequestrating the liquid in up to 80 times its molecular weight, such as the case of sodium polyacrylate, which is transformed into gel 15-17. Despite these specifications, disposal diapers have an occlusive effect that is greater than cloth diapers, not eliminating the contact skin/ feces 13. For this reason, we should discourage parents to maintaining the same diaper for long periods of time.
Disposal diapers versus cloth diapers
Superabsorbent disposable diapers are the ones that have the greatest capacity to maintain the diaper area always dry 17. Previous studies have compared superabsorbent disposal diapers with regular cloth diapers and have demonstrated that the former produced significant less erythema 18-21 and less dermatitis. There have been no allergic reactions to absorbent diaper material ever described 17, 22. Despite the advanced techniques in manufacturing disposal diapers, there are some authors that prefer cloth diapers because they cause less occlusion 23. To reduce local temperature, diapers should be smaller and more anatomical 21.
C. albicans frequently contaminates the diaper area, which is the main complication of the disease. Infection by yeast should also be considered, investigated and treated in cases of dermatitis that last for more than 3 days 24-26.
Daily hygiene and preparations that should be avoided
Hygiene of the diaper region skin should me made with lukewarm water and cotton balls, without soaps, which is enough for daily hygiene of urine. Thus, there is no need to use soap every time the child urinates, which happens many times during the day, because it may lead to contact dermatitis with the soap. To feces, mild soaps are recommended. The use of baby wipes may be useful only when the baby is not at home. We should always bear in mind that they have soap in their content and continuous contact with the skin may damage the skin barrier and cause contact dermatitis. Ideally, the region should be rinsed after wipes use. 27-30
Routine use of topical preparations to prevent diaper dermatitis is not necessary in children with normal skin 30. Additives in these preparations may cause contact sensitivity, irritation and/or percutaneous toxicity.
To avoid excessive humidity in the diaper area, minimize transepidermal loss of water and reduce skin permeability, barrier creams or thicker and adherent pastes made of zinc oxide, titanium dioxide and starch or creams with dexpanthenol may be used. These products may help prevent the contact of feces with the already damaged skin, because they get adhered to the epidermis. They are not easily removed with water and require the use of oils, so they should not be used every diaper change to avoid skin irritation. Its use may be dispensed if hygiene care and diaper change are frequently made. It is not known whether the additives present in some of these barrier creams (such as vitamins) improve their quality. Moreover, some additives, preservatives and aromatizers present in protective creams may have an occlusive effect, leading to diaper dermatitis.
Some preparations should be avoided. They are: boric acid preparations owing to risk of toxicity and diarrhea and erythrodermia; home recipes, with egg white and milk, because of high allergenic potential; products with aniline dye that may lead to intoxication and metahemoglobinemia; disinfectant and softeners, especially the ones that contain hexachlorophene or pentachlorophene owing to the risk of vacuole encephalopathy and tachycardia with metabolic acidosis, respectively.
Medical treatment of primary irritative diaper dermatitis consists of simple measures applied according to the severity and type of dermatitis (Chart 2). 27-30 The most important element in mild dermatitis is to increase the frequency of diaper change and use superabsorbent diapers (not all brands are). We should avoid cloth diapers that allow contact between urine and feces and the skin and require specific measures to eliminate microorganisms (washing with soap and boiling). To clean the diaper region, it is recommended to first use cotton ball soaked in oil (mineral or vegetal) to remove the zinc oxide and residues of feces adhered to the skin, then we can go on washing with soaps that are not aggressive. We should use running water to provide better removal of residues. Another possibility is the use of cold compresses with Burow 1:30 solution three times a day, which provides calming, antiseptic and drying effect 13.
If erythema persists, we can associate low power topical corticoid, such as hydrocortisone at 1% up to two times a day for 2 to 7 days to avoid inflammation. Fluorinated high power corticoid is contraindicated because of the intrinsic risk of atrophy and strias, in addition to the occlusive effect of the diaper that maximizes it. We should be on the watch for systemic adverse effects of this substance, such as Cushing syndrome and intracranial hypertension that have been reported even with low power effects, because in addition to occlusion, body surface of the area is significant 24. If dermatitis does not improve, maintaining marked erythema and pustules, the key suspicion is infection by Candida. In this case, we may add cream with anti-fungal action, such as ketoconazole, nystatin at 100,000U/g or miconazole nitrate 1% topical, twice a day for 7 to 15 days, which are effective and safe 24, 13. Corticoid may be used alternated with antifungal agent, applied before the barrier cream. Even though there is no evidence many severe and prolonged cases benefit from oral nystatin, 4 times a day for 14 days. Fluconazole may be indicated in a dose adjusted to the age, even though its use is exceptional, in the experience of the authors.
In prolonged dermatitis, we may also use tar in creams. However, in some countries, it is contraindicated because of the risk of carcinogenesis.
Bacterial infections are very rare with disposal diapers, differently from regular cloth diapers, and may be treated with topical neomycin, gentamycin or mupirocin at 2%. The latter, however, should not be used in more than 20% of the body surface because of the risk of nephrotoxicity. Oral antibiotics may aggravate the picture because they affect the intestinal flora 13.
If, despite the correct treatment, there is worsening of previous dermatitis, we should always investigate the differential diagnoses already listed, such as atopical dermatitis, seborrheic dermatitis, diaper area psoriasis and contact dermatitis. The follow-up of children with diaper dermatitis should be regular, in addition to requiring special attention in periods of diarrhea or systemic antibiotic use.
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Juliana Dumêt Fernandes
Av. Dr. Enéas de Carvalho Aguiar, 255,
3º andar, sala 3070 - Cerqueira César
05403 001 - São Paulo - SP
Tel./fax: (11) 3069-6000
How to cite this article: Fernandes JD, Machado MCR, Oliveira ZNP. Quadro clínico e tratamento da dermatite da área das fraldas - Parte II. An Bras Dermatol. 2009;84(1):47-54.