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Prevention, Treatment and Parent Education for Diaper Dermatitis

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Prevention, Treatment and Parent Education for Diaper Dermatitis C NE Prevention, Treatment and Parent Education for Diaper Dermatitis Lisa Merrill INTRODUCTION Objectives Diaper dermatitis is a common cutaneous condition charac- Upon completion of this activity, the learner will terized by an acute infl ammatory eruption of the skin in the be able to: diaper area of an infant. Although this condition is relatively common, it can cause considerable pain and stress for infants 1. Describe the prevalence of diaper dermatitis and can be troublesome for their caregivers (Blume-Peytavi et among infants in the United States. al., 2014). 2. Describe the pathophysiology of diaper dermatitis. PREVALENCE It is diffi cult to determine the actual prevalence of diaper der- 3. List the recommended prevention and treat- matitis in the general population due to inconsistencies among ment strategies for diaper dermatitis. published studies and highly variable results, but it is estimated 4. Describe targeted parent education for the that the prevalence of diaper dermatitis in the general popula- prevention and treatment of diaper dermatitis. tion is between 7 percent and 35 percent (Boiko, 1999; Gupta 5. Discuss nursing practice implications in the & Skinner, 2004; Rowe, McCall, & Kent, 2008). It has also been prevention and treatment of diaper dermatitis. reported that the prevalence among hospitalized infants and children ranges from 17 percent to 43 percent (McLane, Book- out, McCord, McCain, & Jeff erson, 2004; Noonan, Quigley, & Continuing Nursing Education (CNE) Credit Curley, 2006). One study of outpatient visits for diaper derma- A total of 1.3 contact hours may be earned as titis in the United States estimated that approximately 1 million CNE credit for reading “Prevention, Treatment health care visits for diaper dermatitis occur per year, with 25 and Parent Education for Diaper Dermatitis” and percent of at-risk children diagnosed with diaper dermatitis for completing an online posttest and participant on at least one occasion (Ward, Fleischer, Feldman, & Krow- feedback form. chuk, 2000). Diaper dermatitis is found equally among male and female infants as well as among infants of all ethnic groups To take the test and complete the participant (Atherton, 2001; Gupta & Skinner, 2004; Ward et al., 2000). feedback form, please visit http://JournalsCNE. Diaper dermatitis is found most commonly among children awhonn.org. Certifi cates of completion will be younger than 2 years of age, with the majority of cases found issued on receipt of the completed participant in children under the age of 1 year (Ward et al., 2000). Diaper feedback form and processing fees. dermatitis typically lasts approximately 3 days (Nield & Kamat, Association of Women’s Health, Obstetric and 2007; Scheinfeld, 2005). Neonatal Nurses is accredited as a provider of continuing nursing education by the American TYPES OF DIAPER DERMATITIS Nurses Credentialing Center’s Commission on Th e three most common types of diaper dermatitis include Accreditation. chaffi ng dermatitis, irritant contact dermatitis and diaper can- didiasis (Paller & Mancini, 2011). Diaper dermatitis is usually Accredited status does not imply endorsement by related to the presence of irritants on the skin, such as mois- AWHONN or ANCC of any commercial products ture from urine and feces, fecal enzymes, diaper materials and displayed or discussed in conjunction with an cleansing agents, as well as friction caused by the diaper itself educational activity. AWHONN is approved by the California Board of Abstract: Diaper dermatitis is a common cutaneous condition character- Registered Nursing, provide #CEP580. ized by an acute infl ammatory eruption of the skin in the diaper area of an infant. Although this condition is relatively common, it can cause consider- able pain and stress for infants and can be troublesome for their caregivers. In the United States, the frequency of diaper dermatitis is substantial and accounts for a high number of visits to health care providers. Th e three most common types of diaper dermatitis are chaffi ng dermatitis, irritant contact dermatitis and diaper candidiasis. Th is article reviews common causes, dif- Lisa Merrill, MN, RN, is a clinical nurse specialist at Women’s Hospital ferential diagnosis, current prevention and treatment recommendations, Health Sciences Center, in Winnipeg, Manitoba, Canada. Th e author nursing implications and practical tips for families to utilize while caring and planners of this activity report no confl icts of interest or relevant for their infants at home. DOI: 10.1111/1751-486X.12218 fi nancial relationships. Th is learning activity was supported through an educational grant from Kimberly-Clark/Huggies®. Address correspond- Keywords: diaper candidiasis | diaper dermatitis | diaper rash | newborn ence to: [email protected]. skin care Opening photo © Comstock / istockphotos.com Images 326 © 2015, AWHONN http://nwh.awhonn.org CNE (Humphrey, Bergman, & Au, 2006; Wolf, Wolf, Tuzun, & Tuzun, Th e development of the acidic properties of the outer layer 2000). Although irritant contact dermatitis is the most common of the skin, or the acid mantle, is important for both barrier cause, alternate diagnosis of underlying conditions should be permeability function and antimicrobial defense of the skin. In considered in cases where response to treatment for diaper der- adaptation to the dry extrauterine environment following birth, matitis is slow or nonexistent (Paller & Mancini, 2011). a newborn’s skin becomes more acidic, the acid mantle devel- ops and the stratum corneum becomes less hydrated (Fluhr et PHYSIOLOGY OF INFANT SKIN al., 2012). At birth, a full-term newborn’s skin surface pH has To understand the development of diaper dermatitis in an in- fant, it is important to appreciate the diff erences in skin between adults, full-term infants and premature infants. Human skin is a complex tissue that assists with thermoregulation, prevents Diaper dermatitis is found equally insensible water loss, acts as a sensory organ and functions as among male and female infants as well http://JournalsCNE.awhonn.org a barrier by providing protection from physical, chemical and biologic threats. It consists of three major layers—the stratum as among infants of all ethnic groups corneum, epidermis and dermis. Th e epidermal barrier is a function of the outermost epidermal layers of the stratum cor- neum and is in direct contact with the environment. It is the main barrier to water loss and permeation by outside agents. been reported to measure 7.08, which is more alkaline than In utero, the maturation of the epidermal barrier of the skin adult skin, which has a pH closer to 5.7 (Yosipovitch, Maayan- occurs as gestational age increases. Although it was once be- Metzger, Merlob, & Sirota, 2000). During the fi rst week of life, lieved that full-term infants are born with a fully competent bar- the pH of newborn skin has been shown to decline rapidly and rier that has been compared to that of an adult (Kalia, Nonato, by the fourth week of like, resemble a pH close to that of an Lund, & Guy, 1998), recent research has shown that full matura- adult, with a pH ranging 5 to 5.5 (Hoeger & Enzmann, 2002). tion of the stratum corneum might not be complete until aft er Following several weeks, a fully hydrated stratum corneum a year of age (Nikolovski, Stamatas, Kollias, & Wiegand, 2008). develops (Fluhr et al., 2012) and the pH of a newborn’s skin Th e skin of premature infants is less developed than that of approaches that of an adult (Horowitz, McLeod, Eichenfi eld, full-term infants and lacks the fully functional barrier proper- Fowler, & Elias, 2013). Th e presence of a fully functional bar- ties of the stratum corneum. With decreasing gestational ages rier in the stratum corneum and an acid mantle approaching and a defi ciency in the stratum corneum, premature infants are that of an adult helps protect the skin of the infant from irri- known to have increased transepidermal water loss (TEWL), tants and microbes that can cause diaper dermatitis. which can lead to signifi cant issues such as dehydration, ther- mal instability and electrolyte imbalances (Eichenfi eld & Hard- PATHOPHYSIOLOGY OF away, 1999). Because the stratum corneum is thinner and less DIAPER DERMATITIS eff ective in premature infants than in adults or full-term in- Th e development of irritant contact diaper dermatitis is mul- fants, these infants may have an increased risk of infection and tifactorial. Th e skin in the diaper area is predisposed to irrita- systemic toxicity due topical absorption of substances on the tion by overhydration or maceration of the stratum corneum skin (Mancini, 2004). It has been demonstrated that full barrier and epidermis, the presence of irritants, such as urine or stool, function develops between 2 and 4 weeks aft er birth for infants friction on the skin and the presence of a high skin pH (Ather- born between 30 and 32 weeks. However, for earlier gestations, ton, 2001). Th e presence of urine can lead to overhydration of full maturation of the barrier function can take until 8 or 9 the skin, making the skin surface more fragile and increasing weeks postbirth, especially in gestations ≤25 weeks (Kalia et al., the permeability of the skin by irritants (Atherton, 2001; Shin, 1998). Th is makes premature infants especially sensitive to the 2014). Th e presence of both stool and urine has shown to in- development of diaper dermatitis. crease the pH of the skin in animal models (Berg, Buckingham, Th e dermis, found beneath the epidermal layer, contains & Stewart, 1986). Th e presence of fecal enzymes, specifi cally connective tissue, hair follicles, sebaceous glands, sweat glands, protease and lipase, has been identifi ed as a major irritant on blood vessels and lymphatic vessels. Th e dermis and epidermis the skin, while bile salts increase the damage of fecal enzyme are anchored together with a matrix of collagen fi bers. In an action on the skin itself (Buckingham & Berg, 1986).
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