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Jacquet Erosive Diaper Dermatitis: a Complication of Adult Urinary Incontinence

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Jacquet Erosive Diaper Dermatitis: a Complication of Adult Urinary Incontinence Jacquet Erosive Diaper Dermatitis: A Complication of Adult Urinary Incontinence Livia Van; Mandy Harting, MD; Ted Rosen, MD Jacquet erosive diaper dermatitis is typically Prior to our evaluation, the patient tried many described as a severe irritant dermatitis of the therapies during a 2-year period with no resolution. perianal region. However, Jacquet erosive dia- Treatment with numerous topical antifungal and per dermatitis, perianal pseudoverrucous papules anti-Candida medications, including clotrimazole and nodules, and granuloma gluteale infantum/ cream and miconazole nitrate powder, were unsuc- adultorum have been regarded as discrete enti- cessful. He was subsequently given oral flucon- ties or all part of the same clinical spectrum, azole by his primary care physician approximately representing the result of chronic, severe, irritant 8 months prior to presentation, also with no benefit. contact dermatitis. We present a case of Jacquet No improvement following application of topical ste- erosive diaper dermatitis and a discussion of the roids or emollients was noted. Our working diagno- clinical spectrum of diseases to which it belongs. sis was Jacquet erosive diaper dermatitis confounded Cutis. 2008;82:72-74. by moniliasis. We treated the patient with zinc oxide bar- Case Report rier paste and naftifine hydrochloride cream 1% A 77-year-old man presented to the dermatology twice daily. We recommended more frequent diaper clinic with complaints of itching and burning of changes as well as regular cleansing and drying of the the buttocks of 2 years’ duration. His medical his- affected area to improve hygiene. Along with these tory included prostate cancer treated with radical treatments, our patient received only one 200-mg prostatectomy 3 years prior to clinical presen- dose of oral fluconazole for candidal superinfection. tation. Postoperatively, he experienced chronic Despite the use of initial anti-Candida medication, urinary incontinence and, consequently, wore our patient did not begin to see improvement of disposable diapers. his skin lesions or symptoms until approximately The patient was afebrile and in no acute dis- 6 weeks after strict diaper hygiene and use of barrier tress. Site-specific physical examination revealed paste and emollients. bilateral, pink, moist perianal plaques and discrete, red, slightly eroded papulonodules within the solid Comment plaques of the gluteal cleft (Figure). The plaques Prior to Jacquet’s recognition of erosive diaper der- had a white pastelike residue at both the center and matitis as a clinical entity in 1905,1 infants with periphery. The aforementioned white borders were this unique presentation of primary irritant diaper positive for candidal infection on potassium hydrox- dermatitis were thought to have congenital syphilis. ide examination. However, the eruption lacked both Also known as erythema papuloerosive of Sevestre the pustules and the satellite array prototypical of and Jacquet, dermatitis syphiloides posterosiva, or cutaneous candidiasis. pseudolues papulosa, Jacquet erosive diaper derma- titis is a rare form of ulcerating severe irritant diaper dermatitis affecting occluded skin exposed to urine Accepted for publication November 14, 2007. and/or feces for a prolonged period of time.1-3 Lesions From Baylor College of Medicine, Houston, Texas. The authors report no conflict of interest. are localized to the genital and/or perianal skin, Correspondence: Mandy Harting, MD, 1514 W Webster St, appearing as nonconfluent, small, well-demarcated Houston, TX 77019 ([email protected]). papules and nodules measuring 2 to 8 mm in diameter 72 CUTIS® Jacquet Erosive Diaper Dermatitis Bilateral, pink, moist perianal plaques and discrete, red, slightly eroded papulonodules within the solid plaques of the gluteal cleft, characteristic of Jacquet erosive diaper dermatitis. with central umbilication and superficial erosions or acuminata, vegetative herpes simplex, acrodermatitis ulcers, often with heaped-up borders. Mucosal tissue enteropathica, cutaneous Crohn disease, Langerhans generally is spared.2,4-6 Biopsies may show acanthosis; cell histiocytosis, Candida diaper dermatitis, neo- hyperkeratosis; spongiosis; superficial ulceration; and plasm, and lichen planus.2,3,5 Perianal pseudover- a mixed dermal inflammatory infiltrate consisting of rucous papules and nodules and granuloma gluteale neutrophils, lymphocytes, and plasma cells.2,6 Because infantum/adultorum are 2 other forms of irritant histopathologic characteristics lack specificity, diag- dermatitis affecting the genital, inguinal, and peri- nosis remains largely clinical. The prevalence of neal regions that may be difficult to distinguish from Jacquet erosive diaper dermatitis in the general pedi- Jacquet erosive diaper dermatitis because of overlap- atric population has dramatically declined since the ping clinical appearance. Typically, perianal pseu- advent of modern disposable diapers, but occasional doverrucous papules and nodules, in contrast with reports of its occurrence in older children and adults Jacquet erosive diaper dermatitis, are characterized still exist.2,4,5,7 Some researchers believe that Jacquet by an erythematous perianal plaque comprising erosive diaper dermatitis exclusively affects patients multiple small, shiny, flattop, round, smooth, red, with chronic urinary and/or fecal incontinence.7,8 moist papules and nodules, though clinical overlap Multiple elements contribute to the pathogen- is common.9 Lesions associated with urostomies esis of Jacquet erosive diaper dermatitis. Persistent have been noted to have a wartlike appearance.10 occlusion, maceration, friction, irritant agents such Microscopically, one may see spongiosis and epi- as urine and stool, and bacterial colonization may dermal acanthosis, but notably, perianal pseudover- be contributing factors.2 Prolonged contact with rucous papules and nodules lack a dense dermal urine under occlusion compromises skin integrity inflammatory infiltrate.8,10 By contrast, granuloma and renders it more permeable to irritants, the most gluteale infantum/adultorum classically presents as potent being pancreatic proteases and lipases pres- large, firm, reddish purple nodules and plaques on ent in feces.1 Urea-splitting bacteria in feces release the medial aspects of the thighs, pubic area, scro- ammonia, creating an elevated pH environment tum, and buttocks. These lesions are granulomatous that increases fecal enzyme activity. Lipase activity in clinical appearance but histologically do not also is potentiated by the presence of bile salts. Fric- demonstrate multinucleated giant cells or other tion generated from the diaper during movement features of well-developed granulomas. Granuloma causes further mechanical damage to macerated gluteale infantum/adultorum is distinguished from skin.1,3,5,6 Ammonia applied to intact skin does not perianal pseudoverrucous papules and nodules and produce erythema, but it does inflame already trau- Jacquet erosive diaper dermatitis by the distribution matized skin.1 pattern that overlies the convex parts of the gluteal Other diagnoses to consider in the setting of region and the presence of a dense mixed dermal an erosive papulonodular eruption of the perineal inflammatory infiltrate.8,10 Granuloma gluteale region should include secondary syphilis, condyloma infantum/adultorum usually affects a younger patient VOLUME 82, JULY 2008 73 Jacquet Erosive Diaper Dermatitis population, in contrast to Jacquet erosive diaper features of all 3 conditions have been reported, and dermatitis, which has been described in adult and some groups have suggested combining the terms pediatric populations.2,4,8 Unlike perianal pseudover- as severe diaper dermatitis or erosive papulonodular rucous papules and nodules and Jacquet erosive dermatosis to minimize confusion.5,10 If these diseases diaper dermatitis, granuloma gluteale infantum/ truly represent a clinical spectrum, there is a high adultorum is not limited to patients with inconti- likelihood of Candida exacerbating Jacquet erosive nence. Halogenated topical steroids, candidal infec- diaper dermatitis, as the existing literature already tion, powders, plastic pants, and the presence of a supports its role in the exacerbation of granuloma primary irritant dermatitis have all been implicated gluteale infantum.8,10 as potential etiologic factors.8,10 Regardless of the final classification, manage- REFERENCES ment of incontinence most effectively brings about 1. Atheeton DJ. The neonate. In: Rook A, Wilkinson DS, resolution of Jacquet erosive diaper dermatitis. Bar- Ebling FJG, eds. Textbook of Dermatology. London, rier agents such as zinc oxide ointment, white petro- England; Blackwell Scientific; 1998:468-472. latum, and sucralfate are useful adjuncts to protect 2. Virgili A, Corazza M, Califano A. Diaper dermatitis in an the skin from irritants and moisture. Antifungal adult: a case of erythema papuloerosive of Sevestre and creams and oral antibiotics may be beneficial for sus- Jacquet. J Reprod Med. 1998;43:949-951. pected or proven superinfection. If hygiene is main- 3. Rodríguez Cano L, García-Patos Briones V, Pedragosa tained and the skin is kept clean and dry, relapses Jové R, et al. Perianal pseudoverrucous papules and are uncommon.1,2,6 nodules after surgery for Hirschsprung disease. J Pediatr. In our patient, we support the diagnosis of 1994;125(6, pt 1):914-916. Jacquet erosive diaper dermatitis with superim- 4. Hara M, Watanabe M, Tagami H. Jacquet erosive diaper
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