www.asianpedderm.com a publication of ASIAN JOURNAL OF PEDIATRIC DERMATOLOGY AJPD Vol. 4/2021 !! !

DiaperDiaper DermatitisDermatitis :: A Narrative ReviewReview

Introduction Case Report Discussion Reference Acknowledgements a publication of the ASIAN JOURNAL OF PEDIATRIC DERMATOLOGY

AJPD Vol. 4/2021 Diaper : A Narrative Review

Ankur Sarin1, Jushya Bhatia2, Rashmi Sarkar1 1Lady Hardinge Medical College and ASS Hospitals, India, 2Sarin Skin Solutions, India

INTRODUCTION Diaper rash (diaper rash, napkin dermatitis or nappy rash) is a common skin CORRESPONDING AUTHOR eruption in infants and toddlers. Diaper rash is a term loosely applied to many Prof. Dr. Rashmi Sarkar Lady Hardinge Medical College and different dermatoses in the diaper area of the infant. The most common cause of ASS Hospitals, Department of diaper rash is irritant due to prolonged contact with soiled diaper. Dermatology and STD, New Delhi, Some diffuse skin diseases that may present with diaper rash are seborrheic India Email: [email protected] dermatitis, , psoriasis vulgaris and like candidiasis, scabies, bullous impetigo, tinea cruris. Rare causes include langerhans cell histocytosis, congenital syphilis, child abuse, acrodermatitis enteropathica. The difference in management makes it imperative to correctly diagnose the cause of diaper rash.

CASE REPORT

EPIDEMIOLOGY Figure 2: Intense with mild scaling in a case of irritant diaper The reported incidence of diaper dermatitis varies worldwide, as dermatitis there is difference in practices such as diaper use, toilet training and hygiene, in different countries. [1-5] In infants, the estimated prevalence of diaper dermatitis ranges from 7 to over 40 percent. [2,6,7] Diaper dermatitis peak incidence is between 9-12 months of age but can develop as early as one week of age.

Etiology Inflammatory Irritant Contact Dermatitis (ICD) Irritant diaper dermatitis involves the convex part of the skin that is in direct contact with the diaper, these locations include the buttocks, lower abdomen, genitalia, and upper thighs. The skin folds are classically spared, as they are not in direct contact with the diaper. (Figure 1) Friction causing erythema and scaling at the margins of the diaper is referred to as "Tidewater dermatitis”. Mild diaper rash may present with mild erythema, scattered erythematous papules and itching. Severe forms may present with extensive Jacquet's Erosive Diaper Dermatitis erythema with maceration and erosions. (Figure 2) In extreme cases Jacquet's erosive diaper dermatitis isa type of ICD presents with there may be glossy appearance with formation of nodules. nodules, and punched-out ulcerations in the perianal area. (Figure 3)

Figure 1: Mild erythema and scaling with sparing of the skin fold are Figure 3: Well-demarcated nodules with superficial ulcerations in an infant with characteristics of irritant diaper dermatitis Jacquet’s erosive diaper dermatitis

AJPD Vol. 4/2021 Page 2

Granuloma Guteale Infantum Scabies Granuloma gluteale occurs after application of high potency topical Scabies is a common cause of diaper rash in infants where there is corticosteroids on pre-existing candidal . [8,9] It is overcrowding. An acute, widespread dermatitis with intense pruritus characterised by reddish-purple nodules in the inguinal folds, is the most common manifestation. Scabies presents with a widespread scrotum, buttocks, and medial thighs and is usually seen between vesiculopapular eruption involving the trunk, axillae, and neck. Palms two and nine months of age. [8,10] and soles are involved more frequently in children. Nocturnal itching and the presence of similar symptoms in the family members are Pseudoverrucous Papules and Nodules highly indicative of scabies.Diagnosis is confirmed by identifying a They have been reported in the patients with urostomy and children mite, egg, or mite stool (Scybala) on microscopic examination of a and adults suffering from incontinence. It presents as multiple scraping from a lesion. shiny, white and grey, papules and nodules on an erythematous background located in the genital area. [11] Congenital Syphilis It presents as copper-colored, scaly macules and papules or moist Sequale erosions around the mouth and nose. In the perianal region moist Irritant dermatitis resolves with treatment within a few days papules also called condyloma lata may be seen. These lesions contain however if left untreated it may become secondarily infected with spirochetes and are highly infectious. Symmetric desquamation of the microorganisms such as C. albicans S. aureus, S. pyogenes, or palms and soles, anemia, hepatosplenomegaly, jaundice, and changes herpes simplex virus. of the long bones may be seen. The diagnosis can be confirmed with serology or dark field microscopy. Seborrheic Dermatitis Seborrheic dermatitis is common in infants from about 3 weeks of Nutritional age; it is uncommon after 6 months. Clinical features include Acrodermatitis Enteropathica (Zinc Deficiency) erythematous papules and plaques with greasy yellow scale Acrodermatitis enteropathica is a recessively inherited partial defect typically involving the skin folds.Seborrheic dermatitis often in intestinal zinc absorption. It is the result of mutations in the involves other area like scalp, face, neck and other body SLC39A4 gene, which encodes a protein that appears to be involved in folds.Seborrheic dermatitis usually responds to short-term topical zinc transport. [12,13] therapy with low-potency corticosteroids and/or topical antifungal preparations. Affected infants develop an erythematous and vesiculobullous dermatitis, alopecia, diarrhea, ophthalmic disorders (including corneal Allergic Contact Dermatitis scarring, cataract formation, retinal degeneration, and optic Warm and moist environment in the skin folds catalyses the release [14]), severe growth retardation, delayed sexual maturation, of allergens and their subsequent absorption in the skin thereby neuropsychiatric manifestations, and frequent infections. The causing Allergic contact dermatitis (ACD). Allergic contact syndrome is associated with severe zinc depletion and responds to oral dermatitis can occur in the diaper region due to diaper dyes and supplementation with pharmacologic doses of zinc. fragrances. Preservatives, fragrances, and additives in baby wipes and topical creams may also trigger allergic response. Miscellaneous Langerhans Cell Histiocytosis Psoriasis The cutaneous lesions present as red or yellow to brown scaly papules, Psoriasis can present with sharply demarcated erythematous scaly erosions or petechiae in groin, intertriginous regions and scalp. It may papules and plaques. Scales may be decreased due to presence of resemble seborrheic dermatitis. Langerhans cell histiocytosis (LCH) moisture. There may be a family history of psoriasis. is a potentially life-threatening hematologic/oncologic disorder. LCH can resemble seborrheic dermatitis; however, the color of the lesions Infectious and presence of petechiae and erosions helps to differentiate between Candidiasis/Candidal Infection the two. In addition to the cutaneous findings, patients with LCH also Candida often causes diaper rash and can be superimposed on may have bone lesions, lymphadenopathy, hepatosplenomegaly, and irritant diaper dermatitis. It presents with red plaques, satellite and anemia. Skin biopsy is necessary to confirm the diagnosis. superficial pustules that leave a collarette of scale once ruptured. (Figure 4) Candidal infection typically involves skin folds, which Child Abuse are spared in Irritant contact dermatitis (ICD). There also may be a It should be considered if the rash is severe, recalcitrant or atypical. history of diarrhea, recent antibiotic use, or oral thrush. Diagnosis The diaper area also is a possible site for scalds, burns, and bruises in usually is based on the clinical presentation, but may be confirmed abused children. Although infection with the human papilloma virus by potassium hydroxide (KOH) preparation demonstrating (condyloma acuminatum or genital warts) in the groin region can be pseudohyphae or or by growth of fungal elements on a culture acquired perinatally from an infected mother, sexual abuse also should medium. Persistent candidal diaper rash in young children may be be considered and addressed as a possible underlying cause. a sign of type 1 diabetes mellitus, chronic mucocutaneous candidiasis, or an underlying immune deficiency. Diagnosis History and thorough physical examination is sufficient to ascertain the cause of diaper rash in most cases. If the rash involves the area in contact with the diaper and spares the folds it indicates ICD. This is

commonly accompanied with candidal infection which should be suspected when there are typical erythematous satellite lesions. Yellow greasy scales with involvement of other seborrheic sites Figure 4 – Diaper indicate seborrheic dermatitis. Such a rash will present with greasy dermatitis with superimposed scales, most commonly in the skin folds. candidiasis. Satellite lesions are typically present at the periphery of the involved area

AJPD Vol. 4/2021 Page 3

DISCUSSION Harmful Products Use of powders such as cornstarch or talcum powder pose a significant MANAGEMENT respiratory risk if accidentally aspirated and therefore should be General Skin Care avoided. [20,21] Baking soda and boric acid powders also should be Frequent diaper changing decreases the exposure to stool and urine. avoided because of the risk of systemic toxicity with percutaneous Few hours of air exposure also helps in keeping the area dry. Gentle absorption. [13,20,22,23] cleansing with warm water and mild pH balanced cleanser should be done. Fragrance-free and alcohol free baby wipes should be used Topical barriers or medications that contain fragrance, preservatives, though methylisothiazolinone is a common cause of allergic contact and other ingredients with irritant or allergic potential (eg, neomycin) dermatitis in baby wipes. should be avoided. [28] Products containing boric acid, camphor, phenol, benzocaine, and salicylates also should be avoided because of Choice of Diaper the potential for systemic toxicity and/or methemoglobinemia. A systematic review of studies that evaluated whether disposable [13,24,25,22,26-29] Some commercially available products contain diapers decrease the incidence of diaper dermatitis concluded that these chemicals for diaper dermatitis. there was not enough evidence that disposable diapers will prevent diaper dermatitis. Thus, the best choice of diapers remains a Refractory Diaper Dermatitis controversial issue. Recalcitrant diaper rash that does not resolve with standard treatment should make us suspect of non-diaper-associated causes of rash like Use of Barrier Preparations Langerhans cell histiocytosis, infections, nutritional deficiencies, and These creams or ointments physically protect the skin from child abuse or neglect are particularly important to remember. chemical irritation and decrease friction. The most common topical barriers contain petrolatum, zinc oxide, lanolin, paraffin, or Persistent candidal diaper rash in young children may be a sign of type dimethicone. 1 diabetes mellitus, chronic mucocutaneous candidiasis, or an underlying immune deficiency. Topical Corticosteroids Use of fluorinated corticosteroids are best avoided as they cause Seborrheic Dermatitis in the diaper area responds well to bathing systemic absorption and may cause adrenal suppression and unsoothing oatmeal baths followed by application of low potent iatrogenic cushing syndrome. A low-potency topical corticosteroid steroids. is preferred if even after the use of barrier preparations the diaper dermatitis persists. Topical steroids and/or calcineurin inhibitors are also useful in rash due to seborrheic dermatitis, psoriasis, ACD. REFERENCE 1. Levy M. Diaper rash syndrome or dermatitis. Cutis Topical Antibacterial Agents 2001;67(suppl):37-8. Topical mupirocin or fusidic acid are effective for gram positive 2. Ward DB, Fleischer AB Jr, Feldman SR, Krowchuk DP. bacterial infections including bullous impetigo and perianal Characterization of diaper dermatitis in the United States. Arch streptococcal infection. Pediatr Adolesc Med 2000;154(9):943-6. 3. Scheinfeld N. Diaper dermatitis: a review and brief survey of Antifungal Agents eruptions of the diaper area. Am J Clin Dermatol 2005;6(5):273- Antifungal agents should be used when irritant dermatitis is 81. complicated by candidal infection. Nystatin, clotrimazole, 4. Thaman LA, Eichenfield LF. Diapering habits: a global ketoconazole are effective topical therapies for diaper dermatitis perspective. Pediatr Dermatol 2014; 31(suppl 1):15-8. complicated by secondary Candida infection. [15-18] Potential 5. Coughlin CC, Eichenfield LF, Frieden IJ. Diaper dermatitis: adverse effects of antifungals include irritation, burning, and clinical characteristics and differential diagnosis. Pediatr itching. Dermatol 2014;31 (Suppl 1):19-24. 6. Li CH, Zhu ZH, Dai YH. Diaper dermatitis: a survey of risk Treatment of Scabies factors for children aged 1-24 months in China. J Int Med Res Diaper rash due to scabies can be treated with application of topical 2012;40(5):1752-60. sulfur for infants less than 2 months. Permethrin is safe and highly 7. Sukhneewat C, Chaiyarit J, Techasatian L. Diaper dermatitis: a efficacious for children above 2 months. Lindane should be avoided survey of risk factors in Thai children aged under 24 months. due to risk of systemic toxicity. Low potency steroid cream with BMC Dermatol 2019;19(1):7. oral anti-histaminic agents may help in symptomatic improvement. 8. Ramos Pinheiro R, Matos-Pires E, Baptista J, Lencastre A. Granuloma Glutaeale Infantum: A Re-emerging Complication of Acrodermatitis Enteropathica Diaper Dermatitis. Pediatrics 2018;141(2) :e20162064. Elemental Zinc 3mg/kg/day should be supplemented. Zinc levels 9. https://pediatrics.aappublications.org/content/141/2/e20162064 should be measured every 3-6 months and dose should be adjusted 10. Dytoc MT, Fiorillo L, Liao J, Krol AL. Granuloma gluteale accordingly. adultorum associated with use of topical benzocaine preparations: case report and literature review. J Cutan Med Surg Langerhans Cell Histiocytosis 2002;6(3):221-5. Treatment depends on organ involvement. For skin-only LCH oral 11. Bluestein J, Furner BB, Phillips D. Granuloma gluteale infantum: methotrexte, 6 mercapto-purine or hydroxyurea are used. case report and review of the literature. Pediatr Dermatol 1990;7(3):196-8. Child Abuse 12. Garrido-Ruiz MC, Rosales B, Luis Rodríguez-Peralto J. Vulvar Clinicians must know and abide by mandatory reporting as pseudoverrucous papules and nodules secondary to a urethral-- perjurisdiction where they practice. Appropriate medical care vaginal fistula. Am J Dermatopathol 2011;33(4):410-2. according to symptoms and support should be provided. 13. Ali SM, Yosipovitch G. Skin pH: from basic science to basic skin care. Acta Derm Venereol 2013;93(3):261-7. Congenital Syphilis 14. Boiko S. Treatment of diaper dermatitis. Dermatol Clin 1999; Penicillin G benzathine is the preferred treatment. 17(1):235-40.

AJPD Vol. 4/2021 Page 4

15. Higuchi R, Mizukoshi M, Koyama H, Kitano N, Koike M. 21. Shin HT. Diaper dermatitis that does not quit. Dermatol Ther Intractable diaper dermatitis as an early sign of biotin 2005; 18(2):124-35. deficiency. Acta Paediatr 1998;87(2):228-9. 22. Silver P, Sagy M, Rubin L. Respiratory failure from corn starch 16. Spraker MK, Gisoldi EM, Siegfried EC, et al. Topical aspiration: a hazard of diaper changing. Pediatr Emerg Care miconazole nitrate ointment in the treatment of diaper 1996; 12(2):108-10. dermatitis complicated by candidiasis. Cutis 2006; 77(2):113- 23. Deadly diapers. Br Med J 1970; 2:314. 20. 24. Gonzalez J, Hogg RJ. Metabolic alkalosis secondary to baking 17. Eichenfield LF, Bogen ML. Absorption and efficacy of soda treatment of a diaper rash. Pediatrics 1981; 67(6):820- miconazole nitrate 0.25% ointment in infants with diaper 22. dermatitis. J Drugs Dermatol 2007; 6(5):522-6. 25. Humphrey S, Bergman JN, Au S. Practical management 18. Bonifaz A, Tirado-Sánchez A, Graniel MJ, Mena C, Valencia strategies for diaper dermatitis. Skin Therapy Lett 2006; A, Ponce-Olivera RM. The efficacy and safety of sertaconazole 11(7):1-6. cream (2 %) in diaper dermatitis candidiasis. Mycopathologia 26. Kokx NP, Comstock JA, Facklam RR. Streptococcal perianal 2013; 175(3-4):249-54. disease in children. Pediatrics 1987(5); 80:659-63. 19. Concannon P, Gisoldi E, Phillips S, Grossman R. Diaper 27. Farrington E. Diaper dermatitis. Pediatr Nurs 1992; 18(1):81- dermatitis: a therapeutic dilemma. Results of a double-blind 2. placebo controlled trial of miconazole nitrate 0.25%. Pediatr 28. Morra P, Bartle WR, Walker SE, Lee SN, Bowles SK, Reeves Dermatol 2001;18(2):149-55. RA. Serum concentrations of salicylic acid following topically 20. Taudorf EH, Jemec GBE, Hay RJ, Saunte DML. Cutaneous applied salicylate derivatives. Ann Pharmacother candidiasis - an evidence-based review of topical and systemic 1996;30(9):935-40. treatments to inform clinical practice. J Eur Acad Dermatol 29. Jensen JP. [Transcutaneous absorption of boron from a baby Venereol 2019; 33(10):1863-73. ointment used prophylactically against diaper dermatitis]. Nord Med 1971; 86:1425-9.

ACKNOWLEDGEMENTS Author Contributions

Dr(s) Ankur Sarin, Jushya Bhatia and Rashmi Sarkar had full access to all of the data in the study and take responsibility of the integrity of the data and the accuracy of the data analysis.

Obtained funding: None. Declaration of Conflict of Interest: None.

Financial Disclosure: None reported

All Financial Interests (including pharmaceutical and device product(s): None.