Lisa Merrill for Diaper Prevention, Treatment and Treatment CNE Parent Education 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 . Although this condition is relatively common, it can cause considerable and for 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 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 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 , 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 | newborn ence to: [email protected]. Opening photo © Comstock / istockphotos.com Images

326 © 2015, AWHONN http://nwh.awhonn.org CNE http://JournalsCNE.awhonn.org a- 327 eld, cally cally e pres- e rst week of life, life, of week rst ed as a major irritant on on irritant ed as a major Nursing for Women’s Health Women’s Nursing for bar- functional a fully of e presence enzymes, specifi fecal of e presence cally the epidermal barrier in the stratum cor- cally the barrier epidermal in the stratum of lead overhydration urine to can of e presence irrita- to is predisposed area in the e skin diaper in- to urine both has shown and stool of e presence Diaper dermatitis is found equally Diaper dermatitis as among infants of all ethnic groups as among infants layer the outer of the acidic properties of e development among male and female infants as well among male and Th ammation and the start of the repair cascade (Odio & Th the repair the start of and ammation is mul- dermatitis diaper contact irritant of e development PATHOPHYSIOLOGY OF PATHOPHYSIOLOGY DIAPER DERMATITIS Th Th tifactorial. corneum the stratum of maceration or overhydration by tion stool, as urine such or irritants, of the epidermis, presence and a high skin pH (Ather- of the presence thefriction skin and on 2001). Th ton, increasing fragile and the skin surfacethe skin, making more 2001; Shin, (Atherton, irritants the skin by of the permeability 2014). Th models the (Berg, skin in animal thecrease pH of Buckingham, 1986). Th & Stewart, protease and lipase, has been lipase, and identifi protease enzyme fecal of the increase damage the salts skin, while bile & Berg, 1986). Th (Buckingham the skin itself on action of in the integrity a disruption cause can these factors ence of the skin, specifi in resulting the skin barrier, of a breakdown to neus, leading infl is underway, process the repair 2014; see 1). As man, Figure of the skin, or the acid mantle, is important for both barrier for important is the acid mantle, the or skin, of the In skin. of defense antimicrobial function and permeability birth, following environment thedry to extrauterine adaptation devel- acidic, the mantle acid becomes skin more a newborn’s et (Fluhr becomes hydrated less corneum the stratum and ops surface skin pH has birth, a full-term newborn’s 2012). At al., alkaline than is more 7.08, which measure been to reported Maayan- 5.7 (Yosipovitch, has a pH closer skin, which to adult the 2000). During fi & Sirota, Merlob, Metzger, the pH of newborn skin has been shown to decline rapidly and and newbornthe pH of rapidly decline skin has been to shown an of that a pH close to resemble like, of week the fourth by 2002). & Enzmann, 5.5 (Hoeger 5 to a pH ranging with adult, corneum stratum hydrated several a fully weeks, Following skin a newborn’s the pH of 2012) and et al., (Fluhr develops Eichenfi McLeod, (Horowitz, adult an of that approaches & Elias, 2013). Th Fowler, approaching acid mantle an and corneum rier in the stratum irri- from the infant the skin of protect helps adult an of that dermatitis. diaper cause can that microbes and tants er bers. In an an bers. In eld & Hard- infants er birth for in skin between erences epidermis e dermis and e epidermal barrier is a cant issues such as dehydration, ther- as dehydration, issues such cant bers are shorter and less dense and the less dense and and shorter bers are fi e collagen ciency in the stratum corneum, premature infants are are infants premature corneum, ciency in the stratum the to especially sensitive infants premature is makes September 2015 of that than is less developed infants premature e skin of contains beneath the epidermal e dermis, layer, found In utero, the maturation of the epidermal barrier the of skin of the maturation utero, In Th Th ective in premature infants than in adults or full-term in- or in adults than infants in premature ective August occurs as gestational age increases. Although it was once be- was once it increases. Although age occurs as gestational Nonato, bar- competent a fully with born are (Kalia, full-term infants that lieved adult an of that to compared been has that rier full matura- that has shown research 1998), recent & Guy, Lund, aft until be complete not might corneum the stratum of tion adults, full-term infants and premature infants. is Human infants. premature and full-term infants adults, prevents thermoregulation, with assists tissue that a complex as loss, acts functions as a sensory and water insensible organ chemical and physical, from protection providing a barrier by stratum layers—the major three of consists It threats. biologic dermis. Th and epidermis corneum, cor- the stratum of epidermal layers function the outermost of is the It the environment. with contact is in direct neum and agents. outside by permeation loss and water barrier to main 2008). & Wiegand, Kollias, Stamatas, (Nikolovski, age of a year PHYSIOLOGY OF INFANT SKIN OF INFANT PHYSIOLOGY in- in an dermatitis diaper of the development understand To the diff appreciate to is important it fant, (Humphrey, Bergman, & Au, 2006; Wolf, Wolf, Tuzun, & Tuzun, Tuzun, & Tuzun, Wolf, 2006; Wolf, Bergman,Au, & (Humphrey, is the common most dermatitis contact irritant Although 2000). be should conditions underlying diagnosis of alternate cause, der- diaper for to treatment in cases response where considered 2011). & Mancini, (Paller nonexistent or is slow matitis mal instability and electrolyte imbalances (Eichenfi imbalances electrolyte and mal instability and increased risk of an have may these infants fants, the on substances of absorption topical due toxicity systemic full barrier that has been demonstrated 2004). It skin (Mancini, aft 4 weeks between 2 and function develops full-term infants and lacks the fully functional barrier proper- functional the fully lacks and full-term infants ages gestational decreasing With corneum. the stratum ties of a defi and loss (TEWL), increased transepidermal water have to known lead signifi to can which less is thinner and corneum 1999). Because the stratum away, eff gestations, earlier for However, 32 weeks. born between 30 and 9 8 or until take can the barrier function of full maturation et al., (Kalia ≤25 weeks postbirth,weeks especially in gestations 1998). Th dermatitis. diaper of development connective tissue, hair follicles, sebaceous glands, sweat glands, glands, sweat glands, sebaceous follicles, hair tissue, connective vessels. Th blood lymphatic vessels and fi collagen of a matrix with together anchored are cohesion and adhesion properties of the epidermal cells are not not the epidermal cells of are properties adhesion and cohesion is makes epidermal-dermalthe junction fully developed. Th skin. in adult found that to compared weaker infant, the dermis is thinner and less developed than that in the dermis less developed that is thinner than and infant, an adult. Th and with the presence of the conditions noted above, diaper contact diaper dermatitis can range in severity from a mild case, dermatitis develops (Odio & Th aman, 2014). As the repair pro- with mild localized and minimal scaling, to a moder- cess continues, the epidermis remains compromised until ir- ate case, with increased erythema as well as noted to the ritation begins to subside aft er a few days and gradually skin aff ected area, and fi nally to a more severe case where the skin in health is restored (Odio & Th aman, 2014). the diaper area is noted to have papules, pustules and skin break- down with open areas (Stamatas & Tierney, 2014; see Figure 2). CLINICAL PRESENTATION Diaper dermatitis complicated with the presence of Can- Chaffi ng or frictional dermatitis is the most widespread form dida albicans presents as a beefy, red, raised-edge skin rash of mild diaper dermatitis commonly aff ecting most infants at with pinpoint satellite lesions, which oft en extend into the folds some point in time. It presents in areas where friction from of the skin in the diaper area (Humphrey et al., 2006). Th e af- the diaper is most prevalent, including the inner surface of the fected area can also have areas of open or weepy skin. When- , , abdomen, and the surface of the genital areas ever diaper dermatitis fails to respond to treatment, candida (Paller & Mancini, 2011). It presents as mild redness in the af- diaper dermatitis should be considered as an alternate cause of fected area and resolves fairly quickly on its own with frequent the presenting rash (Nield & Kamat, 2007). Because C. albicans diaper changes, ensuring the diaper is not too tight, and with is contained in the lower intestine of infants, fecal matter pre- good diaper hygiene (Paller & Mancini, 2011). sents the primary source for candidal diaper dermatitis (Paller Irritant contact diaper dermatitis, the most common cause & Mancini, 2011). In some instances, in addition to candidal of diaper dermatitis, is commonly found in the gluteal crease, diaper dermatitis, oral candidiasis (thrush) may be present buttocks, perianal and the pubic areas. It can also include the (Paller & Mancini, 2011) and an infant might require treatment lower abdominal area as well as the upper area. Irritant with an oral antifungal agent.

FIGURE 1 DIAPER DERMATITIS CASCADE

Source: Odio and Thaman (2014). © 2014 Wiley Periodicals, Inc. Reprinted with permission.

328 Nursing for Women’s Health Volume 19 Issue 4 CNE http://JournalsCNE.awhonn.org 329 eren- eld, & eld, erential ammatory is condition condition is ect of the diaper (Paller (Paller the diaper ect of require may is condition on resolves e rash typically Nursing for Women’s Health Women’s Nursing for ected area to air. also his- be a family may there and ected as well the appearance of the rash and the appearance of the rash and Diaper dermatitis is diagnosed by Diaper dermatitis is diagnosed by excluding other potential causes by excluding other potential in the diaper area presents as symmetric, sharply as symmetric, sharply presents area in the diaper Psoriasis an to due in infants, is rare dermatitis contact Allergic presents as a bright red erythema red as a bright located usually presents Intertrigo ects the inguinal folds. Other areas of the body, such as the such the body, of Other areas ects folds. the inguinal in- as an present can that conditions of a wide variety are ere amed area of skin in the diaper area. A wider range of diff of A wider range area. skin in the diaper of area amed demarcated lesions with bright erythema that do not have the erythema bright have with do not lesions that demarcated eff the hydrating to scaling due typical usually 2014). It 2012; Shin, et al., 2011; Ravanfar & Mancini, aff aff be can , 2014). Th (Shin, thetory condition of as prescribed topical a low-dose with treatment provider. a health care by (Humphrey et al., 2006). Infant diet has been found to be an im- be to an has been diet found 2006). Infant et al., (Humphrey derma- diaper of the development in preventing factor portant the decrease presence to has been shown as titis a lower have infants breastfed of e stools Th dermatitis. diaper of for the potential decreasing thus infants, formula-fed pH than (Berg, 1987). area the skin in the diaper of INFLAMMATORY CONDITIONS INFLAMMATORY in in- dermatitis of cause is a common Seborrheic dermatitis It life. fourth of week to the third around develops fancythat ned erythema,char- with well-defi as asymptomatic, presents scales yellow with plaques greasy salmon-colored, acteristic areas diaper body and chest, creases cheeks, the scalp, on found 2014). Th 2012; Shin, & Pace, Wallace, (Ravanfar, DIFFERENTIAL DIAGNOSES DIFFERENTIAL Th fl failstial dermatitis when diagnoses diaper be should considered ad- are when there or approaches basic treatment to respond to Diff further investigation. require that symptoms ditional infl including categories, be into diagnoses can divided diagnoses. potential other and conditions, infectious conditions, as corticosteroid topical low-dose with treatment require may (Coughlin, Eichenfi provider a healthprescribed care by 2014). Frieden, a by is caused It skin folds. opposing or creases in the inguinal 2014) (Shin, retention sweat and moisture heat, of combination over- is infant an when or weather hot during seen commonly 2011). Th & Mancini, dressed (Paller exposing the aff by own its TING THE RANGE OF SEVERITY OF RANGE OF SEVERITY TING THE September 2015 DIAPER DERMATITIS: (A) SLIGHT, (B) MILD, (B) MILD, (A) SLIGHT, DIAPER DERMATITIS: TO SEVERE, MODERATE (D) (C) MODERATE, (E) SEVERE (E) (D) Source: Stamatas and Tierney (2014). © 2014 Wiley Periodicals, Inc. Reprinted with permission. (C) (B) (A) VISUAL DIGITAL IMAGES DEM- IMAGES 2 VISUAL DIGITAL FIGURE ONSTRA August ASSESSMENT the rash of the appearance is diagnosed by dermatitis Diaper a physi- to addition In causes. potential other excluding by and including be history obtained, must a thorough cal assessment, other to infant and pain as such rash, symptoms, the presenting of an duration predispose dia- type of routine, cleansing and practices hygiene itchiness, might that use the skin and to trauma irritants, potential per to used, exposure recent 2014). Other 2014; Shin, (Lawton, dermatitis diaper of causes defe- and the frequency urination include of to consider factors and medications the skin, diet, other to applied products cation, 2014; 2014; Shin, illnesses (Lawton, gastrointestinal recent any medical conditions other note to is also important see Box 1). It as potential incontinence fecal or stools frequent cause can that as dermatitis, diaper irritant of the development for risk factors enzymes fecal the skin with of contact frequent or prolonged the condition of the development hasten or aggravate can health care provider is necessary. A sample should be taken for BOX 1 FACTORS TO CONSIDER WHEN culture and gram stain to identify the and determine ASSESSING FOR DIAPER DERMATITIS antibiotic sensitivities (Shin, 2014). Viral , such as herpes simplex (HSV), which Duration of the rash appear as grouped vesicles or erosions that can crust over, or varicella zoster infections, which appear as vesicles in the cent- Symptoms (pain and ) er of a , can present in the diaper area of an infant (Shin, Hygiene practices and cleansing routine (frequency 2014). Because of the potential seriousness of the infection, of diaper changes, type of cleanser, washcloths or HSV infections should always be considered as a diff erential wipes, exposure to irritants, such as perfumes and diagnosis when an infant presents with skin sloughing, vesi- dyes) cles or (Ravanfar et al., 2012). When a viral infection Type of diaper used (cloth or disposable) is suspected, a culture might be necessary to confi rm the fi nd- Trauma to the skin (friction from the diaper; a vigor- ings and provide direction for appropriate treatment. A herpes ous cleansing) infection in a newborn younger than 4 weeks of age can cause Recent antibiotic use or other medications severe complications; therefore, additional testing including a blood culture and lumbar puncture may be required along with Frequency of urination and defecation (frequency, intravenous antiviral treatment (Shin, 2014). consistency) , a skin infestation by the Sarcoptes scabei, can Products applied to the skin (barrier creams, pow- present in the diaper area as well as in other areas of the body. ders, home remedies) Th e mite burrows under the skin, creating extremely itchy ery- Diet (formula vs. breastfed, introduction of new thematous burrows as well as infl amed papules and nodules foods and diet) that can become crusted over (Ravanfar et al., 2012; Shin, 2014). Recent gastrointestinal illnesses Aff ected areas can include the fi nger webs, toe webs, , an- kles, palms, soles, and diaper area. Th e recommended topi- Sources: Lawton (2014) and Shin (2014). cal treatment of scabies for infants younger than 2 months of age is 7 percent precipitated compounded in petrolatum. For infants older than 2 months, the recommended treatment infant’s immature immune system; however, it should be con- is permethrin 5 percent (Albakri & Goldman, 2010). sidered as a diff erential diagnosis if dermatitis persists despite treatment. Allergic contact dermatitis can develop from dyes, OTHER DIFFERENTIAL DIAGNOSES elastic found in diapers, perfumes or other preservatives found Nutritional defi ciencies, such as zinc defi ciency, can present in diapers or skin care products (Ravanfar et al., 2012). Local- similarly to diaper dermatitis. enteropathica, an ized dermatitis that is persistent in areas, such as the thighs or autosomal recessive condition that leads to zinc malabsorption, hips, where the skin is in frequent contact with elastic, dyes presents as sharply demarcated, erythematous plaques, papules or perfumes, may be indicative of allergic contact dermatitis and erosion in the periorifi cial areas, on distal portions of the ex- (Shin, 2014). Th is condition usually subsides with the removal tremities and in the diaper area (Coughlin et al., 2014; Ravanfar of the , by changing to dye-free diapers or with the use et al., 2012; Shin, 2014). Dermatitis, alopecia and diarrhea are the of a low-dose topical corticosteroid as prescribed by a health classic symptoms of this disease. Acquired acrodermatitis entero- care provider when necessary. pathica occurs when there are insuffi cient amounts of zinc in the diet due to malnutrition, intestinal malabsorption syndromes, INFECTIOUS CONDITIONS insuffi cient zinc in or during treatment with long- Bacterial infections can present in a variety of forms, including term parenteral nutrition without proper zinc supplementation and bacterial folliculitis. Streptococcal and staphylo- (Tabanlioglu, Ersoy-Evans, & Karaduman, 2009). Treatment for coccal infections account for the highest number of bacterial this condition is by supplementation with zinc in addition to the diaper dermatitis isolates (Brook, 1992). Impetigo, caused by usual strategies for treatment of diaper dermatitis. Th e condition staphylococcus or streptococcus infection, presents as super- will not resolve without improvement in zinc levels in the body. fi cial vesicles or fl accid bullae that eventually develop a honey histiocytosis is a rare disorder that presents colored crust (Scheinfeld, 2005; Shin, 2014). Bacterial folliculi- with erythematous papules, scale crusting, vesiculopustular tis, oft en caused by staphylococcus aureus, can manifest as red- and hemorrhagic papules that resemble petechiae in the diaper dened and infl amed pustules or papules at the base of the hair area (Coughlin et al., 2014; Shin, 2014). Th e disorder can also follicle (Shin, 2014). When a bacterial infection is suspected as have systemic involvement. Th e lesions may appear as reddish the cause of diaper dermatitis that does not resolve, a visit to a brown in color or purpuric (Paller & Mancini, 2011) and skin

330 Nursing for Women’s Health Volume 19 Issue 4 CNE http://JournalsCNE.awhonn.org 331 lm that prevents prevents lm that ectiveness of one prod- ective in the treatment treatment in the ective Nursing for Women’s Health Women’s Nursing for and prevent reoccurrence and prevent reoccurrence cult for families and practitioners (Humphrey (Humphrey practitioners and families cult for repair the damage to the skin repair the damage is prevention, once it develops, the is prevention, once Although the key to diaper dermatitis Although the key Barrier creams provide a protective lipid fi lipid a protective provide Barrier creams overall goal is to decrease infl ammation, to decrease infl overall goal is uct over another, making the selection of an appropriate bar- making the appropriate selection an of another, uct over diffi rier cream these compounds 2008). Regardless, et al., 2006; Rowe et al., prevent to measure as a protective been recommended have the further to against damage guard to and dermatitis diaper barrier prepa- has developed. Most dermatitis diaper skin once ingre- as their active petrolatum and contain rations be to been eff found which have dients, & Stellar, Storey, 2001; Heimall, (Atherton, dermatitis diaper of 2000). et al., 2006; Wolf et al., 2012; Noonan Davis, the while allowing stool, as urine such and irritants, to exposure Tierney, & healskin to (Stamatas underneath the is a lack of clear evidence to prove the eff evidence clear is a lack of to prove Barrier the backbone are compounds topical other and Barrier creams 1999; (Boiko, dermatitis diaper for treatment and prevention of in available are 2006). Several et al., barrier products Humphrey there however, dermatitis; diaper treat to market the consumer DIAPER Use a super absorbent diaper; avoid cloth diapers. Change diaper as soon as diaper is soiled, at least every 1 to 3 hours during the day and once during the night. EDUCATION Provide parents with targeted education for diaper hygiene and good skin practices. Sources: Lawton (2014) and Shin (2014). is is an the allows the diaper of e removal TITIS (“ABCDE”) TITIS (“ABCDE”) and prevention for techniques e basic be exposed as long should area for e diaper ective way to reduce the impact of irritants on on irritants of the impact reduce to way ective September 2015 PRACTICAL SOLUTIONS FOR THE PREVENTION AND TREATMENT PREVENTION AND TREATMENT BOX 2 PRACTICAL SOLUTIONS FOR THE OF DIAPER DERMA AIR Expose the diaper area frequently to air as much as possible; allow diaper-free time. BARRIER Apply barrier cream (zinc oxide or petrolatum) to diaper area for infants at risk of diaper dermatitis or whenever diaper dermatitis is present. CLEANSING Gently cleanse the diaper area with water and a soft cloth or a diaper wipe at every diaper change; avoid rubbing skin vigorously. August Air the time the surface reduces air to area Exposing the diaper and urine, moisture with feces, in contact the skin remains of 2014; & Wiss, Domingues, 1999; Klunk, (Boiko, irritants other 2014). Th & Tierney, Stamatas safe and effeasy, the infant. the skin of “ABCDE” APPROACH “ABCDE” and both prevention for solutions Practical nonpharmacologic approach the “ABCDE” into summarized easily are treatment education and diapering cleansing, barrier, air, includes that 1999; see Box 2). (Boiko, dry air skin to also the friction skin in contact decreases and on Th the diaper. with 2000). Th et al., 2004; Wolf & Skinner, as possible (Gupta treatment are quite similar (Atherton, 2001). Although the key the key 2001). Although (Atherton, similar quite are treatment the overall develops, it once is prevention, dermatitis to diaper to skin the damage the repair ammation, infl decrease is to goal 2014). 2004; Shin, reoccurrence (Atherton, prevent and NONPHARMACOLOGIC NONPHARMACOLOGIC AND TREATMENT PREVENTION best prac- current supports that literature of An abundance has dermatitis diaper of prevention and tices in the treatment evidence-based thebeen most recent including published, the As- from skin care neonatal on guideline practice clinical Nurses Neonatal and Obstetric Health, Women’s of sociation 2013). Th (AWHONN, can show signs of or deep ulcerations (Coughlin et al., deep ulcerations or atrophy of signs show can via skin biopsy. is made Diagnosis 2014). 2014). As both a preventive measure and as part of a treatment Diapering regime for diaper dermatitis, barrier cream should be applied at Th e development of improved disposable diaper technology each diaper change for infants at risk of developing diaper der- and advanced design features has greatly enhanced diaper ab- matitis (Noonan et al., 2006) and whenever diaper dermatitis is sorbency, keeping moisture away from the skin in the diaper present (Atherton, 2004). Barrier cream should be applied in a area (Counts, Helmes, Kenneally, & Otts, 2014). Although a Cochrane Review did not fi nd evidence to support or refute the use of disposable diapers in preventing diaper dermatitis (Baer, Baby powder or cornstarch is not Davies, & Easterbrook, 2006), more recent developments in recommended for use in the diaper area, disposable diaper technology, including superabsorbent cores, breathable outer layers and the addition of emollients to the as these substances promote the growth layers of the diaper in contact with infant skin surfaces, may of bacteria and candida help prevent diaper dermatitis (Atherton, 2001, 2004; Nield & Kamat, 2007; Odio & Th aman, 2014; Scheinfeld, 2005). As the technology of disposable diapers improves, some experts no longer recommend cloth diapers for infants with irritant thick coat to all areas of skin that might be exposed to harmful diaper dermatitis (Humphrey et al., 2006). Disposable diapers irritants and should not be wiped off completely during diaper are aimed at limiting contact with irritants, preventing over- changes (Taquino, 2000). Th e gentle removal of contaminated hydration of the skin, maintaining appropriate pH levels and stool that has adhered to the barrier cream is suffi cient before preventing a break in the skin barrier (Clark-Greuel, Helmes, applying the next layer of barrier cream. Lawrence, Odio, & White, 2014). Cleansing Baby powder or cornstarch is not recommended for use in the diaper area, as these substances promote the growth of bac- Over the last decade a variety of diaper wipes with diff erent teria and candida and can worsen diaper dermatitis when used additives have been developed as an alternative to traditional (AWHONN, 2013). As well, inhaled particles from powdered methods of water and washcloth for cleansing the diaper area. substances such as baby powder can lead to respiratory compli- A systematic review of the effi cacy of nonmedical skin care cations in an infant (Nield & Kamat, 2007). practices on the diaper area of full-term infants found that Frequent diaper changes help reduce the amount of time the wipes or water and washcloth had comparable eff ects on dia- skin is in contact with moisture and irritants, including fecal pered skin and barrier function but did not fi nd evidence that enzymes; therefore, diaper changes are recommended every 1 wipes are soft er or milder on the skin than water and wash- to 3 hours during the day or as soon as the diaper is soiled and cloths alone (Blume-Peytavi et al., 2014). Cleansing the skin of at least once per night to prevent diaper dermatitis and to pro- the diaper area with wipes has been found to be as eff ective mote healing when diaper dermatitis is present (AWHONN, on skin hydration, pH, erythema and microbial colonization 2013; Ness, Davis, & Carey, 2013; Nield & Kamat, 2007; Viss- as using cotton and water without any adverse eff ects (Laven- cher et al., 2009). Care should be taken to avoid rubbing or der et al., 2012). However, water alone may not be as eff ective friction during diaper changes and to gently cleanse the diaper as a mild cleanser in removing stool from the diaper area, as area, rinse and pat dry to minimize further trauma to the skin the water-insoluble fragments may not be removed completely, (Stamatas & Tierney, 2014; Stevenson, 2011). When caring for more friction is necessary to remove the stool and residue may premature infants, special attention must be paid to gentle skin be left on the skin area (Blume-Peytavi et al., 2014). Wipes with care techniques for cleansing and removing irritants from the pH buff ering eff ects might help stabilize the skin pH levels and skin, as the skin of a premature infant can be more friable. help prevent the skin pH from rising in the diaper area (Adam, 2008). Diaper wipes made from soft cloth and emollients have Education been found to be safe and eff ective for cleansing while im- Diaper hygiene is an important part of education for parents proving barrier function and skin integrity when used among and caregivers of newborns. Diaper dermatitis is a preventable both full-term and preterm infant populations (Visscher et al., condition and all parents should receive education about com- 2009). Some diaper wipes contain perfumes, and other mon ways to reduce likelihood of this condition by adhering substances that can cause irritation or an allergic contact der- to proper diaper hygiene and meticulous skin care practices. matitis (Fields, Nelson, & Powell, 2006; Odio, Streicher-Scott, Measures to restore healthy skin and to prevent recurrent epi- & Hansen, 2001). When skin irritation occurs, care should be sodes can be provided safely in the home environment by par- taken to use alternate products without these ingredients. Fur- ents and other caregivers. ther research is required to identify specifi c skin care practices Parents must receive appropriate education from nurses and to prevent or reduce diaper dermatitis. other clinicians to ensure that the importance of diaper hygiene

332 Nursing for Women’s Health Volume 19 Issue 4 CNE http://JournalsCNE.awhonn.org 333 oral of course a ective, Nursing for Women’s Health Women’s Nursing for is understood untreated, complications including in- including complications untreated, diaper the incidence of is will reduce help education from nurses and other education from nurses and other Parents must receive appropriate Parents must receive appropriate all types for is discouraged topical e use of clinicians to ensure that the importance clinicians to ensure that the importance Th of diaper hygiene and good skin practices of diaper hygiene and good skin untreated (Ravanfar et al., 2012). et al., (Ravanfar untreated COMPLICATIONS OF COMPLICATIONS DIAPER DERMATITIS UNTREATED as the condition rare are dermatitis diaper from Complications creams barrier practices, care skin good with treatable easily is if or instances, rare In infections. underlying of treatment and is left dermatitis diaper bacte- and skin breakdown severity of increasing pain, creasing occur can 2014). One (Shin, infections super fungal rial and of form a severe dermatitis, diaper erosive is Jacquet’s example or ulcerations severe with present can that dermatitis diaper is dermatitis diaper if irritant borders elevated with erosions left PRACTICE FOR NURSING IMPLICATIONS among phenomenon a common remains dermatitis Diaper is important It ages. wearing diaper of children and infants the de- for identify risk and factors of to be nurses aware for newborn within pediat- and dermatitis diaper of velopment strategies prevention consistent employ and ric populations infants all diapered of the best possible skin care promote to Th children. and for suspected bacterial infections, consultation with a health a health with consultation suspected bacterial infections, for when a diagnosis instances, rare In is necessary. provider care treatment bacterial a and infection, of is indicative is made that is ineff topical prescribed with 2014). (Shin, be required may antibiotics absorption, Cushing’s syndrome, adrenal axial suppression and and axial suppression adrenal syndrome, Cushing’s absorption, 2007; Humphrey & Ozgen, Gulumser, skin (Guven, of atrophy 2014). 2007; Shin, & Kamat, 2006; Nield et al., of diaper dermatitis and should only be used only when necessary should and as dermatitis diaper of 2013). Infants (AWHONN, provider a health care by directed their larg- to due agents topical of absorption to prone more are the need 2014); thus, (Shin, ratio weight er body to surface area In be understated. cannot in the these use of agents caution for the in- and in general diapers of nature the occlusive addition, absorp- lead faster to can environment creased moisture-laden (Humphrey agents these increased potency topical of and tion cases, lead systemic some this to can 2014). In 2006; Shin, et al., e nal layer nal layer C. albicans is nys- C. albicans ective in the treatment treatment in the ective C. albicans are resistant C. albicans cloth or a gentle diaper diaper a gentle or cloth , the goal of treatment is both both is treatment of goal , the days. er a few C. albicans least at be should changed a diaper that is means September 2015 Topical antibacterial agents are generally not recommended recommended not generally are agents antibacterial Topical Parents should be reminded to wash their before and and before their wash hands to be should reminded Parents er every diaper change. Once a diaper is soiled with either either is soiled with Once a diaper er every change. diaper August PHARMACOLOGIC TREATMENT PHARMACOLOGIC TREATMENT AND POTENTIAL SIDE EFFECTS antibacte- includes when required Pharmacologicaltreatment diaper For therapy. corticosteroid topical and rial, antifungal by caused dermatitis however, dermatitis; diaper in cases of required not usually and to treat the infection and prevent further skin breakdown. Th further skin breakdown. prevent and the infection treat to treat- for agent antifungal topic prescribed most commonly by complicated dermatitis diaper of ment of treatment adequate facilitate 2000). To al., et (Ward tatin protection, barrier providing still while infection fungal the (2012) describe in which et al. a crusting technique Heimall the covering the skin, sealed by on is placed powder antifungal a fi by then protected and a skin protectant with area of strains some As barrier cream. of and as clotrimazole such agents, antifungal other nystatin, to con- randomized fact, in one be In prescribed. can miconazole, be to in reducing superior was found clotrimazole study, trol as dermatitis diaper of global assessment and scores symptom rates cure both had adequate although nystatin, to compared antibac- an 2 percent, 2010). Muciprocin & Jost, Stark, (Hoeger, terial has also topical ointment, been eff of the presence by complicated dermatitis diaper candidal of 1999). Dyk, Rode, van & Millar, bacteria (de Wet, every 1 to 3 hours during the day and at least once per night. per night. least once at and the day every during hours 3 1 to a soft and water warm with Cleansing is the skin every from change diaper irritants remove to wipe Parents urine. with soiled is only if the diaper even imperative, as the dia- back to front from area the genital wipe gently should the diaper scrubbing of excessive avoid and is cleansed per area is being a barrier cream the If skin. to trauma reduce to area from the stool remove be gently to needs taken to used, care trying than to rather the infant, the skin of on the barrier cream dry al- or the skin. Patting from the barrier completely remove in the pre- as possible helps as long the air-dry for skin to lowing remains the area If dermatitis. diaper of treatment and vention over barrier cream of layer another apply can parents reddened, petroleum apply or it reinforce to barrier cream the remaining these continue to encouraged are Parents area. the diaper to jelly a health seek from should advice and the rash is gone until steps to these does respond not dermatitis if the diaper provider care aft becomes worse or strategies aft as soon as pos- be should changed the diaper stool, urine or is mini- the diaper from irritants with contact ensure to sible mized. Th and good skin practices is understood. In addition to the practi- to addition good In is understood. skin practices and derma- diaper of treatment and the prevention for cal solutions be conveyed. must parents for reminders several helpful titis, BOX 3 SUGGESTED PERINEAL SKIN CARE GUIDELINES FOR DIAPERED/INCONTINENT PATIENTS

Th e full-size chart below may be found online at: http://onlinelibrary.wiley.com/doi/10.1111/1751-486X.12218/suppinfo

Chart reprinted with permission from Neonatal Skin Care Evidence-Based Clinical Practice Guideline, Third Edition (AWHONN, 2013). Content © The Children’s Hospital of Philadelphia. Adapted with permission. x Intact skin x Intact skin x Intact skin x Intact skin x Denuded skin* x Denuded skin* x No erythema x High risk for skin x Erythema x Erythema, satellite lesions x No Candida** x Evidence of Candida**† breakdown due to causticity x No Candida** typically on thighs, of stool (short gut, post pull perineum through or ostomy closure) x Evidence of Candida** Skin x With or without erythema Assessment

Goal of Prevent skin Prevent skin breakdown; Prevent skin breakdown; Treat Candida Prevent further skin breakdown; Prevent further skin breakdown; Treatment breakdown Provide barrier Provide barrier Provide barrier Treat Candida; Provide barrier No-sting barrier film may be applied prior to application of any of the below products (in patients > 28 days old) Antifungal ointment or cream Pectin powder then then zinc oxide barrier cream zinc oxide barrier cream Zinc oxide barrier cream OR OR OR Zinc oxide barrier Antifungal powder and alcohol- Petrolatum Antifungal topical treatment Pectin powder then alcohol-free, Treatment Alcohol-free, pectin-based cream free skin protectant crusting pectin-based paste then petrolatum paste, covered with petrolatum technique then alcohol-free, OR pectin-based paste then One of above plus crusting technique petrolatum Apply a thick Apply a thick layer of zinc Apply a thick layer of Apply antifungal ointment; if Apply a thin layer of pectin powder to Apply antifungal ointment or layer of oxide-based cream (think icing zinc oxide-based cream no improvement in 24-48 denuded areas. Brush off excess. cream, followed by zinc oxide petrolatum on a cake”). (think “icing on a hours, consider using a Powder will stick to the open skin. barrier cream. over the entire OR cake”). different antifungal Then apply thick layer of zinc oxide OR area to be For alcohol-free, pectin-based preparation. barrier cream or alcohol-free, pectin- Crusting technique: protected paste: based paste on top of pectin powder. Apply a thin layer of antifungal (think “icing -“Press” into place vs. For alcohol-free, pectin-based paste: powder to denuded areas. Brush on a cake”). “spreading.” -Press into place vs. spreading. off excess. Then apply thick -Apply a thick layer of -Apply thick layer of petrolatum over layer alcohol-free, pectin-based Application petrolatum on top of pectin pectin product to prevent pectin from paste or zinc oxide barrier cream product, to prevent pectin sticking to diaper. on top of antifungal powder Instructions product from sticking to diaper. With each diaper change: layer. With each diaper change: -Only remove stool, try to leave pectin -Only remove stool, try to leave product in place. pectin product in place. -Skin showing: replace pectin product -If skin showing, replace pectin prn, re-apply petrolatum. product as needed, re-apply Crusting technique: Pectin powder, petrolatum. then seal with alcohol-free skin protectant. Repeat this step, then layer alcohol-free, pectin-based paste or zinc oxide cream.

*Denuded skin: Skin with moist, open, oozing ulcerations. **Candida infection: Beefy red skin with oval/ dotty lesions scattered at edges (satellite lesions), usually involves skin folds, skin may or may not be denuded. NOTE: These products promote moist wound healing, therefore do not leave diaper open to air or have air/oxygen blowing on diaper area. † Photo source: ¤Douglas Hoffman, MD, Dermatlas, www.dermatlas.org, reprinted with permission.

dermatitis. Th e development of standardized protocols, guide- for parents by all health care providers both within hospital and lines (AWHONN, 2013) or algorithms can assist in nurses the community is essential. Although diaper dermatitis is oft en providing consistent evidence-based practice when caring for a preventable condition, it remains a common problem among infants with diaper dermatitis (see Box 3). Nurses must under- infants and children both within a hospital setting and at home. stand the etiology of diaper dermatitis, preventive measures Nurses are in the ideal position to infl uence and educate fami- and recommended management strategies to provide appro- lies on this important topic through consistent evidence-based priate care for this common condition and to provide suitable care. education for families. Nurses can provide specifi c targeted education about diaper CONCLUSION dermatitis, including meticulous diaper hygiene practices, to Diaper dermatitis is a common condition that can cause parents of infants, as good diaper hygiene is integral in pre- considerable pain and stress for infants and be troublesome venting diaper dermatitis. Providing parents with information for their caregivers. Diff erential diagnosis is important, as along with the rationale for prevention and management strate- is identifying any potential underlying conditions, such as a gies might encourage compliance and increase understanding. bacterial or viral infection. Nurses play a pivotal role in help- Off ering guidance for parents in choosing suitable products to ing families understand the risk factors for diaper dermatitis prevent or manage diaper dermatitis may also be helpful. and how to prevent it through appropriate diaper hygiene Incorporating well-infant skin care into routine education practice. NWH

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336 Nursing for Women’s Health Volume 19 Issue 4 CNE http://JournalsCNE.awhonn.org 337 Nursing for Women’s Health Women’s Nursing for Langerhans cell histiocytosis prevent recurrence skin and prevent recurrence skin and promote recurrence the skin is in contact with irritants changes cream a. Calcium b. Magnesium c. Zinc and ammation, remove barriers a. decrease infl To ammation, repair the damage to the b. decrease infl To the ammation, repair the damage to c. increase infl To a. Antibacterial b. Antifungal c. Zinc oxide a. 1 to 3 hours to decrease the amount of time Every ng with diaper b. 3 to 4 hours to minimize chafi Every c. 4 to 6 hours in order to not disturb the barrier Every enteropathica a. Acrodermatitis b. Jacquet’s erosive dermatitis c. a rash similar to irritant diaper dermatitis? a rash similar to irritant dermatitis? ed for the treatment of an infant with diaper an infant How often should a diaper be changed when has diaper dermatitis? diaper dermatitis? 8. ciencies can cause nutritional defi Which of the following 9. goal when diaper dermatitis develops? What is the overall 10. What type of barrier cream is most frequently recommend- 11. 12. What is one associated with untreated To receive contact hours for this learning contact hours for this receive To 2 percent to 14 percent 7 percent to 35 percent 10 percent to 50 percent 3 to 4 weeks 8 to 9 weeks 11 to 12 weeks treatment strategies September 2015 a. b. c. a. Dermis b. Epidermis c. Stratum corneum a. water loss Decrease in transepidermal b. water loss Increase in transepidermal c. Reduction of transepidermal water loss a. b. c. a. Candidiasis ng b. Chafi c. Irritants a. When the rash fails to respond to usual treatment b. When there is improvement in the rash with normal c. When the skin has healed a. Diaper dye b. enzymes Fecal c. Urine dermatitis? agents? chemical and biologic which leads to a: infant born functional skin barrier be complete for an at 24 weeks gestation? in infants? the case of diaper dermatitis? August 1. of diaper What is the estimated range of prevalence 2. skin is the protective barrier to physical, Which layer of the 3. Premature infant skin lacks a fully functional skin barrier 4. At how many weeks would the full maturation of the 5. What is the most common cause of diaper dermatitis 6. be considered in When should a 7. dermatitis? What is a common cause of allergic contact Instructions: post-test and participant complete the online please activity, . CNE at http://JournalsCNE.awhonn.org feedback form submit- ; written tests is available online only for this activity be accepted. will not ted to AWHONN Post-Test Questions Post-Test