Diaper Rash - Red Diode Laser Module 670nm - 785nm Diode Laser Module
Differential diagnosis
Differential diagnosis
Other rashes that occur in the diaper area include Seborrheic dermatitis and Atopic dermatitis. Both Seborrheic and Atopic dermatitis require individualized treatment; they are not the subject of this article.
Seborrheic dermatitis, typified by oily, thick yellowish scales, is most commonly seen on the scalp (cradle cap) but can also appear in the inguinal folds.
Atopic dermatitis, or eczema, is associated with allergic reaction, often hereditary. This class of rashes may appear anywhere on the body and is characterized by intense itchiness.
Causes
Irritant diaper dermatitis develops when skin is exposed to prolonged wetness, decreased skin pH caused by urine and feces, and resulting breakdown of the stratum corneum, or outermost layer of the skin. In adults, the stratum corneum is composed of 25 to 30 layers of flattened dead keratinocytes, which are continuously shed and replaced from below. These dead cells are interlaid with lipids secreted by the stratum granulosum just underneath, which help to make this layer of the skin a waterproof barrier. The stratum corneum's function is to reduce water loss, repel water, protect deeper layers of the skin from injury and to repel microbial invasion of the skin (Tortora and Grabowski, 2003). In infants, this layer of the skin is much thinner and more easily disrupted.
Effects of urine
Although wetness alone macerates the skin, softening the stratum corneum and greatly increasing susceptibility to friction injury, urine has an additional impact on skin integrity because of its effect on skin pH. While studies show that ammonia alone is only a mild skin irritant, when urea breaks down in the presence of fecal urease it increases skin acidity (lower pH), which in turn promotes the activity of fecal enzymes such as protease and lipase (Atherton, 2004; Wolf, Wolf, Tuzun and Tuzun, 2001). These fecal enzymes increase the skin's permeability to bile salts and act as irritants in and of themselves.
There is no detectable difference in rates of diaper rash in conventional disposable diaper wearers and reusable cloth diaper wearers. "Babies wearing superabsorbent disposable diapers with a central gelling material have fewer episodes of diaper dermatitis compared with their counterparts wearing cloth diapers. However, keep in mind that superabsorbent diapers contain dyes that were suspected to cause allergic contact dermatitis (ACD)." (Kazzi, 2006) Whether wearing cloth or disposable diapers they should be changed frequently to prevent diaper rash, even if they don't feel wet.
Effects of diet
The interaction between fecal enzyme activity and IDD explains the observation that infant diet and diaper rash are linked, since fecal enzymes are in turn affected by diet. Breast-fed babies, for example, have a lower incidence of diaper rash, possibly because their stools have lower pH and lower enzymatic activity (Hockenberry, 2003). Diaper rash is also most likely to be diagnosed in infants 812 months old, perhaps in response to an increase in eating solid foods and dietary changes around that age that affect fecal composition. Any time an infant diet undergoes a significant change (i.e. from breast milk to formula or from milk to solids) there appears to be an increased likelihood of diaper rash (Atherton and Mills, 2004).
The link between feces and IDD is also apparent in the observation that infants are more susceptible to developing diaper rash after treatment with antibiotics, which affect the intestinal microflora (Borkowski, 2004; Gupta & Skinner, 2004). Also, there is an increased incidence of diaper rash in infants who have suffered from diarrhea in the previous 48 hours, which may be because fecal enzymes such as lipase and protease are more active in feces which have passed rapidly through the gastrointestinal tract (Atherton, 2004).
The incidence of diaper rash is lower among breastfed infantserhaps due to the less acidic nature of their urine and stool. (Kazzi, 2006)
Secondary infections
The significance of secondary infection in IDD remains controversial. Atherton contends that, andida albicans can only be isolated from a minority of IDD cases; in many cases this is a reflection of antibiotic therapy. It has also been established that bacterial infection does not play a substantial part in the development of IDD.(Atherton, 2004, p. 646).
However, there is little argument that once the stratum corneum has been damaged by a combination of physical and chemical factors, the skin is necessarily more vulnerable to secondary infections by bacteria and fungi. In analyzing swab samples at the perianal, inguinal and oral areas of 76 infants, Ferrazzini et al. (2003) found that colonization with Candida albicans was significantly more likely in children with symptomatic diaper rash than without. Staphylococcus aureus was also present more frequently in symptomatic than in healthy infants, but the difference was not statistically significant. A wide variety of other infections has been reported on occasion, including Proteus mirabilis, enterococci and Pseudomonas aeruginosa, but it appears that Candida is the most common opportunistic invader in diaper areas (Ferrazzini et al., 2003; Ward et al., 2000).
Although apparently healthy infants sometimes culture positive for Candida and other organisms without exhibiting any symptoms, there does seem to be a positive correlation between the severity of the diaper rash noted and the likelihood of secondary involvement (Ferrazzini et al., 2003; Gupta & Skinner, 2004; Wolf et al., 2001).
Treatments
The most effective treatment, although not the most practical one, is to discontinue use of diapers, allowing the affected skin to air out. Thorough drying of the skin before diapering is a good preventive measure, since it's the excess moisture, either from urine and feces or from sweating, that sets the conditions for a diaper rash to occur. Various moisture-absorbing powders, such as talcum or starch, also help prevention.
Another approach is to block moisture from reaching the skin, and commonly recommended remedies using this approach include oil-based protectants or barrier cream, various over-the-counter "diaper creams", petroleum jelly and other oils. Such sealants sometimes accomplish the opposite if the skin is not thoroughly dry, in which case they serve to seal the moisture inside the skin rather than outside.
Zinc oxide-based ointments are quite effective, especially in prevention, because they have both a drying and an astringent effect on the skin, being mildly antiseptic without causing irritation.
In persistent or especially bad rashes, an antifungal cream often has to be used. In cases that the rash is more of an irritation, a mild topical corticosteroid preparation, e.g. hydrocortisone cream, is used. As it is often difficult to tell a fungal infection apart from a mere skin irritation, many physicians prefer an antifungal-and-corticosteroid combination cream.
Some sources claim that diaper rash is more common with cloth diapers, yet others claim that the type of diaper makes no difference, but that cloth diapers can speed the healing process. In truth the material of the diaper is relevant inasmuch as it can wick and keep moisture away from the baby's skin.
See also
Diaper candidiasis
Notes
^ James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. ISBN 0721629210.
^ "Patient information: Diaper rash in infants and children". UpToDate Marketing. http://www.uptodate.com/patients/content/topic.do?topicKey=~xrAHHNqmCOJqF1t.
^ "Diapers/Diaper Rash". UVa Health System. http://www.healthsystem.virginia.edu/uvahealth/peds_newborn/diprrash.cfm.
References
Atherton DJ (2001). "The aetiology and management of irritant diaper dermatitis". J Eur Acad Dermatol Venereol 15 Suppl 1: 14. doi:10.1046/j.0926-9959.2001.00001.x. PMID 11720071. http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=0926-9959&date=2001&volume=15&issue=&spage=1.
Atherton DJ (2004). "A review of the pathophysiology, prevention and treatment of irritant diaper dermatitis". Curr Med Res Opin 20 (5): 6459. doi:10.1185/030079904125003575. PMID 15140329.
Atherton, D.J. & Mills, K. (2004) What can be done to keep babies skin healthy? RCM Midwives Journal, 7(7), p. 288-290.
Borkowski S (2004). "Diaper rash care and management". Pediatr Nurs 30 (6): 46770. PMID 15704594.
Concannon P, Gisoldi E, Phillips S, Grossman R (2001). "Diaper dermatitis: a therapeutic dilemma. Results of a double-blind placebo controlled trial of miconazole nitrate 0.25%". Pediatr Dermatol 18 (2): 14955. doi:10.1046/j.1525-1470.2001.018002149.x. PMID 11358560. http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=0736-8046&date=2001&volume=18&issue=2&spage=149.
Ferrazzini G, Kaiser RR, Hirsig Cheng SK, et al. (2003). "Microbiological aspects of diaper dermatitis". Dermatology (Basel) 206 (2): 13641. doi:10.1159/000068472. PMID 12592081.
Gupta AK, Skinner AR (2004). "Management of diaper dermatitis". Int. J. Dermatol. 43 (11): 8304. doi:10.1111/j.1365-4632.2004.02405.x. PMID 15533067.
Hockenberry, M.J. (2003) Wong Nursing Care of Infants and Children. St. Louis, MO; Mosby, Inc.
Tortora, G.J & Grabowski, S.R. (2003) Principles of Anatomy and Physiology, Tenth Edition; New York, NY; John Wiley & Sons, Inc.
Ward DB, Fleischer AB, Feldman SR, Krowchuk DP (2000). "Characterization of diaper dermatitis in the United States". Arch Pediatr Adolesc Med 154 (9): 9436. PMID 10980800. http://archpedi.ama-assn.org/cgi/pmidlookup?view=long&pmid=10980800.
Wolf R, Wolf D, Tzn B, Tzn Y (2000). "Diaper dermatitis". Clin. Dermatol. 18 (6): 65760. doi:10.1016/S0738-081X(00)00157-7. PMID 11173200. http://linkinghub.elsevier.com/retrieve/pii/S0738-081X(00)00157-7.
External links
Some practical advice for dealing with the condition
Using Elimination Communication to Prevent Diaper Rash (Part Time Diaper Free US/CAN)
Baby-Bean.com/Nappy-Rash.php - Cloth Nappies and Nappy Rash. What Causes Nappy Rash. How to Prevent and Cure it.
Using Elimination Communication to Prevent Nappy Rash (Part Time Nappy Free UK / AUST / NZ)
Links to pictures of Diaper Rash (Hardin MD/Univ of Iowa)
www.babycentre.co.uk - Nappy rash
vde
Diseases of the skin and subcutaneous tissue (integumentary system) (L, 680-709)
Infections
Bacterial
skin disease
Staphylococcus (Staphylococcal scalded skin syndrome, Impetigo, Boil, Carbuncle) Strep (Impetigo) Corynebacterium (Erythrasma)
Viral
skin disease
Wart Molluscum contagiosum Erythema infectiosum Exanthema subitum Herpes simplex (Herpetic whitlow, Eczema herpeticum)
General
Cellulitis (Paronychia) Acute lymphadenitis Pilonidal cyst Pimple (Pustule)
Bullous
disorders
acantholysis (Pemphigus, Transient acantholytic dermatosis) Pemphigoid (Bullous, Cicatricial, Gestational) Dermatitis herpetiformis
Inflammatory
Dermatitis
and eczema
Atopic dermatitis Seborrhoeic dermatitis (Dandruff, Cradle cap) Contact dermatitis (Diaper rash, Urushiol-induced contact dermatitis) Erythroderma Lichen simplex chronicus/Prurigo nodularis Itch (Pruritus ani, Pruritus scroti, Pruritus vulvae) Nummular dermatitis Dyshidrosis Pityriasis alba
Papulosquamous
disorders
Psoriasis (Psoriatic arthritis) Parapsoriasis (Pityriasis lichenoides et varioliformis acuta, Pityriasis lichenoides chronica, Lymphomatoid papulosis) other pityriasis (Pityriasis rosea, Pityriasis rubra pilaris) other lichenoid (Lichen planus, Lichen nitidus)
Urticaria
Dermatographic urticaria Cold urticaria Cholinergic urticaria Solar urticaria
Erythema
Erythema multiforme/
drug eruption
Stevens-Johnson syndrome Toxic epidermal necrolysis Erythema nodosum Acute generalized exanthematous pustulosis
Other erythema
Erythema annulare centrifugum Erythema marginatum Keratolytic winter erythema Necrolytic migratory erythema Erythema toxicum
Radiation-related
disorders
Sunburn actinic rays (Actinic keratosis, Actinic cheilitis) Polymorphous light eruption (Acne aestivalis) Radiodermatitis Erythema ab igne
Pigmentation/
Dyschromia
hypopigmentation (Albinism, Vitiligo) hyperpigmentation (Melasma, Freckle, Caf au lait spot, Lentigo/Liver spot, Acanthosis nigricans, Acral acanthotic anomaly)
Other skin
keratosis/hyperkeratosis (Seborrheic keratosis, Callus) other epidermal thickening (Ichthyosis acquisita, Palmoplantar keratoderma)
skin ulcer (Pyoderma gangrenosum, Bedsore)
Cutaneous Markers of Internal Malignancy (Florid cutaneous papillomatosis, acanthosis nigricans, sign of Leser-Trelat)
atrophic (Lichen sclerosus, Acrodermatitis chronica atrophicans)
necrobiosis (Granuloma annulare, Necrobiosis lipoidica) other granuloma (Granuloma faciale, Pyogenic granuloma)
cutaneous vasculitis (Livedoid vasculitis, Erythema elevatum diutinum)
Connective
tissues
collagen disease: Keloid
localized connective tissue disorders: Lupus erythematosus (Discoid lupus erythematosus, Subacute cutaneous lupus erythematosus) Scleroderma/Morphea Linear scleroderma Calcinosis cutis Sclerodactyly Ainhum
integument, SF, LCT navs: anat/physio, noncongen/congen/neoplasia, symptoms+signs/eponymous, proc
Categories: Diapers | Babycare | Eczema
by: gaga
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