Practical management strategies for diaper dermatitis

Common diaper dermatitis is an irritant contact diaper dermatitis (IDD) created by the combined influence of moisture, warmth, urine, feces, friction, and secondary infection. It is difficult to completely eradicate these predisposing factors in a diapered child. Thus, IDD presents an ongoing therapeutic challenge for parents, family physicians, pediatricians, and dermatologists. This article will focus on practical management strategies for IDD.

Unusual report of diaper rash in a premature infant with group B streptococcal infection

We present the case of a 980-g, female, premature infant with a late-onset maternofetal sepsis, of which the first sign was a diaper-shaped cellulitis. This dermatologic sign in a premature infant is very unusual and needs prompt investigation. Late-onset group B Streptococcus infection can be manifested by a cellulitis-adenitis syndrome.

Topical miconazole nitrate ointment in the treatment of diaper dermatitis complicated by candidiasis

Diaper dermatitis (DD) complicated by candidiasis is a common problem in diaper-wearing infants and children. We report a double-blind, vehicle-controlled, parallel-group study evaluating the efficacy and safety of a low concentration of miconazole nitrate in a zinc oxide/petrolatum ointment for the treatment of DD complicated by candidiasis. Patients (N=330) who had DD with a severity score of 3 or higher were enrolled. Those patients with a baseline potassium hydroxide (KOH) preparation and a baseline culture specimen that both tested positive for Candida were retained for efficacy analysis (n=236). Miconazole nitrate 0.25% ointment or a zinc oxide/petrolatum vehicle control were applied to all clinically affected areas of patients with DD for 7 days at each diaper change and after bathing. A follow-up test-of-cure visit was conducted at day 14. Among the patients completing the study, the overall rate of cure (clinical cure plus microbiologic cure) was 23% for the miconazole nitrate group and 10% for the vehicle control group (P=.005); the rate of clinical cure (complete rash clearance, DD severity score=0 at day 14) was 38% for the miconazole nitrate group and 11% for the vehicle control group (P<.001); and the rate of microbiologic cure (no culture growth of Candida) was 50% for the miconazole nitrate group and 23% for the vehicle control group. The vehicle control resulted in mild improvement at day 3 but little or no subsequent improvement. The discontinuation rate due to clinical failure was substantially lower for the miconazole nitrate group (4%) than the vehicle control group (47%). The mean DD severity index score for the miconazole nitrate group was significantly lower from day 3 through day 14 compared with that of the vehicle control group (P<.001). Adverse events were assessed as either unlikely to be related to study medication or unrelated to study medication. By including only those patients with microbiologically confirmed Candida infection, the study population may not be fully indicative of patients treated for DD in routine clinical practice. Our data show that miconazole nitrate 0.25% ointment was well tolerated and significantly more effective than the zinc oxide/petrolatum vehicle control for treatment of DD complicated by candidiasis.

Topical vitamin A, or its derivatives, for treating and preventing napkin dermatitis in infants

BACKGROUND

Napkin dermatitis (nappy or diaper rash) is a non-specific term used to describe inflammatory eruptions (rashes) in the napkin area. Most infants develop napkin dermatitis at least once during their infancy. Topical vitamin A has been suggested as a treatment for napkin dermatitis.

OBJECTIVES

To determine if treatment with topical vitamin A is successful in either preventing napkin dermatitis, or producing resolution or decreasing the severity of napkin dermatitis.

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (May 2005); Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2005); Ovid MEDLINE from 1966 to August 2005; EMBASE (2003 to May 2005); Ovid OLDMEDLINE (1950 to 1965); and CINAHL (1982 to August 2005). We also searched reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials, where the topical application of medication containing vitamin A (or its derivatives) was compared with either placebo, no treatment or other topical medication, for the prevention or treatment of napkin dermatitis in infants aged from zero to two years.

DATA COLLECTION AND ANALYSIS

Two authors (AJD and MWD) identified and checked titles and abstracts obtained from the searches, and reviewed the full text where necessary. They decided which trials met the inclusion criteria, and recorded their methodological quality. They assessed studies as either adequate, unclear or inadequate using the following key criteria: (a) randomisation (method of generation and concealment of allocation); (b) blinding; (c) loss to follow-up.

MAIN RESULTS

We did not find any studies for the treatment of napkin dermatitis. We found only one study comparing the use of topical application of medication containing vitamin A, with another topical medication or placebo, to prevent napkin dermatitis. This included study, of 114 newborn infants, reported no significant differences between groups with regard to the severity or duration of napkin dermatitis.

AUTHORS' CONCLUSIONS

For the treatment of napkin dermatitis there is no evidence to support or refute the use of topical vitamin A preparations. For the prevention of napkin dermatitis there is no evidence to suggest that topical vitamin A alters the development of napkin dermatitis. Further RCTs are required to determine whether topical vitamin A is efficacious in treating or preventing napkin dermatitis.

[Effectiveness of topical acetate tocopherol for the prevention and treatment of skin lesions in newborns: a 5 years experience in a 3rd level Italian Neonatal Intensive Care Unit]

AIM

Neonates in NICU (especially when premature) are particularly prone to skin damage by action of external aggressive conditions such as chemical, physical, infectious, radiant, mechanical and iatrogenic factors. Strategies for avoiding disruption of the skin barrier are thus highly needed in such patients.

METHODS

We evaluated the effectiveness of a acetate tocopherol (AT) ointment for topical use in 21 neonates admitted to our NICU and affected by neonatal abstinence syndrome with severe diaper exulcerative and erosive erythema with ulcer and granulation tissue at the bottom of the lesion (group A), and compared them to 19 matched neonates affected by the same condition and treated with a commonly used skin ointment (emollient type, water-in-oil category) (group B). For all newborns we calculated: the dermatological severity score (using a clinical score from 0 to 9 points according to the increasing severity of the lesions) at time 0, 4 and 7 days; the mean days for achieving complete recovery; the rate of therapeutical failures.

RESULTS

Mean score at day 0 was 7.8 in group A vs 7.9 in group B (P=0.35 NS). At day 4 it was 4.6 in group A vs 6.5 in group B (P=0.03), at day in 7 it was 3.1 in group A vs 5.2 in group B (P=0.04). A complete recovery with restitutio ad integrum occurred after 9.1 mean days in group A vs 12.2 mean days in group B (P=0.04). The rate of therapeutical failures was significantly lower in group A (4.2% vs 30.6%; OR 0.235; P<0.01) than in group B. No adverse effects related to AT use were reported.

CONCLUSIONS

AT in our experience proved to be safe and more effective than the commonly used skin ointments in the topical treatment of exulcerative skin lesions in NICU neonates.

Reminder: radiopacities from metal-containing substances

A 17-month-old boy with a toed-out left lower extremity was presented for evaluation. Before coming to the doctor, the mother had applied a zinc oxide lotion to treat a simple diaper rash in the groin. The radiologist did not remove the boy's diaper for the radiographic examination and so did not notice the lotion. The first radiograph showed what looked like multiple soft-tissue calcifications in the groin, but the radiopacities had been produced by the zinc oxide. This case serves as a reminder to be aware that metal-containing substances both on and in the body can produce radiopacities.

Diaper dermatitis: a review and brief survey of eruptions of the diaper area

Eruptions in the diaper area are the most common dermatologic problem in infancy. Such eruptions can be subdivided into primary diaper dermatitis, an acute inflammation of the skin in the diaper area with an ill-defined and multifactorial etiology, and secondary diaper dermatitis, a term which encompasses eruptions in the diaper area with defined etiologies. The most important factors in the development of primary diaper dermatitis are: (i) water/moisture, (ii) friction, (iii) urine, (iv) feces, and (v) microorganisms (sometimes). Possible treatments include minimizing diaper use and using disposable diapers, barrier creams, mild topical cortisones, and antifungal agents. A variety of other inflammatory and infectious processes can occur in the diaper area and an awareness of these secondary types of diaper dermatitis aids in the accurate diagnosis and treatment of patients.

A multicenter, open-label study to assess the safety and efficacy of ciclopirox topical suspension 0.77% in the treatment of diaper dermatitis due to Candida albicans

Ciclopirox is a broad-spectrum antifungal, antibacterial, and anti-inflammatory agent. This open-label study investigated the safety and efficacy of ciclopirox topical suspension 0.77% in the treatment of diaper dermatitis due to Candida albicans (C. albicans). Forty-four male and female subjects aged 6 to 29 months were included in the study. Study medication was applied topically to the affected diaper area twice daily for 1 week. Subjects were clinically evaluated at baseline and days 3, 7, and 14 (7 days post-treatment). Safety and efficacy variables included adverse events, mycological culture studies, KOH tests, Severity Scores, and Global Evaluation of Clinical Response. All adverse events were mild to moderate and considered not related to the study medication. Treatment provided statistically significant improvement (P < .05) for both the rate of mycological cure and reduction of Severity Score at each time point compared with baseline. Ciclopirox was safe and effective in the treatment of diaper dermatitis due to C. albicans.

An infantile Cushing syndrome due to misuse of topical steroid

Chronic low-dose exogenous steroid therapy in children can result in hypothalamic-pituitary-adrenal axis dysfunction. However, the development of Cushing syndrome from topical steroid therapy is unusual. A 9-month-old girl with a diagnosis of Cushing syndrome caused by long-term topical clobetasol propionate application was evaluated. The patient was found to have severe adrenal suppression. Limiting the use of steroid-containing drugs, prescription of less potent agents, especially during infancy, and warning of parents about potential side effects are very important.

Pediatricians who prescribe clotrimazole-betamethasone diproprionate (Lotrisone) often utilize it in inappropriate settings regardless of their knowledge of the drug's potency

Clotrimazole-betamethasone diproprionate (C-BMV) is a fluorinated, high potency topical steroid that has been formulated with clotrimazole in the brand-named product, Lotrisone. The product is frequently used inappropriately in intertriginous areas, particularly in children. The following evaluates the use of this combination based upon a survey of 106 US-based pediatricians with at least two years post-residency, who attended the 1999 American Academy of Pediatrics. Of pediatricians who prescribe C-BMV, 23% prescribe it for diaper dermatitis. 11% of C-BMV prescriptions exceed the recommended duration of therapy. Only 18% of prescribing pediatricians correctly identify "Lotrisone" as a high potency steroid. There is no significant association between knowledge of C-BMV potency and frequency of use (p>.1). These self-reported data confirm and complement the findings of previous studies that used representative national data to assess the use of C-BMV. Pediatricians continue to utilize C-BMV in inappropriate settings, such as diaper dermatitis, regardless of their knowledge of the agent's potency. Our advice is to refrain from using high-potency steroids, such as C-BMV, in pediatric cases as there are more appropriate, safer alternatives with many fewer side effects.

Diaper dermatitis: a therapeutic dilemma. Results of a double-blind placebo controlled trial of miconazole nitrate 0.25%

Diaper dermatitis, an acute inflammation of the skin in the diaper area, is the most common dermatologic disorder of infancy. This placebo-controlled, randomized, double-blind, parallel-group trial compared the efficacy and safety of miconazole nitrate 0.25% in a zinc oxide/petrolatum base with that of the ointment base alone in treating acute diaper dermatitis in infants and evaluated the role of Candida albicans in the response to treatment. Infants age 2-13 months with diaper rash were treated with either miconazole nitrate 0.25% (N = 101) or ointment base (N = 101) for 7 days. Although improvement in rash from baseline was seen in both treatment groups on days 3, 5, and 7, patients receiving miconazole nitrate 0.25% had significantly fewer rash sites and lower mean total rash scores on days 5 and 7 (p < 0.001). In the miconazole nitrate 0.25% group, improvement was most marked among those with moderate or severe diaper dermatitis at baseline and among patients whose baseline rashes were positive for C. albicans. Treatment with miconazole nitrate 0.25% was as safe as with ointment base alone. Miconazole nitrate 0.25% ointment is a safe and effective treatment for diaper dermatitis in infants.

Henna-induced hemolytic anemia and acute renal failure

Henna is a traditional cosmetic agent and is used worldwide, especially in the Middle East. Its active agent is lawsone (2-hydroxy-1,4-naphthoquinone). Henna is not only applied to hands or hair as a cosmetic agent in traditional ceremonies, but is also applied to the body on lesions in the treatment of seborrheic dermatitis or fungal infections. However, its application over the body or in newborns is rare. Here we report a 27-day-old boy who developed hemolytic anemia and acute renal failure following topical application of henna to his abdomen, intertriginous region and legs to treat diaper rash.

Characterization of diaper dermatitis in the United States

BACKGROUND

Diaper dermatitis is the most common dermatologic disorder of infancy. This study evaluates the frequency of outpatient visits resulting in this diagnosis, specialties of physicians providing services, demographics of patients, and leading agents used in treatment.

DESIGN

Records of 272,841 encounters from the National Ambulatory Medical Care Survey (1990-1997) were examined for visits in which diaper dermatitis was diagnosed in children. The likelihood of diagnosis in the general pediatric population was calculated and the leading treatment agents were ranked.

RESULTS

There were approximately 8.2 million visits in which diaper dermatitis was diagnosed. For the pediatric population in the at-risk age range, there was a 1 in 4 likelihood of being diagnosed with the skin disorder. Pediatricians provided 75% of services for the treatment of diaper dermatitis; the demographics of patients were similar to those of comparably aged individuals in the general population. Nystatin was the leading treatment agent prescribed (27% of visits), followed by clotrimazole (16%), a combination product of nystatin and triamcinolone (16%), hydrocortisone (8%), and a combination product of clotrimazole and betamethasone dipropionate (6%).

CONCLUSIONS

Visits for diaper dermatitis are frequent, and pediatricians are the physicians most often called on to provide treatment. No portion of the pediatric population is disproportionately diagnosed. The frequent use of potent corticosteroids contained in combination agents is a potential target for improving the management of diaper dermatitis.

Efficacy of topical application of eosin compared with zinc oxide paste and corticosteroid cream for diaper dermatitis

BACKGROUND

Corticosteroids, zinc paste and eosin 2% are well-known topical agents for the treatment of moderate to severe diaper dermatitis. Among these treatments, the aqueous solution of eosin 2% is extensively used in several European countries, but not in the USA or Israel.

OBJECTIVE

To assess the therapeutic efficacy of eosin 2% solution compared to the other treatment modalities for diaper dermatitis.

METHODS

Fifty-four infants with diaper dermatitis, recruited from hospital wards and community clinics, were randomly assigned to three treatment groups: zinc oxide paste (containing allantoin 0.5%, cod liver oil 17% and zinc oxide 47epercnt;); clobetasone butyrate 0.05%, and aqueous solution of eosin 2%. The severity of the disorder was graded on a 6-point scale by observation and quantitative measurement of the lesions. The groups were compared for rates and time to heal. Due to the red color of eosin, a double-blind controlled study was impossible.

RESULTS

Following 5 days of treatment, the rate of complete healing in the group treated with eosin (61%) was significantly higher (p = 0.0479) than that in the zinc oxide paste and corticosteroid groups (22 and 33%, respectively). Furthermore, in cases of partial healing, the degree of improvement was higher in the eosin group than the other two (p = 0.0205). The fastest improvement was observed in the group treated with corticosteroid cream.

CONCLUSION

Considering the potential hazards of topical corticosteroids and the greater overall efficacy of eosin 2% solution, we suggest that eosin is the preferred treatment for diaper dermatitis.

Perianal candidosis--a comparative study with mupirocin and nystatin

OBJECTIVE

To assess the efficacy and clinical outcome of 2% mupirocin in a polyethylene glycol base and nystatin cream as treatment regimens in diaper candidosis.

DESIGN

A prospective randomized comparative study.

METHODS

In vitro. The susceptibility of 20 clinical isolates of Candida albicans to 2% mupirocin, nystatin, and five additional antifungal agents was evaluated using the Nathan agar-well diffusion assay. The minimum inhibitory concentration (MIC) of mupirocin against the Candida species was determined using a tube dilution method. In vivo. Twenty patients (mean age, 12 months; range, 1 month to 4 years) with moderate to severe Monilia diaper dermatitis either had mupirocin ointment or nystatin cream applied to the infected area every 8 h or after every diaper change for a period of 7 days. Microscopic examination of skin scrapings and mycologic and microbiological cultures were performed before treatment and daily for 7 days, and progress was clinically assessed.

RESULTS

In vitro. Topical mupirocin produced a greater zone of inhibition than nystatin cream, i.e. a mean of 27.2 mm (SD 1.55) compared with a mean of 17.3 mm (SD 1.08) for nystatin cream. MIC for mupirocin of 512 microg/mL in one case, 256 microg/mL in six cases, 200 microg/mL in 10 cases and 400 microg/mL in three cases were obtained for the 20 clinical isolates. C. albicans also displayed a universal sensitivity to mupirocin and nystatin. In vivo. Eradication of all Candida organisms was achieved within 2-6 days (mean, 2.6 days) in 10 patients receiving topical mupirocin therapy with rapid healing of the excoriated wounds (mean, 4.7 days). Both Gram-positive and Gram-negative bacteria were eradicated from the infected area within the trial period. Ten patients received topical nystatin cream and, in each case, Candida was successfully cleared within 5 days (mean, 2.8 days). Only three wounds were clinically healed within the trial period, however. The remaining seven wounds showed evidence of improved, but ongoing excoriated dermatitis and a heavy growth of polymicrobial organisms.

CONCLUSIONS

Both agents eradicated Candida, the major difference being the marked response of the diaper dermatitis to mupirocin. Mupirocin should be applied topically 3-4 times daily or with each diaper change and is an excellent antifungal agent.

Skin care practices in the neonatal nursery: a clinical survey

OBJECTIVE

To survey the details of skin care practices in a sample of level I, II, and III nurseries in the United States.

DESIGN

A survey conducted by written questionnaire, personal inspection, and phone contact.

PARTICIPANTS

Information was obtained from staff physicians and nurses about routine neonatal skin care practices, including bathing, cord care, emollient use, diapering, use of antimicrobial skin preparations, management of intravenous infiltration, approach to diaper rash, and methods used to minimize transcutaneous water loss.

SETTING

Fifteen nurseries from twelve hospitals in four states were surveyed.

RESULTS

Among the nurseries surveyed, we found no uniform approach to skin care. Only two individual maneuvers were consistently performed in all the nurseries: criteria for bathing and skin antisepsis with povidone-iodine. Other than these, a wide range of practices and products were used, some with a high ratio of risk and/or cost to benefit.

CONCLUSION

A better understanding of the principles of infant skin care and a more uniform approach to skin care in the neonatal nursery can minimize risks and costs to this special population of patients.

Methemoglobinemia induced by an over-the-counter medication

OBJECTIVE

To report a case of methemoglobinemia induced by benzocaine and resorcinol (Vagisil) cream, an over-the-counter medication that was used to treat diaper rash in a neonate.

CASE REPORT

A 6-day-old, 3350-g white boy was found to be cyanotic with blue mucous membranes on presentation. He had a diaper rash that was red and irritated, which his mother had treated with Vagisil cream. Methemoglobinemia secondary to absorption of benzocaine and resorcinol (1,3-benzenediol) from the Vagisil was diagnosed, with a methemoglobin level of 35% on admission (normal 0.4-1.5). Intravenous methylene blue 3 mg (1 mg/kg) was given; the neonate's skin color returned to normal 45 minutes after the dose.

DISCUSSION

Methemoglobinemia is a condition in which hemoglobin is oxidized to the ferric form. Oxidized hemoglobin, methemoglobin, is incapable of reversibly binding oxygen at the physiologic partial oxygen pressure. Main causes of methemoglobin formation are exposure to certain oxidizing agents and drugs, deficiency of one of the enzymes necessary for reduction of methemoglobin to hemoglobin, or the presence of an abnormal hemoglobin resistant to reduction. Clinical manifestations of methemoglobinemia include diffuse slate-gray cyanosis with low oxygen saturation in the absence of respiratory distress. A single intravenous dose of methylene blue 1-2 mg/kg is the treatment of choice.

CONCLUSIONS

Newborn infants are at increased risk for methemoglobinemia due to diminished enzyme systems required to reduce ferrihemoglobin to ferrohemoglobin, as well as because fetal hemoglobin is more easily oxidized than is adult hemoglobin. It is important to recognize possible drug reactions and educate parents on the potential risks of treatment with over-the-counter medications, especially in neonates.

Pigmented and hyperkeratotic napkin dermatitis: a liquid detergent irritant dermatitis

BACKGROUND

Napkin or diaper dermatitis (DD) is an inflammatory cutaneous eruption limited to the diaper area and common in the first 2 years of life. A number of clinical variants of DD have been identified.

OBJECTIVE

We report a new variant of DD characterized by papyraceous skin, brownish discoloration and predilection for the depth of folds.

METHODS

15 infants and toddlers affected by this peculiar type of DD were evaluated regarding duration, localization, morphology and evolution of their dermatosis.

RESULTS

This variant of DD was mainly confined to the depth of inguinal and gluteal folds and invariably associated with severe xerosis with papyraceous and glazed skin. The patients were healthy and asymptomatic and all laboratory investigations performed were normal. All patients were frequently changed and thoroughly washed with synthetic detergents with acid pH. DD improved rapidly with reduced frequency of washing and discontinuation of liquid detergents.

CONCLUSIONS

We conclude that this condition is a type of irritant contact dermatitis from excessive use of lipid acid detergents.

Nappy rash: a pharmaceutical approach

Before dealing with nappy rash, first examine the cause. Simple precautions such as frequent changing of the nappy, cleaning the skin and applying a water-repellent barrier cream can prevent some types of nappy rash from occurring. Creams and ointments for nappy rash contain a variety of ingredients such as emollients, water-repellents, antiseptics, astringents and anti-inflammatory agents. Nappy rash caused by Candida (thrush) needs to be treated with specific antifungals, eg clotrimazole, nystatin, miconazole. Rashes which do not settle or which recur frequently should be referred to a doctor for further investigation and treatment.