Irritant diaper dermatitis

Irritant diaper dermatitis is the most common cause of diaper dermatitis (diaper rash), a cutaneous reaction localized to the diaper area. While it can affect any individual who wears diapers, it most commonly affects infants 9–12 months of age. The underlying cause is persistent moisture (e.g., from urine and feces) in the diaper area, often due to infrequent diaper changes. Irritant diaper dermatitis is diagnosed clinically. Diagnostic studies are reserved for severe manifestations, diagnostic uncertainty, or to evaluate for other causes of diaper dermatitis. Management includes diaper hygiene with or without low-potency topical glucocorticoids.

• Can occur in any individual wearing diapers; typically seen in infants
• Peak incidence: 9–12 months of age ^[1]

Epidemiological data refers to the US, unless otherwise specified.

• Persistent moisture (e.g., from urine and feces); often due to infrequent diaper changes ^[2]
• Friction between the diaper and skin
• Hygiene products (e.g., scented soaps, wipes, or moisturizers)

• Location
  • Affects convex skin surfaces in contact with the diaper
  • Skin folds are characteristically spared.
• Appearance: well-defined erythema that differs by severity
• Severity
  • Mild: painless, scattered red papules with minimal erythema
  • Moderate: widespread erythema with painful maceration and superficial erosions
  • Severe : widespread erythema with painful papules, nodules, and punched-out erosions

• Irritant diaper dermatitis is a clinical diagnosis based on history and physical examination.
• Diagnostic studies are reserved for severe infection, diagnostic uncertainty, and to rule out alternative conditions. ^[2][3][4]
  • Fungal studies (e.g., KOH test, fungal culture) for suspected severe fungal infection and/or poor response to empiric topical antifungals ^[2][4]
  • Rapid strep test and culture of the perianal region for suspected perianal streptococcal infection ^[5]
  • Bacterial cultures for suspected severe bacterial infection and/or poor response to empiric antibiotics ^[2][4]
  • Patch testing for diagnostic uncertainty in suspected allergic contact dermatitis ^[6]

Consider other causes of diaper dermatitis in individuals with severe or systemic symptoms, cutaneous lesions extending outside the diaper region, or lesions that persist or recur despite appropriate management. ^[4][6][7]

Common causes of diaper dermatitis

Suspect severe infections such as staphylococcal scalded skin syndrome (SSSS) or herpes simplex virus (HSV) infection in individuals with systemic symptoms, rapidly evolving rash, and/or vesicles. ^[3]

Less common causes of diaper dermatitis

• Chronic skin conditions ^[6]
  • Seborrheic dermatitis
  • Atopic dermatitis
  • Psoriasis (e.g., napkin psoriasis)
  • Lichen sclerosus
• Other ^[4][6]
  • Child maltreatment (e.g., neglect, nonaccidental burns) ^[4][15]
  • Scabies ^[3][4]
  • Folliculitis
  • Langerhans cell histiocytosis
  • Acrodermatitis enteropathica

Consider child maltreatment in patients with chronic and/or severe diaper dermatitis. ^[4][15]

The differential diagnoses listed here are not exhaustive.

Approach ^[4][6][7]

• Start appropriate treatment.
  • All patients: Start diaper hygiene.
  • Inflammation: Consider short-term use ; (i.e., < 2 weeks) of a low-potency topical glucocorticoid (e.g., hydrocortisone ). ^[3][4][16]
  • Infectious causes: Provide treatment for identified infections.
• Consider alternative causes and/or dermatology referral for:
  • Inadequate response to treatment ^[7]
  • Unexplained recurrent episodes
  • Diagnostic uncertainty

Use glucocorticoids cautiously in candidal and bacterial infections as they can mask or worsen symptoms. ^[17]

Diaper hygiene (ABCDE) ^{[3][4][6][18]}

• Air: Allow diaper-free time to let the skin fully dry out.
• Barrier
  • Liberally apply barrier emollients containing zinc oxide and/or petrolatum.
  • Avoid combination products that contain a glucocorticoid.
• Clean
  • Gently clean the diaper area with lukewarm water with or without a mild cleanser.
  • Do not remove emollients; reapply if needed to maintain barrier protection.
• Diaper
  • Recommend more frequent diaper changes.
  • Recommend superabsorbent, breathable diapers.
• Education: Discuss the treatment plan.

Avoid using diaper powders (e.g., talc, cornstarch) due to the risk for inhalation pneumonitis. ^[2][7][19]

Ointments and pastes are preferred to creams. ^[20]

• Frequent diaper changes to prevent excessive moisture
• Avoidance of potential allergens
  • Use of unscented mild soaps, wipes, and clothing detergents
  • A soft towel dampened with water may be used instead of wipes.
• Recurrent episodes of irritant diaper dermatitis: The ABCDE approach of diaper hygiene may be used prophylactically.