Elsevier

Nursing for Women's Health

Volume 19, Issue 4, August–September 2015, Pages 324-337
Nursing for Women's Health

Features
Prevention, Treatment and Parent Education for Diaper Dermatitis

https://doi.org/10.1111/1751-486X.12218Get rights and content

Abstract

Diaper dermatitis is a common cutaneous condition characterized by an acute inflammatory eruption of the skin in the diaper area of an infant. Although this condition is relatively common, it can cause considerable 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. The three most common types of diaper dermatitis are chaffing dermatitis, irritant contact dermatitis and diaper candidiasis. This article reviews common causes, differential diagnosis, current prevention and treatment recommendations, nursing implications and practical tips for families to utilize while caring for their infants at home.

Section snippets

Objectives

Upon completion of this activity, the learner will be able to:

  • 1.

    Describe the prevalence of diaper dermatitis among infants in the United States.

  • 2.

    Describe the pathophysiology of diaper dermatitis.

  • 3.

    List the recommended prevention and treatment strategies for diaper dermatitis.

  • 4.

    Describe targeted parent education for the prevention and treatment of diaper dermatitis.

  • 5.

    Discuss nursing practice implications in the prevention and treatment of diaper dermatitis.

INTRODUCTION

Diaper dermatitis is a common cutaneous condition characterized by an acute inflammatory eruption of the skin in the diaper area of an infant. Although this condition is relatively common, it can cause considerable pain and stress for infants and can be troublesome for their caregivers (Blume‐Peytavi et al., 2014).

PREVALENCE

It is difficult to determine the actual prevalence of diaper dermatitis in the general population due to inconsistencies among published studies and highly variable results, but it is estimated that the prevalence of diaper dermatitis in the general population is between 7 percent and 35 percent (Boiko, 1999; Gupta & Skinner, 2004; Rowe, McCall, & Kent, 2008). It has also been reported that the prevalence among hospitalized infants and children ranges from 17 percent to 43 percent (McLane,

TYPES OF DIAPER DERMATITIS

The three most common types of diaper dermatitis include chaffing dermatitis, irritant contact dermatitis and diaper candidiasis (Paller & Mancini, 2011). Diaper dermatitis is usually related to the presence of irritants on the skin, such as moisture from urine and feces, fecal enzymes, diaper materials and cleansing agents, as well as friction caused by the diaper itself (Humphrey, Bergman, & Au, 2006; Wolf, Wolf, Tuzun, & Tuzun, 2000). Although irritant contact dermatitis is the most common

PHYSIOLOGY OF INFANT SKIN

To understand the development of diaper dermatitis in an infant, it is important to appreciate the differences in skin between adults, full‐term infants and premature infants. Human skin is a complex tissue that assists with thermoregulation, prevents insensible water loss, acts as a sensory organ and functions as a barrier by providing protection from physical, chemical and biologic threats. It consists of three major layers—the stratum corneum, epidermis and dermis. The epidermal barrier is a

PATHOPHYSIOLOGY OF DIAPER DERMATITIS

The development of irritant contact diaper dermatitis is multifactorial. The skin in the diaper area is predisposed to irritation by overhydration or maceration of the stratum corneum and epidermis, the presence of irritants, such as urine or stool, friction on the skin and the presence of a high skin pH (Atherton, 2001). The presence of urine can lead to overhydration of the skin, making the skin surface more fragile and increasing the permeability of the skin by irritants (Atherton, 2001;

CLINICAL PRESENTATION

Chaffing or frictional dermatitis is the most widespread form of mild diaper dermatitis commonly affecting most infants at some point in time. It presents in areas where friction from the diaper is most prevalent, including the inner surface of the thighs, buttocks, abdomen, and the surface of the genital areas (Paller & Mancini, 2011). It presents as mild redness in the affected area and resolves fairly quickly on its own with frequent diaper changes, ensuring the diaper is not too tight, and

ASSESSMENT

Diaper dermatitis is diagnosed by the appearance of the rash and by excluding other potential causes. In addition to a physical assessment, a thorough history must be obtained, including duration of the presenting rash, symptoms, such as pain and itchiness, hygiene practices and cleansing routine, type of diaper used, exposure to potential irritants, trauma to the skin and recent antibiotic use that might predispose an infant to other causes of diaper dermatitis (Lawton, 2014; Shin, 2014).

DIFFERENTIAL DIAGNOSES

There are a wide variety of conditions that can present as an inflamed area of skin in the diaper area. A wider range of differential diagnoses should be considered when diaper dermatitis fails to respond to basic treatment approaches or when there are additional symptoms that require further investigation. Differential diagnoses can be divided into categories, including inflammatory conditions, infectious conditions, and other potential diagnoses.

Diaper dermatitis is diagnosed by the

INFLAMMATORY CONDITIONS

Seborrheic dermatitis is a common cause of dermatitis in infancy that develops around the third to fourth week of life. It presents as asymptomatic, well‐defined erythema, with characteristic salmon‐colored, greasy plaques with yellow scales found on the scalp, cheeks, chest, body creases and diaper areas (Ravanfar, Wallace, & Pace, 2012; Shin, 2014). This condition may require treatment with low‐dose topical corticosteroid as prescribed by a health care provider (Coughlin, Eichenfield, &

INFECTIOUS CONDITIONS

Bacterial infections can present in a variety of forms, including impetigo and bacterial folliculitis. Streptococcal and staphylococcal infections account for the highest number of bacterial diaper dermatitis isolates (Brook, 1992). Impetigo, caused by staphylococcus or streptococcus infection, presents as superficial vesicles or flaccid bullae that eventually develop a honey colored crust (Scheinfeld, 2005; Shin, 2014). Bacterial folliculitis, often caused by staphylococcus aureus, can

OTHER DIFFERENTIAL DIAGNOSES

Nutritional deficiencies, such as zinc deficiency, can present similarly to diaper dermatitis. Acrodermatitis enteropathica, an autosomal recessive condition that leads to zinc malabsorption, presents as sharply demarcated, erythematous plaques, papules and erosion in the periorificial areas, on distal portions of the extremities and in the diaper area (Coughlin et al., 2014; Ravanfar et al., 2012; Shin, 2014). Dermatitis, alopecia and diarrhea are the classic symptoms of this disease. Acquired

NONPHARMACOLOGIC PREVENTION AND TREATMENT

An abundance of literature that supports current best practices in the treatment and prevention of diaper dermatitis has been published, including the most recent evidence‐based clinical practice guideline on neonatal skin care from the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN, 2013). The basic techniques for prevention and treatment are quite similar (Atherton, 2001). Although the key to diaper dermatitis is prevention, once it develops, the overall goal is to

“ABCDE” APPROACH

Practical nonpharmacologic solutions for both prevention and treatment are easily summarized into the “ABCDE” approach that includes air, barrier, cleansing, diapering and education (Boiko, 1999; see Box 4).

PHARMACOLOGIC TREATMENT AND POTENTIAL SIDE EFFECTS

Pharmacological treatment when required includes antibacterial, antifungal and topical corticosteroid therapy. For diaper dermatitis caused by C. albicans, the goal of treatment is both to treat the infection and prevent further skin breakdown. The most commonly prescribed topic antifungal agent for treatment of diaper dermatitis complicated by C. albicans is nystatin (Ward et al., 2000). To facilitate adequate treatment of the fungal infection while still providing barrier protection, Heimall

COMPLICATIONS OF UNTREATED DIAPER DERMATITIS

Complications from diaper dermatitis are rare as the condition is easily treatable with good skin care practices, barrier creams and treatment of underlying infections. In rare instances, or if diaper dermatitis is left untreated, complications including increasing pain, increasing severity of skin breakdown and bacterial and fungal super infections can occur (Shin, 2014). One example is Jacquet's erosive diaper dermatitis, a severe form of diaper dermatitis that can present with severe

CONCLUSION

Diaper dermatitis is a common condition that can cause considerable pain and stress for infants and be troublesome for their caregivers. Differential diagnosis is important, as is identifying any potential underlying conditions, such as a bacterial or viral infection. Nurses play a pivotal role in helping families understand the risk factors for diaper dermatitis and how to prevent it through appropriate diaper hygiene practice. NWH

Post‐Test Questions

Instructions: To receive contact hours for this learning activity, please complete the online post‐test and participant feedback form at http://JournalsCNE.awhonn.org. CNE for this activity is available online only; written tests submitted to AWHONN will not be accepted.

  • 1.

    What is the estimated range of prevalence of diaper dermatitis?

    • a.

      2 percent to 14 percent

    • b.

      7 percent to 35 percent

    • c.

      10 percent to 50 percent

  • 2.

    Which layer of the skin is the protective barrier to physical, chemical and biologic agents?

    • a.

Lisa Merrill, MN, RN, is a clinical nurse specialist at Women's Hospital Health Sciences Center, in Winnipeg, Manitoba, Canada. The author and planners of this activity report no conflicts of interest or relevant financial relationships. This learning activity was supported through an educational grant from Kimberly‐Clark/Huggies®.

REFERENCES (49)

  • Awhonn

    Neonatal skin care evidence‐based clinical practice guideline

    (2013)
  • D.J. Atherton

    The aetiology and management of irritant diaper dermatitis

    Journal of the European Academy of Dermatology and Venereology: JEADV

    (2001)
  • D.J. Atherton

    A review of the pathophysiology, prevention and treatment of irritant diaper dermatitis

    Current Medical Research and Opinion

    (2004)
  • E.L. Baer et al.

    Disposable nappies for preventing napkin dermatitis in infants

    Cochrane Database of Systematic Reviews

    (2006)
  • R.W. Berg et al.

    Etiologic factors in diaper dermatitis: The role of urine

    Pediatric Dermatology

    (1986)
  • U. Blume‐Peytavi et al.

    Prevention of diaper dermatitis in infants—A literature review

    Pediatric Dermatology

    (2014)
  • I. Brook

    Microbiology of secondarily infected diaper dermatitis

    International Journal of Dermatology

    (1992)
  • K.W. Buckingham et al.

    Etiologic factors in diaper dermatitis: The role of feces

    Pediatric Dermatology

    (1986)
  • J.N. Clark‐Greuel et al.

    Setting the record straight on diaper rash and disposable diapers

    Clinical Pediatrics

    (2014)
  • C.C. Coughlin et al.

    Diaper dermatitis: Clinical characteristics and differential diagnosis

    Pediatric Dermatology

    (2014)
  • J.L. Counts et al.

    Modern disposable diaper construction: Innovations in performance help maintain healthy diapered skin

    Clinical Pediatrics

    (2014)
  • P.M. de Wet et al.

    Perianal candidiosis: A comparative study with muciprocin and nystatin

    International Journal of Dermatology

    (1999)
  • L.F. Eichenfield et al.

    Neonatal dermatology

    Current Opinion in Pediatrics

    (1999)
  • J.W. Fluhr et al.

    Infant epidermal skin physiology: Adaptation after birth

    British Journal of Dermatology

    (2012)
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    Lisa Merrill, MN, RN, is a clinical nurse specialist at Women's Hospital Health Sciences Center, in Winnipeg, Manitoba, Canada. The author and planners of this activity report no conflicts of interest or relevant financial relationships. This learning activity was supported through an educational grant from Kimberly‐Clark/Huggies®.

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