Diaper dermatitis

INTRODUCTION — Diaper dermatitis, also called diaper rash, napkin dermatitis, and nappy rash, is the most common skin eruption in infants and toddlers [1-3]. It typically occurs on convex skin surfaces that are in direct contact with the diaper, including the buttocks, lower abdomen, genitalia, and upper thighs (figure 1).

Although diaper dermatitis is a form of irritant contact dermatitis in most cases, eruptions in the diaper area may represent exacerbations of more diffuse skin diseases, such as seborrheic dermatitis or atopic dermatitis, or may be the manifestation of unrelated skin conditions that coincidently manifest in the diaper area (table 1) [3,4].

The clinical features, diagnosis, treatment, and prevention of irritant diaper dermatitis will be reviewed here. Contact dermatitis, seborrheic dermatitis, and psoriasis in children are discussed separately. Irritant contact dermatitis in adults and incontinence-associated dermatitis are also discussed separately.

●(See "Allergic contact dermatitis in children".)

●(See "Cradle cap and seborrheic dermatitis in infants".)

●(See "Psoriasis in children: Epidemiology, clinical manifestations, and diagnosis".)

●(See "Irritant contact dermatitis in adults".)

●(See "Incontinence-associated dermatitis".)

EPIDEMIOLOGY — The reported prevalence and age of onset of diaper dermatitis in infants vary worldwide in relation to differences in diaper use, toilet training, hygiene, and child-rearing practices in different countries [5-10]. In the United States, dermatitis of the diaper area represents 10 to 20 percent of all skin disorders evaluated by the general pediatrician [5,6,9].

According to the 1990 to 1997 National Ambulatory Medical Care Survey, there were 8.2 million pediatric visits for diaper dermatitis in the United States, and the calculated risk of developing diaper dermatitis throughout childhood was one in four [6]. In infants, the estimated prevalence of diaper dermatitis ranges from 7 to over 40 percent [6,11,12]. Diaper dermatitis can develop as early as one week of age, but the peak incidence occurs between 9 and 12 months [13].

PATHOGENESIS — Several factors concur in the pathogenesis of diaper dermatitis, all of which contribute to the local disruption of the skin barrier function [14,15]. They include:

●Excessive moisture – The increased moisture in the diaper area due to a combination of the occlusive effect of the diaper with the presence of fecal and urinary waste leads to maceration of the skin and disruption of the stratum corneum [16-18].

●Friction – Maceration increases the susceptibility to frictional damage from the diaper with further impairment of the skin barrier function [3,19,20]. An altered skin barrier then permits increased permeation of chemical irritants and microorganisms [17,19].

●Increased skin pH and change in skin microbiome – The normal acidic pH of the stratum corneum ("acid mantle") has an important role in the formation and maintenance of the permeability barrier and in the antimicrobial defense [21]. In addition, the elevated pH alters the cutaneous microbiome, making the skin more susceptible to colonization by organisms commonly found on the skin surface (eg, Staphylococcus aureus, Streptococcus pyogenes) and organisms found in the stool (eg, Candida albicans) [22].

●Fecal enzymatic activity – The primary chemical irritants in the diaper area are derived from the synergistic action of urine and stool [23]. Fecal bacteria produce the enzyme urease, which interacts with urine to increase the pH level beneath the diaper. Elevated pH levels activate fecal enzymes (protease and lipase) that directly irritate and damage the skin, causing an inflammatory skin reaction [24].

RISK FACTORS — A variety of factors may increase the risk of diaper dermatitis:

●Immature skin barrier function.

●Infrequent diaper changing.

●Diarrhea/chronic stooling – Infants with diarrhea or chronic stooling have an increased risk of developing diaper dermatitis due to continuous local skin irritation [11,25,26].

●Diet – Dietary factors also may play a role. Breast-fed infants have a lower incidence of diaper dermatitis than formula-fed infants, possibly because breast-fed infants have lower stool pH [23].

●Recent antibiotic therapy – Recent use of broad-spectrum antibiotics may predispose infants to develop diaper dermatitis by increasing the risk of developing diarrhea and secondary yeast infections [27].

CLINICAL FEATURES

Common findings — Irritant diaper dermatitis typically occurs on convex skin surfaces that are in direct contact with the diaper (picture 1A) [16,17]. These locations include the buttocks, lower abdomen, genitalia, and upper thighs (figure 1). The skin folds (areas not in direct contact with the diaper) are classically spared [9].

Diaper dermatitis presents with intense erythema, macules and papules often coalescing into plaques, edema, and scaling in the involved areas. Superficial erosions may be noted in severe cases. In infants with darkly pigmented skin, the erythematous skin may appear deep-red to violaceous (picture 1C) or hyperpigmented (picture 2A). Scaling areas may appear hypopigmented (picture 1B).

The severity of irritant diaper dermatitis ranges from mild asymptomatic erythema to severe inflammation [2].

●Mild diaper dermatitis – Mild diaper dermatitis is characterized by scattered erythematous papules or mild asymptomatic erythema over limited skin areas with minimal maceration and frictional irritation (picture 3).

●Moderate diaper dermatitis – Moderate diaper dermatitis is characterized by more extensive erythema with maceration or superficial erosions (picture 1A-C). Pain and discomfort are associated symptoms.

●Severe diaper dermatitis – Severe diaper dermatitis is characterized by extensive erythema with a glossy appearance, painful erosions, papules, and nodules (picture 4).

Rare presentations — Rare presentations of severe chronic irritant diaper dermatitis that are seen in children usually older than six months and in adults with urinary or fecal incontinence include [3] (see "Incontinence-associated dermatitis"):

●Jacquet's erosive diaper dermatitis – Jacquet's erosive diaper dermatitis is an uncommon variant of diaper dermatitis characterized by multiple well-demarcated punched-out ulcerations, papules, and nodules in the perineal region (picture 5) [28]. Factors contributing to the development of Jacquet's erosive dermatitis include urinary incontinence, infrequent diaper changing, and chronic stooling.

●Granuloma gluteale infantum – Granuloma gluteale infantum is a rare variant of diaper dermatitis that presents with characteristic reddish-purple or hyperpigmented nodules in the inguinal folds, scrotum, buttocks, and medial thighs and is usually seen between two and nine months of age (picture 2A-B) [29,30]. Numerous precipitating factors have been identified, including the use of high-potency topical corticosteroids and pre-existing candidal infections [30]. Although granuloma gluteale infantum may clinically resemble a neoplastic process, it is considered a benign inflammatory dermatosis. Skin biopsy may help confirm the diagnosis. Histology shows acanthosis, hypergranulosis, and a nonspecific dermal inflammatory infiltrate [29,30].

●Pseudoverrucous papules and nodules – Pseudoverrucous papules and nodules present as multiple shiny, white-gray, wart-like papules and nodules on an erythematous background located in the genital area (picture 6) [31]. They have been reported in the peristomal area of patients with urostomy and in children and adults who are incontinent [32-36].

Clinical course — The course of diaper dermatitis is typically episodic. Each episode of mild to moderate diaper dermatitis treated with conventional therapies has an average duration of two to three days. (See 'Mild to moderate diaper dermatitis' below.)

Diaper dermatitis that persists for several days despite standard treatment may be secondarily infected with C. albicans.

COMPLICATIONS — If irritant dermatitis is left untreated for more than three days, it may become secondarily infected with microorganisms such as C. albicans or, less frequently, S. aureus, S. pyogenes, or herpes simplex virus [19].

●Candida infection – Candida superinfection classically presents with beefy red plaques, satellite papules, and superficial pustules that leave a collarette of scale once ruptured. In contrast to simple irritant diaper dermatitis, Candida infections commonly involve the skin folds (picture 7A-E). There also may be a history of diarrhea, recent antibiotic use, or oral thrush. Diagnosis is usually based on the clinical presentation but may be confirmed by potassium hydroxide (KOH) preparation demonstrating pseudohyphae or by fungal culture (picture 8A-B).

Persistent Candida diaper rash in young children may be a sign of disorders that increase the susceptibility to Candida infections, such as type 1 diabetes mellitus, chronic mucocutaneous candidiasis, or an underlying immune deficiency. (See "Epidemiology, presentation, and diagnosis of type 1 diabetes mellitus in children and adolescents" and "Chronic mucocutaneous candidiasis", section on 'Clinical features of AIRE deficiency/APECED'.)

●Impetigo – Secondary infection from S. aureus and, less frequently, from S. pyogenes may also develop in the diaper region. Hallmarks of impetigo include 1 to 2 mm fragile pustules and honey-colored, crusted erosions. Bullous impetigo describes large, flaccid, pus-filled bullae that tend to rupture easily, leaving erosions with a collarette of scale (picture 9A-B). Gram stain and bacterial culture of a pustule should be performed to confirm the diagnosis. (See "Impetigo".)

Infants with bacterial diaper dermatitis who are febrile and/or have systemic symptoms (eg, irritability, lethargy, hypotonia) require additional evaluation and treatment. (See "The febrile infant (29 to 90 days of age): Outpatient evaluation" and "Approach to the ill-appearing infant (younger than 90 days of age)".)

●Perianal streptococcal dermatitis – Infants and children may develop perianal streptococcal dermatitis, a superficial skin infection in most cases caused by group A Streptococcus (picture 10A-B). Clinical features include a bright red, sharply demarcated perianal or perineal erythema, sometimes associated with perirectal fissures, blood-streaked stools, pruritus, and pain with defecation [37,38]. Some children present with intermittent episodes of irritability [39]. The patient and/or household contacts may have a history of recurrent streptococcal pharyngitis [40]. (See "Group A streptococcal tonsillopharyngitis in children and adolescents: Clinical features and diagnosis".)

●Herpes simplex virus infection – Herpes simplex virus infection may manifest with clusters of vesicular, papular, or pustular lesions in the diaper area. Herpes simplex virus infection in the diaper area is a possible manifestation of child abuse. (See "Epidemiology, clinical manifestations, and diagnosis of herpes simplex virus type 1 infection" and "Evaluation of sexual abuse in children and adolescents".)

DIAGNOSIS AND EVALUATION — The diagnosis of irritant diaper dermatitis is made clinically based upon the presence of an erythematous eruption that involves the convex surfaces of buttocks and genital area. It should be noted that in children with darkly pigmented skin, erythema may appear dark brown or violaceous instead of pink or red (as typically seen in patients with lightly pigmented skin). The sparing of the skin folds is characteristic of irritant diaper dermatitis unless there is Candida superinfection.

The evaluation of the child with skin inflammation involving the diaper area is focused on determining whether the eruption is a typical irritant contact dermatitis, the exacerbation of a more diffuse skin disease (eg, seborrheic dermatitis, atopic dermatitis), or the manifestation of unrelated skin conditions that coincidently manifest in the diaper area (table 1) [3,41-44]. (See 'Differential diagnosis' below.)

●History – Aspects of the history that can help identify contributing factors and support or exclude non-diaper-associated dermatitis include [12,16,45-48]:

•Associated symptoms (eg, diarrhea).

•Systemic symptoms.

•Information about diapers and diapering: type of diaper, how often diapers are changed, method of laundering cloth diapers (if cloth diapers are used).

•Information about how the diaper area is cleansed (eg, soaps, cleansers, washcloths, wipes, etc).

•Past history of dermatologic, allergic, or infectious illnesses.

•Family history of inflammatory skin diseases (eg, psoriasis, atopy).

•Recent antibiotic use.

•Exposure to contagious disease (eg, scabies, herpes simplex virus).

•Previous therapies that have been used for the diaper dermatitis. Caregivers should be asked about all products being used in the diaper area since some topical "home remedies" are toxic to infant skin or have the potential for systemic toxicity with percutaneous absorption (eg, boric acid, camphor, phenol, salicylates, and baking soda).

●Laboratory tests – Laboratory tests are not usually necessary in the evaluation of irritant diaper dermatitis. However, they may be helpful in atypical or recalcitrant cases [46].

•Potassium hydroxide (KOH) preparation/fungal culture – In infants with recalcitrant diaper dermatitis that involves the skin folds, a KOH preparation and fungal culture of skin scrapings for Candida (picture 8A-B) can confirm Candida superinfection. (See "Candida infections in neonates: Epidemiology, clinical manifestations, and diagnosis", section on 'Diagnosis'.)

•Scabies preparation – Mineral oil slide preparation for scabies (picture 11). (See "Scabies: Epidemiology, clinical features, and diagnosis", section on 'Diagnosis'.)

•Tests for herpes simplex infection – Polymerase chain reaction (PCR) or viral culture can confirm the diagnosis of herpes simplex virus in infants with suspected herpes simplex infection of the diaper area. (See "Epidemiology, clinical manifestations, and diagnosis of herpes simplex virus type 1 infection", section on 'Diagnosis'.)

•Bacterial culture – Culture of skin lesions for S. aureus or group A Streptococcus. (See "Skin and soft tissue infections in children >28 days: Evaluation and management", section on 'Laboratory evaluation'.)

•Skin biopsy – A skin biopsy may be necessary in cases in which the rash is atypical or unresponsive to therapy.

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of diaper dermatitis is broad and includes [42,43]:

●Infantile seborrheic dermatitis – Clinical features of infantile seborrheic dermatitis include well-circumscribed erythematous papules and plaques with greasy yellow scale most prominent in the skin folds. In the diaper region, the inguinal creases are mainly involved (picture 12). Seborrheic dermatitis is rarely isolated to the diaper area. Most infants also have involvement of the scalp ("cradle cap"), face, neck, and other skin folds (axillae, antecubital fossa, and popliteal fossa) (picture 13). Seborrheic dermatitis usually responds to short-term topical therapy with low-potency corticosteroids or topical antifungal preparations. (See "Cradle cap and seborrheic dermatitis in infants".)

●Atopic dermatitis – Atopic dermatitis usually spares the diaper area since the diaper provides a moist environment that hydrates the underlying skin, preventing the development of eczematous dermatitis (picture 14). When the diaper area is affected by atopic dermatitis, signs of chronic scratching (eg, increase in skin lines and excoriations) may be observed. Atopic dermatitis is usually present elsewhere on the body, and there is typically a history of pruritus and a family history of atopy. (See "Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis" and "Treatment of atopic dermatitis (eczema)".)

●Allergic contact dermatitis – Allergic contact dermatitis is an uncommon cause of dermatitis of the diaper area. Diaper dyes, fragrances, elastic bands, and adhesives are the sensitizing allergens in diapers [46,49,50]. Preservatives, fragrances, and additives in baby wipes and topical creams have also been implicated [46,51,52]. Heat and moisture associated with diaper use may facilitate allergen release and absorption into the skin. (See "Allergic contact dermatitis in children", section on 'Diaper allergic contact dermatitis'.)

●Psoriasis – Psoriasis can appear at any age and may initially develop in the diaper area [53]. It usually presents with sharply demarcated, erythematous, scaly papules and plaques in the diaper area (picture 15A-B). Significant scale may be lacking in involved areas in the diaper region due to the presence of maceration and moisture beneath the diaper. There may be a family history of psoriasis, and erythematous plaques with scale may also be noted elsewhere on the body. (See "Psoriasis in children: Epidemiology, clinical manifestations, and diagnosis".)

●Scabies – Scabies can involve the diaper region in infants (picture 16). An acute, widespread, pruritic dermatitis is the most common manifestation. Cutaneous findings include a widespread vesiculopapular eruption involving the trunk, axillae (picture 17), neck, palms, and soles (picture 18A-B). Other family members with similar lesions and a history of pruritus support the diagnosis. Diagnosis is confirmed by identifying a mite, egg, or stool on microscopic examination of a scraping from a lesion (picture 11). (See "Scabies: Epidemiology, clinical features, and diagnosis".)

●Langerhans cell histiocytosis – Langerhans cell histiocytosis is a potentially life-threatening neoplastic histiocytic disorder that can present as a severe or recalcitrant diaper dermatitis. The cutaneous lesions usually present during infancy or early childhood and consist of red/orange or yellow/brown scaly papules, erosions, or petechiae most commonly in the groin, intertriginous regions, and scalp (picture 19A-B). A skin biopsy is necessary to confirm the diagnosis. (See "Clinical manifestations, pathologic features, and diagnosis of Langerhans cell histiocytosis".)

●Child abuse – Child abuse is an important consideration in severe, recalcitrant, or atypical diaper dermatitis. A severe diaper dermatitis that appears "resistant" to treatment may be the result of neglect by the parent or caregiver. The diaper area is also a possible site for scalds, burns, and bruises in abused children [54]. (See "Child neglect: Evaluation and management" and "Physical child abuse: Recognition".)

●Congenital syphilis – The skin lesions of congenital syphilis may be present at or after birth [9,55]. They may be seen in the diaper area and/or around the mouth and nose and are characteristically copper-colored, scaly macules and papules or moist erosions (picture 20). Perianal papular lesions (condyloma lata) may also be seen. The skin lesions contain spirochetes and are highly infectious. Other manifestations of congenital syphilis include symmetric desquamation of the palms and soles, anemia, hepatosplenomegaly, jaundice, and changes of the long bones. The diagnosis is confirmed with serology or dark field microscopy, if available. (See "Congenital syphilis: Clinical manifestations, evaluation, and diagnosis".)

●Other – Rarely, nutritional deficiencies and immunodeficiencies can present as a recalcitrant diaper dermatitis. These include acrodermatitis enteropathica (zinc deficiency (picture 21)), biotin deficiency, and cystic fibrosis (secondary to malabsorption) as well as many other uncommon disorders [55-58].

MANAGEMENT — The management of diaper dermatitis involves general skin care measures, choice of diapers, and use of topical barrier preparations [2]. Low-potency topical corticosteroids and topical antifungals may be used in severe cases and in cases complicated by Candida superinfection.

General measures

●Skin care of the diaper area

•Increasing diaper change frequency – Increasing the frequency of diaper changing and skin cleansing limits prolonged skin contact with stool and urine and therefore is an essential aspect of the management of diaper dermatitis [55,59].

•Rest periods without a diaper – If possible, an infant with irritant diaper dermatitis should be allowed periods of rest without a diaper (eg, a few hours per day), allowing the skin to be exposed directly to air [2,3].

•Gentle cleansing – The diaper area should be gently cleaned with warm water and a small amount of a mild cleansing product with physiologic pH (see 'Prevention' below). As an alternative, fragrance-free and alcohol-free baby wipes can be used but should be discontinued if the skin becomes irritated or broken down. Preservatives, such as methylisothiazolinone, in baby wipes may cause allergic contact dermatitis [52]. (See 'Differential diagnosis' above and "Common allergens in allergic contact dermatitis", section on 'Isothiazolinones'.)

•Avoidance of harmful products – Powders such as cornstarch or talcum powder pose a significant respiratory risk if accidentally aspirated and therefore should be avoided [45,60]. Baking soda and boric acid powders also should be avoided because of the risk of systemic toxicity with percutaneous absorption [16,45,61,62].

●Choice of diaper – The best choice of diapers for use in infants is a controversial issue [63]. Disposable diapers using advanced diaper technology may be preferred during the treatment of diaper dermatitis because their high absorbing capacity minimizes the skin exposure to urine and feces [64].

Mild to moderate diaper dermatitis

●Topical barrier creams/ointments – Topical barrier preparations in the form of creams, ointments, or pastes are generally used as the initial therapy for mild to moderate diaper dermatitis [16,65]. Topical barriers are applied with every diaper change. They should be applied thickly and can be covered with petroleum jelly to prevent sticking to the diaper [66].

Barrier preparations physically block chemical irritants and moisture from contacting the skin and minimize friction [17,65]. Pastes and ointments generally are better barriers than creams and lotions, which are poorly adherent, minimally occlusive, and may contain fragrances and preservatives.

The most common over-the-counter topical barriers contain petrolatum, zinc oxide, or both. Some also contain lanolin, paraffin, or dimethicone (a silicone oil) [45].

The use of topical barrier ointments and pastes for the treatment of diaper dermatitis is based on long-standing clinical experience. There are no high-quality studies comparing these agents with placebo or with one another [65,67].

●Breast milk – Human breast milk is thought to have anti-inflammatory and antimicrobial properties [68]. In one study including 150 infants with mild to moderate diaper dermatitis, breast milk was as effective as 1% hydrocortisone cream in clearing the rash after seven days of treatment [69]. Another study compared breast milk with a zinc oxide-containing barrier cream for the treatment of moderate to severe diaper dermatitis in 63 infants in the neonatal intensive care unit [70]. The time to improvement was similar in the two groups, although the clinical score post-treatment was lower in the barrier cream group.

●What to avoid – Topical barriers or medications that contain fragrances, preservatives, and other ingredients with irritant or allergic potential (eg, neomycin) should be avoided [65]. Products containing boric acid, camphor, phenol, benzocaine, and salicylates should also be avoided because of the potential for systemic toxicity and/or methemoglobinemia [16,61,65,71-75]. These agents are contained in some commercially available products for diaper dermatitis. (See "Methemoglobinemia", section on 'Acquired causes'.)

Severe diaper dermatitis — We suggest low-potency topical corticosteroids (group 7 (table 2)), such as 1% hydrocortisone, for the treatment of severely inflamed irritant diaper dermatitis that does not respond to skin care measures and use of barrier preparations. Topical corticosteroids are applied twice a day for three to five days concomitantly with barrier preparations [5,9,17,19,55]. Barrier products should be applied last.

The use of topical corticosteroids for diaper dermatitis has not been evaluated in randomized trials. Their use is based on evidence of efficacy in other childhood inflammatory skin conditions and clinical experience.

Potent or fluorinated corticosteroids should not be used in the diaper since the occlusion in the area promotes systemic absorption and may cause adrenal suppression and iatrogenic Cushing syndrome [76-79]. (See "Topical corticosteroids: Use and adverse effects", section on 'Use in children'.)

Candida superinfection — We suggest a topical azole antifungal agent (eg, miconazole, clotrimazole, econazole) for the treatment of diaper dermatitis in any of the following situations:

●Clinical evidence of Candida superinfection (eg, beefy red plaques, satellite papules, superficial pustules, involvement of the skin folds) (picture 7C, 7E)

●Candida superinfection confirmed by potassium hydroxide (KOH) preparation or fungal culture (picture 8A-B)

●Dermatitis that has been present for several days, which increases the likelihood of secondary infection with Candida

Topical antifungals are applied to the diaper area beneath the barrier ointment two to three times a day until the rash has resolved and up to two weeks. Potential adverse effects of topical antifungals include irritation, burning, and itching.

Several randomized and nonrandomized studies have shown the efficacy of topical antifungals, including nystatin, clotrimazole, miconazole, ketoconazole, and sertaconazole, for the treatment of diaper dermatitis complicated by secondary Candida infection [80-85]. In a randomized trial that included 202 infants with diaper dermatitis (63 with culture positive for C. albicans), miconazole nitrate 0.25% in a zinc oxide/petrolatum ointment applied at each diaper change was more effective than vehicle alone in reducing the total rash score at seven days, with the greatest benefit seen in infants with severe dermatitis [82].

Combination topical corticosteroids and antifungal creams, such as betamethasone dipropionate and clotrimazole cream or triamcinolone acetonide and nystatin cream, should not be used in the diaper area. Both contain topical corticosteroids that are too potent for infant skin and may cause unwanted corticosteroid side effects, such as skin atrophy and adrenal suppression.

Bacterial superinfection — If a secondary bacterial infection is present, topical or oral antibiotics may be necessary. For localized infection, topical mupirocin applied twice a day for five to seven days may be sufficient to treat a staphylococcal infection. Oral antibiotics are indicated for more severe infections, including perianal streptococcal dermatitis [18,55,86]. (See 'Complications' above.)

Neosporin ointment should not be used because it contains neomycin, a common inciting allergen for allergic contact dermatitis. Similarly, bacitracin ointment should be avoided. (See "Common allergens in allergic contact dermatitis", section on 'Antibiotics'.)

Refractory diaper dermatitis — In children with recalcitrant diaper rash that does not resolve with standard treatment, non-diaper-associated causes of dermatitis or underlying conditions that predispose to diaper dermatitis must be considered [43]. Additional laboratory testing or a skin biopsy may be required for precise diagnosis. (See 'Differential diagnosis' above.)

Persistent Candida diaper rash in young children may be a sign of type 1 diabetes mellitus, chronic mucocutaneous candidiasis, or an underlying immune deficiency. (See "Epidemiology, presentation, and diagnosis of type 1 diabetes mellitus in children and adolescents" and "Chronic mucocutaneous candidiasis", section on 'Clinical features of AIRE deficiency/APECED'.)

PREVENTION — There are no randomized trials evaluating the efficacy of specific skin care practices, including the use of barrier ointments, in the prevention of diaper dermatitis [87].

●Frequent diaper change – Based on clinical experience, the most effective way to prevent irritant diaper dermatitis is to minimize direct skin contact with urine and feces by frequent diaper change and gentle cleansing of the diaper area [26,47,48,87-89].

●Type of diaper – Although there is significant debate about the environmental impact of disposable versus cloth diapers, disposable diapers have been designed specifically to mitigate factors that predispose to irritant diaper dermatitis [90-93]. Disposable diapers have an absorbent gel core that can absorb up to 80 times its weight in water and outer layers that absorb liquids quickly and prevent liquid from leaking back out of the diaper on the skin [91-93].

However, a systematic review of studies evaluating whether disposable diapers prevent diaper dermatitis in children concluded that there was not enough evidence from good-quality randomized trials to support or refute the use and type of disposable diapers to prevent diaper dermatitis in infants [63]. Whether parents/caregivers choose to use cloth or disposable diapers, frequent diaper changes help prevent irritant diaper dermatitis.

●Cleansing – Overzealous cleansing can promote irritation and delay skin healing.

•Water and cloth – Limited gentle cleansing with warm water and a soft cloth is usually sufficient. If soaps are desired, mild fragrance-free liquid soaps may be used. If the diaper area is eroded, it may be irrigated with warm water from a plastic squeeze bottle or by squeezing a washcloth soaked in warm water [45,94]. Dried feces can be gently removed with mineral oil applied to a cotton ball. It is not necessary to wipe off barrier paste completely at each diaper change, but when removal is required, mineral oil is helpful [45,65,66,94,95]. To avoid unnecessary friction, the diaper area should be dried by gently patting with a towel [45,65].

•Wet wipes – Infant wipes are widely used for practical reasons, although there is limited evidence from randomized trials that they are gentler than water for cleansing the diaper area [96-98]. Fragrance-free and alcohol-free baby wipes are preferred. Baby wipes containing the preservative methylisothiazolinone may cause allergic sensitization and should be avoided [52,99]. (See "Allergic contact dermatitis in children", section on 'Methylisothiazolinone'.)

In a randomized trial including 280 healthy newborns, alcohol-free baby wipes were comparable with cotton wool and water in terms of skin hydration, skin surface pH, transepidermal water loss, and density of microbial skin contaminants [96]. In a randomized study comparing wipes with water and cloth for skin cleansing in preterm and term neonatal intensive care unit newborns, skin erythema, pH, and transepidermal water loss were lower in the wipes group than in the water and cloth group [97].

●Parent/caregiver education – Educating parents and caregivers in ways of preventing and treating diaper dermatitis is of utmost importance. Providing educational materials/handouts can be helpful since it allows families/caregivers to review the information again at home.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Diaper dermatitis".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Diaper rash (The Basics)" and "Patient education: Giving your child over-the-counter medicines (The Basics)")

●Beyond the Basics topics (see "Patient education: Diaper rash in infants and children (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Etiology and risk factors – Diaper dermatitis, also called napkin dermatitis or nappy rash, is a common form of irritant contact dermatitis in most cases due to prolonged contact of the skin with urine and stool, resulting in the disruption of the stratum corneum and inflammation. Infrequent diaper changing, diarrhea, dietary factors, and recent use of antibiotics are the main risk factors for diaper dermatitis. However, eruptions in the diaper area may be the manifestation of unrelated skin conditions, which coincidently manifest in the diaper area (table 1). (See 'Introduction' above and 'Pathogenesis' above.)

●Clinical presentation – Characteristic features of irritant diaper dermatitis include involvement of the convex surfaces and sparing of the skin folds (picture 1A) unless there is Candida superinfection (picture 7E). The lesions may vary from asymptomatic erythema to painful scaling papules and superficial erosions (picture 4). Rare presentations of severe chronic irritant diaper dermatitis include Jacquet's erosive diaper dermatitis (picture 5), granuloma gluteale infantum (picture 2B), and pseudoverrucous papules and nodules (picture 6). (See 'Clinical features' above.)

●Diagnosis – The diagnosis of irritant diaper dermatitis is clinical, based upon the presence of an erythematous eruption that involves the convex surfaces of the diaper area and spares the folds. Atypical-appearing diaper rashes and those that fail to resolve with conventional treatment warrant additional evaluation. (See 'Diagnosis and evaluation' above and 'Differential diagnosis' above.)

●Management

•General measures – General measures for the management of diaper dermatitis include (see 'General measures' above):

-Frequent diaper changing

-Air exposure for a few hours per day

-Gentle skin cleansing

Powders such as cornstarch or talcum powder should not be used for the skin care of infants, as they pose a significant respiratory risk if accidentally aspirated.

•Mild to moderate diaper dermatitis – In addition to general skin care measures, topical barrier ointments or creams (eg, petroleum jelly, zinc oxide creams) are generally used for the treatment of mild to moderate diaper dermatitis. They are applied in a thick layer with every diaper change. Based on limited evidence, the local application of breast milk, if available, may be an alternative to barrier creams.

Topical preparations that contain fragrances, preservatives, and other ingredients with irritant or allergic potential should be avoided. Products containing boric acid, camphor, phenol, benzocaine, and salicylates should also be avoided due to the risk of systemic toxicity. (See 'Mild to moderate diaper dermatitis' above.)

•Severe diaper dermatitis – For severe diaper dermatitis without clinical evidence of Candida superinfection, we suggest low-potency nonhalogenated topical corticosteroids such as 1% hydrocortisone (group 7 (table 2)) in addition to barrier preparations (Grade 2C). The barrier preparations should be applied last. Topical corticosteroids are applied once or twice daily for three to five days. (See 'Severe diaper dermatitis' above.)

•Candida superinfection – For diaper dermatitis complicated by Candida superinfection, we suggest the addition of a topical antifungal azole to barrier preparations (Grade 2C). Topical antifungals are applied two to three times a day until the rash has resolved and up to two weeks. (See 'Candida superinfection' above.)

•Refractory diaper dermatitis – In children with recalcitrant diaper dermatitis, other causes of dermatitis involving the diaper area must be considered. A skin biopsy and/or additional laboratory testing may be required for precise diagnosis. (See 'Differential diagnosis' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Trisha A Prossick, MD, who contributed to an earlier version of this topic review.