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| {{DiseaseDisorder infobox |
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| Name = Diaper rash |
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| ICD10 = {{ICD10|L|22||l|20}} |
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| ICD9 = {{ICD9|691.0}} |
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| }}
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| __NOTOC__ | | __NOTOC__ |
| | '''For patient information, click [[Diaper rash (patient information)|here]]''' |
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| | {{Diaper rash}} |
| {{CMG}} | | {{CMG}} |
| | ==[[Diaper rash overview|Overview]]== |
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| ==Overview== | | ==[[Diaper rash historical perspective|Historical Perspective]]== |
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| '''Diaper rash''' (U.S.) or '''nappy rash''' (UK), is a generic term applied to [[skin]] rashes in the [[diaper]] area that are caused by a various skin disorders and/or irritants.
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| ''Generic'' rash or ''irritant diaper dermatitis'' (IDD) is characterized by joined patches of [[erythema]] and scaling mainly seen on the [[wikt:convex|convex]] surfaces, with the [[skin fold]]s spared.
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| Diaper [[dermatitis]] with secondary [[bacteria|bacterial]] or [[fungi|fungal]] involvement tends to spread to [[wikt:concave|concave]] surfaces (i.e. skin folds), as well as convex surfaces, and often exhibits a central red, beefy [[erythema]] with satellite [[pustules]] around the border (Hockenberry, 2003).
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| ==Differential diagnosis==
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| 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.
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| *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.
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| *Atopic dermatitis, or [[eczema]], is associated with [[allergic reaction]], often [[heredity|hereditary]]. This class of rashes may appear anywhere on the body and is characterized by intense [[itch|itchiness]].
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| ==Causes== | |
| Irritant diaper dermatitis develops when skin is exposed to prolonged wetness, increased 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 [[Microbe|microbial]] invasion of the skin (Tortora and Grabowski, 2003). In infants, this layer of the skin is much thinner and more easily disrupted.
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| ===Urine's effects===
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| 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 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.
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| ===Diet's effects===
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| 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 8–12 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’s 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).
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| 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 [[Gut flora|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 due to the fact that fecal enzymes such as [[lipase]] and [[protease]] are more active in feces which have passed rapidly through the [[gastrointestinal tract]] (Atherton, 2004).
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| ==Secondary infections== | | ==[[Diaper rash classification|Classification]]== |
| The significance of [[secondary infection]] in IDD remains controversial. Atherton contends that, “''[[Candida 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).
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| 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 [[Wiktionary:oral|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]]'', [[Enterococcus|enterococci]] and ''[[Pseudomonas aeruginosa]]'', but it appears that ''[[Candida albicans|Candida]]'' is the most common opportunistic invader in diaper areas (Ferrazzini et al., 2003; Ward et al., 2000).
| | ==[[Diaper rash pathophysiology|Pathophysiology]]== |
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| Although apparently healthy infants sometimes culture positive for ''[[Candida albicans|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).
| | ==[[Diaper rash causes|Causes]]== |
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| ==Treatments== | | ==[[Diaper rash differential diagnosis|Differentiating Diaper rash from other Diseases]]== |
| The most effective treatment, although not always the most practical one, is to discontinue use of diapers, allowing the affected skin to air out. Other commonly recommended remedies include oil-based protectants, often using various over-the-counter "diaper creams", but sometimes people use [[petroleum jelly]] and [[shark liver oil]] or [[cod liver oil]]; [[zinc oxide]] based ointments, and, in extreme cases, anti-fungal cremes. Low concentration [[hydrocortisone]] creams are also sometimes used to treat the symptoms of diaper rash, although they do little to clear up the rash itself. Some claim that discontinuing the use of baby "wipes" can be effective in alleviating the symptoms of diaper rash.
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| ==References== | | ==[[Diaper rash epidemiology and demographics|Epidemiology and Demographics]]== |
| *Atherton, D.J. (2001) The aetiology and management of irritant diaper dermatitis. ''Journal of the European Academy of Dermatology and Venereology 15 (Supplement 1)'', p. 1-4.
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| *Atherton, D.J. (2004) A review of the pathophysiology, prevention and treatment of irritant diaper dermatitis. ''Current Medical Research and Opinion, 20(5)'', p. 645-649.
| | ==[[Diaper rash risk factors|Risk Factors]]== |
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| * Atherton, D.J. & Mills, K. (2004) What can be done to keep babies’ skin healthy? ''RCM Midwives Journal, 7(7)'', p. 288-290.
| | ==[[Diaper rash natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| * Borkowski, S. (2004) Diaper rash care and management. ''Pediatric Nursing, 30 (6)'' p. 467-470.
| | ==Diagnosis== |
| | [[Diaper rash history and symptoms|History and Symptoms]] | [[Diaper rash physical examination|Physical Examination]] | [[Diaper rash laboratory findings|Laboratory Findings]] | [[Diaper rash other imaging findings|Other Imaging Findings]] | [[Diaper rash other diagnostic studies|Other Diagnostic Studies]] |
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| * 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%. ''Pediatric Dermatology, 18(2)'' p.149-55.
| | ==Treatment== |
| | [[Diaper rash medical therapy|Medical Therapy]] | [[Diaper rash primary prevention|Primary Prevention]] | [[Diaper rash secondary prevention|Secondary Prevention]] | [[Diaper rash cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Diaper rash future or investigational therapies|Future or Investigational Therapies]] |
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| * Ferrazzini, G., Kaiser, R.R., Hirsig Cheng, S.K., Wehrli, M., Della Casa, V., Pohlig, G., Gonser, S., Graf, F. & Jorg, W. (2003) Microbiological aspects of diaper dermatitis. ''Dermatology, 206'', p. 136-141.
| | ==Case Studies== |
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| * Gupta, A.K., Skinner, A.R. (2004) Management of diaper dermatitis. ''International Journal of Dermatology, 43'' p. 830-834.
| | [[Diaper rash case study one|Case #1]] |
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| * Hockenberry, M.J. (2003) ''Wong’s Nursing Care of Infants and Children''. St. Louis, MO; Mosby, Inc.
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| * Tortora, G.J & Grabowski, S.R. (2003) ''Principles of Anatomy and Physiology, Tenth Edition''; New York, NY; John Wiley & Sons, Inc.
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| * Ward, D.B, Fleischer, A.B., Feldman, S.R., & Krowchuk, D.P. (2000). Characterization of diaper dermatitis in the United States. ''Archives of Pediatrics & Adolescent Medicine, 154 (9)'', p. 943-946.
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| * Wolf, R., Wolf, D., Tuzun, B. & Tuzun, Y. (2001) Diaper Dermatitis. ''Clinics in Dermatology, 18'', p. 657-660.
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| ==External links==
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| * [http://www.medinfo.co.uk/conditions/nappyrash.html Some practical advice for dealing with the condition]
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| * [http://www.lib.uiowa.edu/hardin/md/diaperrash.html Links to pictures of Diaper Rash (Hardin MD/Univ of Iowa)]
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| {{Diseases of the skin and subcutaneous tissue}} | | {{Diseases of the skin and subcutaneous tissue}} |
| [[zh:尿布疹]] | | [[zh:尿布疹]] |
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