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Diaper Rash, Candida (Infant/Toddler)

Candida is type of yeast. It grows best in warm, moist areas. It is common for Candida to grow in the skin folds under a child’s diaper. When there is an overgrowth of Candida, it can cause a rash called a Candida diaper rash.

The entire area under the diaper may be bright red. The borders of the rash may be raised. There may be smaller patches that blend in with the larger rash. The rash may have small bumps and pimples filled with pus. The scrotum in boys may be very red and scaly. The area will itch and cause the child to be fussy.

Candida diaper rash is most often treated with over-the-counter antifungal cream or ointment. The rash should clear a few days after starting the medicine. Infections that don’t go away may need a prescription medicine. In rare cases, a bacterial infection can also occur.

Home care

Medicines

Your child’s healthcare provider will recommend an antifungal cream or ointment for the diaper rash. He or she may also prescribe a medicine to help relieve itching. Follow all instructions for giving these medicines to your child. Apply a thick layer of cream or ointment on the rash. It can be left on the skin between diaper changes. You can apply more cream or ointment on top, if the area is clean.

General care

Follow these tips when caring for your child:

  • Be sure to wash your hands well with soap and warm water before and after changing your child’s diaper and applying any medicine.

  • Check for soiled diapers regularly. Change your child’s diaper as soon as you notice it is soiled. Gently pat the area clean with a warm, wet soft cloth. If you use soap, it should be gentle and scent-free. Topical barriers such as zinc oxide paste or petroleum jelly can be liberally applied to help prevent urine and stool contact with the skin.

  • Change your child’s diaper at least once at night. Put the diaper on loosely. 

  • Use a breathable cover for cloth diapers instead of rubber pants. Slit the elastic legs or cover of a disposable diaper in a few places. This will allow air to reach your child’s skin. Note: Disposable diapers may be preferred until the rash has healed.

  • Allow your child to go without a diaper for periods of time. Exposing the skin to air will help it to heal.

  • Don’t over clean the affected skin areas. This can irritate the skin further. Also don’t apply powders such as talc or cornstarch to the affected skin areas. Talc can be harmful to a child’s lungs. Cornstarch can cause the Candida infection to get worse.

Follow-up care

Follow up with your child’s healthcare provider, or as directed.

When to seek medical advice

Unless your child’s healthcare provider advises otherwise, call the provider right away if:

  • Your child has a fever (see Fever and children, below)

  • Your child is fussier than normal or keeps crying and can’t be soothed.

  • Your child’s symptoms worsen, or they don’t get better with treatment.

  • Your child develops new symptoms such as blisters, open sores, raw skin, or bleeding.

  • Your child has unusual or foul-smelling drainage in the affected skin areas.

Fever and children

Always use a digital thermometer to check your child’s temperature. Never use a mercury thermometer.

For infants and toddlers, be sure to use a rectal thermometer correctly. A rectal thermometer may accidentally poke a hole in (perforate) the rectum. It may also pass on germs from the stool. Always follow the product maker’s directions for proper use. If you don’t feel comfortable taking a rectal temperature, use another method. When you talk to your child’s healthcare provider, tell him or her which method you used to take your child’s temperature.

Here are guidelines for fever temperature. Ear temperatures aren’t accurate before 6 months of age. Don’t take an oral temperature until your child is at least 4 years old.

Infant under 3 months old:

  • Ask your child’s healthcare provider how you should take the temperature.

  • Rectal or forehead (temporal artery) temperature of 100.4°F (38°C) or higher, or as directed by the provider

  • Armpit temperature of 99°F (37.2°C) or higher, or as directed by the provider

Child age 3 to 36 months:

  • Rectal, forehead (temporal artery), or ear temperature of 102°F (38.9°C) or higher, or as directed by the provider

  • Armpit temperature of 101°F (38.3°C) or higher, or as directed by the provider

Child of any age:

  • Repeated temperature of 104°F (40°C) or higher, or as directed by the provider

  • Fever that lasts more than 24 hours in a child under 2 years old. Or a fever that lasts for 3 days in a child 2 years or older.

Diaper rash – Symptoms and causes

Overview

Diaper rash is a common form of inflamed skin (dermatitis) that appears as a patchwork of bright red skin on your baby’s bottom.

Diaper rash is often related to wet or infrequently changed diapers, skin sensitivity, and chafing. It usually affects babies, though anyone who wears a diaper regularly can develop the condition.

Diaper rash can alarm parents and annoy babies. But it usually clears up with simple at-home treatments, such as air drying, more frequent diaper changes and ointment.

Symptoms

Diaper rash is characterized by the following:

  • Skin signs. Diaper rash is marked by red, tender-looking skin in the diaper region — buttocks, thighs and genitals.
  • Changes in your baby’s disposition. You may notice your baby seems more uncomfortable than usual, especially during diaper changes. A baby with a diaper rash often fusses or cries when the diaper area is washed or touched.

When to see a doctor

If your baby’s skin doesn’t improve after a few days of home treatment, talk with your doctor. Sometimes, you’ll need a prescription medication to treat diaper rash.

Have your child examined if the rash:

  • Is severe or unusual
  • Gets worse despite home treatment
  • Bleeds, itches or oozes
  • Causes burning or pain with urination or a bowel movement
  • Is accompanied by a fever

Causes

Diaper rash can be traced to a number of sources, including:

  • Irritation from stool and urine. Prolonged exposure to urine or stool can irritate a baby’s sensitive skin. Your baby may be more prone to diaper rash if he or she is experiencing frequent bowel movements or diarrhea because feces are more irritating than urine.
  • Chafing or rubbing. Tightfitting diapers or clothing that rubs against the skin can lead to a rash.
  • Irritation from a new product. Your baby’s skin may react to baby wipes, a new brand of disposable diapers, or a detergent, bleach or fabric softener used to launder cloth diapers. Other substances that can add to the problem include ingredients found in some baby lotions, powders and oils.
  • Bacterial or yeast (fungal) infection. What begins as a simple skin infection may spread to the surrounding region. The area covered by a diaper — buttocks, thighs and genitals — is especially vulnerable because it’s warm and moist, making a perfect breeding ground for bacteria and yeast. These rashes can be found within the creases of the skin, and there may be red dots scattered around the creases.
  • Introduction of new foods. As babies start to eat solid foods, the content of their stool changes. This increases the likelihood of diaper rash. Changes in your baby’s diet can also increase the frequency of stools, which can lead to diaper rash. If your baby is breast-fed, he or she may develop diaper rash in response to something the mother has eaten.
  • Sensitive skin. Babies with skin conditions, such as atopic dermatitis or seborrheic dermatitis (eczema), may be more likely to develop diaper rash. However, the irritated skin of atopic dermatitis and eczema primarily affects areas other than the diaper area.
  • Use of antibiotics. Antibiotics kill bacteria — the good kinds as well as the bad. When a baby takes antibiotics, bacteria that keep yeast growth in check may be depleted, resulting in diaper rash due to yeast infection. Antibiotic use also increases the risk of diarrhea. Breast-fed babies whose mothers take antibiotics are also at increased risk of diaper rash.

Prevention

The best way to prevent diaper rash is to keep the diaper area clean and dry. A few simple strategies can help decrease the likelihood of diaper rash developing on your baby’s skin.

  • Change diapers often. Remove wet or dirty diapers promptly. If your child is in child care, ask staff members to do the same.
  • Rinse your baby’s bottom with warm water as part of each diaper change. You can use a sink, tub or water bottle for this purpose. Moist washcloths, cotton balls and baby wipes can aid in cleaning the skin, but be gentle. Don’t use wipes with alcohol or fragrance. If you wish to use soap, select a mild, fragrance-free type.
  • Gently pat the skin dry with a clean towel or let it air dry. Don’t scrub your baby’s bottom. Scrubbing can further irritate the skin.
  • Don’t overtighten diapers. Tight diapers prevent airflow into the diaper region, which sets up a moist environment favorable to diaper rashes. Tight diapers can also cause chafing at the waist or thighs.
  • Give your baby’s bottom more time without a diaper. When possible, let your baby go without a diaper. Exposing skin to air is a natural and gentle way to let it dry. To avoid messy accidents, try laying your baby on a large towel and engage in some playtime while he or she is bare-bottomed.
  • Consider using ointment regularly. If your baby gets rashes often, apply a barrier ointment during each diaper change to prevent skin irritation. Petroleum jelly and zinc oxide are the time-proven ingredients in many diaper ointments.
  • After changing diapers, wash your hands well. Hand-washing can prevent the spread of bacteria or yeast to other parts of your baby’s body, to you or to other children.

In the past, it was common to use powders, such as cornstarch or talcum powder, to protect a baby’s skin and absorb excess moisture. Doctors no longer recommend this. Inhaled powder can irritate a baby’s lungs.

Cloth or disposable diapers?

Many parents wonder about what kind of diapers to use. When it comes to preventing diaper rash, there’s no compelling evidence that cloth diapers are better than disposable diapers or vice versa.

Because there’s no one best diaper, use whatever works for you and your baby. If one brand of disposable diaper irritates your baby’s skin, try another. If the laundry soap you use on cloth diapers seems to cause a diaper rash, switch products.

Whether you use cloth diapers, disposables or both kinds, always change your baby as soon as possible after he or she wets or soils the diaper to keep the bottom as clean and dry as possible.

Washing cloth diapers

If you use cloth diapers, careful washing can help prevent diaper rash. Washing methods vary and many routines work well. They key is to clean, disinfect and remove soap residue. Here’s one effective method:

  • Pre-soak heavily soiled cloth diapers in cold water.
  • Wash diapers in hot water with a mild detergent and bleach. Bleach kills germs. You could also add vinegar to the wash cycle to eliminate odors and rinse out soap residue.
  • Double rinse the diapers in cold water to remove traces of chemicals and soap.
  • Skip fabric softener and dryer sheets because they can contain fragrances that may irritate your baby’s skin.

When a simple diaper rash turns severe

Diaper rashes are one of the banes of infancy. Most are mild, caused simply by irritation of the skin, and disappear within a few days. But rashes complicated by a fungal infection can persist for weeks, making babies fussy and uncomfortable.

The combination of drugs used to treat these severe rashes is not ideal. One medication has side effects; the other hasn’t been tested on children. However, a new topical cream, called Zimycan, appears to safely treat both the cause and the symptoms in infants.

“This cream will be nice to have because these infections are so common and the kids are miserable, which makes the parents miserable too,” says Dr. Dennis B. Woo, chairman of the department of pediatrics at Santa Monica-UCLA Medical Center.

Each year, about 400,000 babies suffer from severe diaper rash caused by Candida, a yeast-like fungus that thrives in the warm and moist environment of the diaper. Typically, yeast rashes are a bright, beefy red with sharp, raised borders and white scales on the surface. The main patches are often surrounded by smaller patches and painful pus-filled sores or blisters. In severe cases, the rash can cover the entire diaper area.

Infants get yeast infections when their diapers chafe and break the surface of the skin. When this protective barrier is breached, it’s easier for microorganisms such as the yeast fungus to invade the skin, Woo says. Babies taking antibiotics for ear infections or other illnesses are prone to these severe rashes because penicillin kills off bacteria that fight yeast infections.

“And it’s not just babies,” says Dr. James J. Leyden, a dermatologist at the University of Pennsylvania School of Medicine in Philadelphia who helped develop Zimycan. “Even the very elderly, who are incontinent and unable to care for themselves, are getting these type of diaper rashes.”

No drugs have been approved for diaper rash complicated by a yeast infection, but pediatricians often prescribe antifungal agents designed for adults, plus topical steroids to reduce the inflammation. However, prolonged use of steroids can thin a baby’s sensitive skin, leaving stretch marks, and may exacerbate bacterial and fungal infections, says Dr. Mary K. Spraker, a pediatric dermatologist at Emory University in Atlanta who assisted in a recent study of Zimycan.

“With the adult antifungal preparations,” she adds, “we don’t know if they’re really safe for babies, or if they provide optimal relief because they have never been tested on infants.”

Zimycan, in contrast, contains zinc oxide and a weakened version of miconazole, a fungus-fighting medication used for adults. “Zinc oxide by itself doesn’t have much effect on the yeast,” Leyden says. “But we found that zinc oxide enhanced the effects of the miconazole, so the two compounds in combination were more potent than when they were used individually.”

A recent test comparing Zimycan with a zinc oxide ointment, which is the standard of care for diaper dermatitis, was encouraging. In the study, 236 children younger than 3 who had a Candida yeast infection in the diaper area were treated for seven days with either Zimycan or the zinc ointment. At the end of treatment, the Zimycan group experienced a 72% reduction in signs and symptoms of the disease, versus 25% with the ointment. “These results were exciting because we could prove the cream really works,” Spraker says.

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Keeping babies rash-free

More than half of infants younger than 15 months develop diaper rash at least once every two months because their skin is so sensitive.

Excessive moisture is the primary culprit. When the skin is wet, it rubs against other skin or the diaper, causing friction and redness, especially in the skin folds of the groin and upper thighs. Enzymes and other substances in the stool can also irritate the skin. Babies may also be allergic to the diaper material, soap or laundry detergent.

Today’s super-absorbent disposable diapers are better at keeping the skin dry, but experts say diapers should still be changed six or seven times a day, and immediately after stooling. If an allergy is the cause, then changing the diaper, soap or laundry detergent brand usually solves the problem. “If the rash persists more than three days or seems to get worse,” says Dr. Mary K. Spraker, “then it’s time to see your pediatrician.”

Yeast Diaper Rash (Candidiasis) | Latham, NY

A shiny red rash, pinker than usual skin, or red bumps in the diaper area that may be caused by a yeast called Candida. There are other causes of diaper rash that produce a similar skin appearance but are not caused by an infection.

What is diaper rash?

Red and irritated skin in the diaper area. There are many causes. The most common are fungal, irritant contact, and seborrheic dermatitis.

  • Fungal diaper rash is caused by a yeast called Candida albicans. It can happen naturally, or commonly during or after a course of antibiotics.

  • Irritant contact dermatitis is caused by skin rubbing against a wet, soiled diaper.

  • Seborrheic dermatitis does not have a clear cause but may also be due to a fungus called Malassezia.

What are the signs or symptoms?

What are the incubation and contagious periods?

  • Incubation period for fungal diaper rash: Unknown.

  • Contagious period: The yeast that infects the diaper area is widespread in the environment, normally lives on the skin, and is found in the mouth and stool. Candida diaper rash may occur with or following antibiotic use. Repetitive or severe Candida diaper rash could signal immune problems.

How do you control it?

  • Use good hand-hygiene technique at all the times listed in Chapter 2.

  • Candidal (yeast) diaper rash: Treat with an antifungal cream so the quantity of yeast in any area is reduced to levels the body can control.

  • Contact/irritant diaper dermatitis: Keep the skin dry and reduce irritation through friction from rubbing of a diaper or other clothing. Avoid soaps or wipes that contain fragrance. Frequent diaper changes, air exposure, or avoiding rubbing of material against the involved skin may help.

  • Seborrhea: Treatment with antifungal cream or shampoo may help.

What are the roles of the teacher/caregiver and the family?

  • Report the infection to the staff member designated by the child care program or school for decision-making and action related to care of ill children. That person, in turn, alerts the parents/guardians so they can seek treatment for the child.

  • Administer prescribed medication as instructed by the child’s health professional.

Exclude from group setting?


No.

Adapted from Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide.

Any websites, brand names, products, or manufacturers are mentioned for informational and identification purposes only and do not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not responsible for the content of external resources. Information was current at the time of publication.

The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.


Last Reviewed: 11/11/2021 2:20:25 AM
Last Revised: 1/14/2021 2:20:26 AM
© 2020 American Academy of Pediatrics. All rights reserved.

Yeast Diaper Rash (Candidiasis)

A shiny red rash, pinker than usual skin, or red bumps in the diaper area that may be caused by a yeast called Candida. There are other causes of diaper rash that produce a similar skin appearance but are not caused by an infection.

What is diaper rash?

Red and irritated skin in the diaper area. There are many causes. The most common are fungal, irritant contact, and seborrheic dermatitis.

  • Fungal diaper rash is caused by a yeast called Candida albicans. It can happen naturally, or commonly during or after a course of antibiotics.

  • Irritant contact dermatitis is caused by skin rubbing against a wet, soiled diaper.

  • Seborrheic dermatitis does not have a clear cause but may also be due to a fungus called Malassezia.

What are the signs or symptoms?

What are the incubation and contagious periods?

  • Incubation period for fungal diaper rash: Unknown.

  • Contagious period: The yeast that infects the diaper area is widespread in the environment, normally lives on the skin, and is found in the mouth and stool. Candida diaper rash may occur with or following antibiotic use. Repetitive or severe Candida diaper rash could signal immune problems.

How do you control it?

  • Use good hand-hygiene technique at all the times listed in Chapter 2.

  • Candidal (yeast) diaper rash: Treat with an antifungal cream so the quantity of yeast in any area is reduced to levels the body can control.

  • Contact/irritant diaper dermatitis: Keep the skin dry and reduce irritation through friction from rubbing of a diaper or other clothing. Avoid soaps or wipes that contain fragrance. Frequent diaper changes, air exposure, or avoiding rubbing of material against the involved skin may help.

  • Seborrhea: Treatment with antifungal cream or shampoo may help.

What are the roles of the teacher/caregiver and the family?

  • Report the infection to the staff member designated by the child care program or school for decision-making and action related to care of ill children. That person, in turn, alerts the parents/guardians so they can seek treatment for the child.

  • Administer prescribed medication as instructed by the child’s health professional.

Exclude from group setting?


No.

Adapted from Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide.

Any websites, brand names, products, or manufacturers are mentioned for informational and identification purposes only and do not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not responsible for the content of external resources. Information was current at the time of publication.

The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.


Last Reviewed: 11/11/2021 2:20:25 AM
Last Revised: 1/14/2021 2:20:26 AM
© 2020 American Academy of Pediatrics. All rights reserved.

Diaper Dermatitis: Clinical Characteristics and Differential Diagnosis – Coughlin – 2014 – Pediatric Dermatology

Abstract

A diverse group of diseases can cause skin conditions in the diaper area including those which are directly caused by diapers or the diaper environment, some which are not directly due to, but are worsened by, the wearing of diapers, and those which are independent of the presence of the diaper or its resulting environment. Many of these conditions are limited to this area of the skin, but others extend to skin outside this area, and some are signs of systemic disease. We review many of the important causes of eruptions in the diaper area and emphasize key points in the differential diagnosis.

Diagnosing rashes in the diaper area is an important skill. Diaper dermatitis (DD) is common, estimated to occur in 25% of children seeking care from a pediatrician 1. To help facilitate diagnosis, eruptions in the diaper region can be divided into three subgroups: skin conditions caused by the presence of the diaper, rashes exacerbated by the diaper (but not directly caused by it), and eruptions present regardless of the presence of the diaper (Table 1).

Table 1.
Quick Guide to Eruptions in the Diaper Area

Subgroup Eruption Morphology Distribution in the diaper area
Skin conditions caused by the presence of the diaper Irritant diaper dermatitis Redness, papules, scaling, superficial erosions; less commonly elevated papules or nodules Skin under the diaper
Allergic diaper dermatitis Redness, edema, vesicles, superficial erosions Skin in contact with the diaper
Miliaria Erythematous papules, occasionally small pustules Occluded skin in the diaper area
Rashes exacerbated by the diaper (but not directly caused by it) Candida albicans diaper dermatitis Bright-red patches with satellite macules or pustules, collarettes of scale Intertriginous folds
Streptococcal diaper dermatitis Bright-red patches, some maceration, no satellitosis Perianal or inguinal creases
Staphylococcal diaper dermatitis Small red papules, pustules, fragile blisters, folliculitis, less commonly furuncles or abscesses Skin under the diaper
Seborrheic dermatitis Red patches, some scale Intertriginous folds
Psoriasis (napkin psoriasis) Red patches, some scale Intertriginous folds, gluteal cleft
Psoriasiform id reaction Red patches and papules, some scale Buttocks, legs, abdomen, neck, face
Eruptions present irrespective of the presence of the diaper Infantile hemangiomas Erythematous papules, plaques, and nodules Skin under the diaper
Langerhans cell histiocytosis Scale, crusting, barely palpable hemorrhagic papules resembling petechiae, atrophy, deep ulcerations Inguinal creases
Zinc deficiency (including acrodermatitis enteropathica) Red patches and plaques with accentuated scale (golden brown to mahogany color) at the margin Periorificial
Kawasaki disease Erythema, desquamation Perianal
Coxsackie virus infection (especially the A6 strain) Vesicles, bullae, punched-out erosions, purpura, petechiae, Gianotti-Crosti–like papules Buttocks, groin

Dermatitis Due to the Diaper or Diaper Environment

The most common cause of DD is irritant DD (Fig.  1A), triggered by prolonged contact between the skin and urine and feces. Irritant DD is most prominent in areas where the diaper is in direct contact with the skin, particularly on the convex surfaces, typically sparing the inguinal creases and gluteal cleft. At the same time, an increasingly common location for irritant DD is the perianal skin, where, in the presence of frequent stools or diarrhea, the diaper is not able to adequately wick away feces. When severe, this can cause erosions (Fig. 1B). Clinical manifestations are variable and include redness, papules, scaling, superficial erosions, and, less commonly, elevated papules or nodules, referred to as “pseudoverrucous papules and nodules (PVPN).” PPVN (Fig. 2) are typically due to chronic, severe irritant DD 2. Jacquet’s DD, an erosive DD, and granuloma gluteal infantum, a nodular DD, are often considered on a spectrum with PVPN because they have the same predisposing factors.

Perianal erythema and superficial erosions present in this 2 month-old infant are common in infants with a high frequency of bowel movements. The areas of macular erythema and fine papules lateral to this with a sharp cut-off are other common features of irritant diaper dermatitis (DD) (A). Irritant DD can be more severe, as shown by this erosive perianal irritant DD in a 1 month-old infant (B).

Pseudoverrucous papules and nodules.

Management of irritant DD requires attention to multiple contributing factors. First, decreasing exposure to urine and liquid stool is paramount. This often requires frequent diaper changes, regardless of whether infants are in cloth or disposable diapers. Next, if using disposable diapers, diapers with absorbent gel material (AGM), which moves moisture away from the skin more efficiently, should be considered. Barrier pastes are also important to decrease contact between skin and urine and feces. Antifungal and antiyeast topical medications can be beneficial in infants with a rash for longer than 3 days, because they commonly develop Candida infection, which complicates the irritant dermatitis 3. Mild topical steroids (e.g., hydrocortisone) can help treat the inflammatory component of these rashes. If this management strategy is not effective, other causes of diaper rash should be considered. For infants with PVPN, treatment of the root cause of the chronic fecal exposure, if possible, is the best approach 3. Otherwise, frequent diaper changes, use of superabsorbent diapers, and thick application of barrier creams is the best approach 2.

Allergic contact dermatitis (ACD) also occurs in the diaper area. Some children are allergic to dyes 4, adhesives, rubber 5, and other components of disposable diapers. Clues to this etiology of diaper rash include rash only in areas the allergen contacts, such as linearly arranged pink patches or plaques corresponding to areas of skin contact with elastic diaper components (typically waistline and upper thighs). More generally, rash in the areas in contact with the diaper, but not in protected areas, can point to ACD as the etiology of DD. Products used to clean the diaper area, such as disposable wipes, can also cause ACD. The 2013 Contact Allergen of the Year, as chosen by the American Contact Dermatitis Society, was methylisothiazolinone, which is found in many diaper wipes 6. For selected patients, patch testing can be helpful in identifying the causative allergy 7.

Miliaria, most commonly miliaria rubra, can occur as a result of the heat and humidity of the diaper environment. It is caused by retention of eccrine sweat in the eccrine duct. Typical findings include erythematous papules, but small pustules are occasionally present 8. The eruption can be pruritic. Treatment involves decreasing the exacerbating heat and humidity, airing the diaper area, if possible, and using diapers with AGM, which can wick away moisture more effectively.

Dermatitis Worsened by the Diaper or Diaper Environment

The second main group of diaper rashes includes eruptions exacerbated, but not directly caused by, the diaper. This group includes eruptions with infectious and noninfectious causes. The most common cause of diaper rash other than irritant DD is infection with Candida albicans (Fig. 3). Candida infection can be a primary cause of DD, although in many chronic cases of DD, Candida albicans acts as a secondary infectious organism, exacerbating preexisting DD. Primary Candida infection typically presents as bright, beefy-red patches with satellite macules or pustules. Small collarettes are also often present. The rash from Candida is typically accentuated in the skin folds and in male infants can involve the scrotum. Topical treatment with nystatin ointment or topical imidazole antifungals is often sufficient. Examination for oral thrush is essential. Cases with oral candidiasis, recurrent cases, and recalcitrant cases may require systemic antifungal therapy, such as nystatin solution or oral fluconazole. Severe, chronic Candida DD can sometimes be a clue to underlying immunodeficiency.

Candida albicans diaper dermatitis with confluent erythema and satellite macules.

Staphylococcal and streptococcal infections can also cause DD. Perianal streptococcal infection, due to group A beta-hemolytic streptococcus, is most often characterized by bright red perianal patches. Streptococcal infection in the diaper area also presents with fiery-red erythema and maceration without satellite lesions in the intertriginous folds, similar to its presentation on the neck and axillary folds, but is less common. Pain, low-grade fever, and malaise may accompany this infection.

Staphylococcus aureus infection (Fig. 4) can develop in newborns due to colonization of the umbilical stump. Staphylococcus aureus infection affects older diapered children as well. Small papules and pustules may be present, or in the case of toxin-producing bacteria, larger, fragile blisters of bullous impetigo can be seen. Other findings such as folliculitis or—much less commonly—furuncles or abscesses may also occur with S. aureus infection. Staphylococcus aureus infection can also present with perianal dermatitis with a virtually identical appearance to classic perianal streptococcal infection 9. Bacterial infections in the diaper area typically require oral antibacterial treatments, although topical agents such as mupirocin may be helpful in recurrent cases or as adjunctive treatment 10.

Staphylococcal infection of the diaper area with erythematous papules, subtle flaccid vesicles, and collarettes of scale.

Inflammatory conditions such as seborrheic dermatitis and psoriasis may also present in the diaper area. Seborrheic dermatitis is most commonly recognized as “cradle cap,” with white to yellow scaling on the scalp, but the diaper area may be affected in conjunction with scalp or intertriginous involvement (Fig. 5). Diaper rashes due to seborrheic dermatitis usually present as well-demarcated, erythematous patches with inguinal fold involvement but without the degree of scale often seen on the scalp. Resolution of seborrheic dermatitis usually occurs by age 6 to 9 months 11. Treatment with mild topical corticosteroids is usually sufficient.

Faintly red patches with a minor degree of scale in the inguinal creases; the presence of severe “cradle cap” helped in diagnosing this as seborrheic dermatitis in the diaper area.

So-called napkin psoriasis in the diaper area may present as an unusually persistent DD, even in the absence of other signs of psoriasis. It typically involves the skin folds and often the gluteal cleft; patients can have a family history of psoriasis, which together with the eruption’s lack of complete response to low-potency steroids, can be a clue to diagnosis.

A unique eruption seen in the setting of Candida infection or napkin psoriasis is the so-called psoriasiform id eruption (Fig. 6A, B) 12. It is typically seen after a fairly severe Candida DD and often develops soon after the initiation of treatment, with scaly papules and plaques spreading onto the torso, neck, and face. It usually resolves spontaneously, although treatment with low- to mid-potency corticosteroids may hasten resolution. It does not necessarily indicate a tendency toward the future development of psoriasis 12.

A widespread eruption in the diaper area with erythematous patches with overlying scale (A) extending beyond the diaper area (B) is characteristic of psoriasiform id eruption.

Eruptions in the Diaper Area Independent of the Diaper

Eruptions can be located in the diaper area independent of the presence of the diaper. The list of such conditions is long and beyond the scope of this article, but several important ones are highlighted 3. Infantile hemangiomas (IH), can present in the diaper area as localized superficial vascular plaques or nodules or as an area of erythema and ulceration, which is occasionally misdiagnosed as a “diaper rash” (Fig. 7). In cases with involvement of a territory of skin, extracutaneous anomalies can be present with a Lower body infantile hemangioma, including Urogenital anomalies or ulceration, Myelopathy, Bony deformities, Anorectal malformations or arterial anomalies, and Renal anomalies (LUMBAR syndrome). Patients with suspected LUMBAR syndrome warrant more-detailed examination with imaging. Ulceration can complicate IH in the diaper area in up to 50% of cases 13.

This 1-month-old infant presented with a unilateral, bright-red plaque with ulceration (now partially healed) as the presentation of a perineal infantile hemangioma. Evidence of an incidental Candidal diaper dermatitis is also present.

Langerhans cell histiocytosis is one of the most serious causes of eruptions in the diaper area. Typically, patients with this rare disorder will have scale, crusting, and barely palpable hemorrhagic papules resembling petechiae, often involving the inguinal creases. They can also have atrophy and deep ulcerations. Clues to this diagnosis include additional involvement of the scalp, ears, or oral mucosa. The majority of patients with Langerhans cell histiocytosis have skin findings 14, and skin biopsy can be vital to making the diagnosis. Early recognition of these findings in the diaper area facilitates timely treatment for affected infants.

Zinc deficiency is an important cause of diaper rashes, most often presenting with a sharply demarcated eruption with accentuated scale at the margin. The scale typically has a slightly golden brown to mahogany color. These plaques may also occur around the mouth and eyes and in the neck folds. The most commonly affected infants are exclusively breastfed premature infants. These children can become zinc deficient as they outgrow the zinc supplied in breast milk. Other causes include cystic fibrosis and an autosomal-recessive disorder (acrodermatitis enteropathica) in which patients lack a zinc transporter to aid in gastrointestinal absorption.

Kawasaki disease (KD; mucocutaneous lymph node syndrome) is another important, potentially life-threatening condition in which a perineal eruption may be an important clue to diagnosis. The majority of patients with KD have accentuated erythema in the diaper area 15. Erythematous macules and patches with early desquamation are typical.

The exanthem seen with hand, foot, and mouth syndrome often involves the diaper area. With the advent of epidemics of Coxsackie virus A6 infection, this may be even more commonly seen than with other causative enteroviruses 16. The rash with Coxsackie A6 infection is more exuberant than with other strains of the virus and presents with variable morphologies, including vesicles, bullae, eczema herpeticum–like punched-out erosions, purpura, petechiae, and Gianotti-Crosti–like papules 16. Although the diaper area, especially the groin and buttocks, is often affected, the exanthem may be more generalized. Involvement of the hands, feet, and perioral area are seen in most cases.

In sum, cutaneous eruptions in the diaper area can be caused by the diaper, exacerbated by the diaper, or occur independent of the presence of the diaper. Using this classification scheme can aid in efficient diagnosis and treatment of these conditions.

Conflicts of interest

Lawrence F. Eichenfield has served as a consultant for Procter and Gamble.

References