Diaper dermatitis: don’t make a rash decision

CASE

LL is an afebrile 26-month-old female who presents with “diaper rash,” which she has had for approximately 10 days. Her mother asks for assistance in choosing a product, as LL’s symptoms are now disrupting her sleep. Upon further investigation, you discover that LL has been given Ex-lax chocolate pieces daily for the past week to treat minor constipation. Skin examination reveals a well-demarcated area of erythema with small blistering on the bilateral buttocks. The perianal skin and genitalia are unaffected.

BACKGROUND

Diaper dermatitis (DD)—diaper rash—is the most common skin eruption in infants and toddlers, but can occur in any person with incontinence.(1,2) This condition arises when the normal skin barrier is impaired due to prolonged exposure to moisture (urine and feces) and destructive fecal enzymes (urease, protease, lipase) become activated in the alkaline environment of the diaper area.(3,4) Mechanical friction produced by diaper wearing further perpetuates skin damage.(4)

Irritant DD is a nonimmunologic reaction triggered by irritants in the diaper area. Convex skin surfaces in direct contact with irritants are affected, while those areas not exposed (e.g., skin folds) are typically spared. Irritant DD often begins as acute erythema, but may progress to an intensely erythematous rash affecting the groin creases and perianal area. The presence of satellite pustules on nearby skin (e.g., thighs or abdomen) is often indicative of a yeast infection. Candida albicans is isolated in up to 80% of infants with perineal skin irritation that persists for three days or longer.(5)

Senna, a plant-based cathartic, is a common ingredient in over-the-counter laxatives (e.g., Ex-lax chocolate pieces) and has been implicated in cases of contact dermatitis in the diaper region.(4,6-9) This type of erosive dermatitis has been observed with a range of senna doses, including therapeutically appropriate doses.

ASSESSMENT AND THE PHARMACIST’S ROLE

While most rashes in the diaper region are simple cases of irritant contact or candidal DD, it is important to recognize that eruptions in this area may reflect an exacerbation of a more diffuse dermatologic condition, or be related to a condition that has coincidently manifested in the diaper area but is otherwise unrelated.(10) Because of the often sharp borders and blistering, irritant DD can be confused with abusive scald burns. A thorough history is important to ensure the correct diagnosis is made. This includes gathering information the rash has been present, exposure to potential irritants (e.g., detergents, medications) and other information (e.g., type of diaper used, frequency of diaper changes), as pertinent. A visual inspection of the rash may be appropriate in certain circumstances. If inspection is inappropriate, the pharmacist should use open-ended questions to gain a description of the rash. DD that lasts three or more days is usually sufficient to confirm a secondary yeast infection. Patients presenting with a rash in the diaper area should be referred when red flags are identified (Table 1). If the dermatitis is deemed to be irritant DD with or without Candida infection, self-care recommendations can be made.

TABLE 1: Diaper Dermatitis Red Flags⁽¹³⁾

• Acute onset with oozing, pus, vesicles or ulceration at lesion site(s)
• Frequent recurrences, especially with no rash-free period
• Moderate/severe presentation with or without systemic signs and symptoms (e.g., fever, nausea, vomiting)
• Rash or skin lesions present outside the diaper area
• Symptoms are part of, or caused by, another disease state
• Complicated secondary infection or comorbid urinary tract infection
• Significant behavioural change in patient (e.g., incessant crying, lethargy, sleep)
• Signs of abuse or neglect
• Patient is immunocompromised
• Symptoms fail to improve despite 7 days of appropriate treatment, or fail to resolve after 14 days

MANAGEMENT STRATEGIES

Primary goals for DD management include relieving symptoms, resolving the dermatitis and preventing recurrence. There is no evidence that any single method is effective alone.(11) Combination methods, including nonpharmacologic and pharmacologic measures, should address all causative factors according to the ABCDE mnemonic (Figure 1).(12) Discontinuation of aggravating factors is a critical first step in DD management;(13) however, the best management of DD is prevention.(11,14)

Irritant DD responds well to a topical barrier applied liberally with each diaper change.(13) In moderate to severe cases, very-low-potency topical corticosteroids (e.g., hydrocortisone 0.5%–1%) may be recommended for a limited duration (1–2 weeks).(13) When candidiasis is suspected, a topical antifungal (e.g., clotrimazole 1%) should also be applied twice daily for one to two weeks, before the barrier product.(13)

PHARMACIST’S RECOMMENDATION

A thorough history reveals well-demarcated borders restricted to the diaper area and sparing of the gluteal folds, suggesting that LL has irritant DD. The senna-containing laxative used to manage constipation may be causing or exacerbating LL’s condition, as sennosides are an established skin irritant when held in the diaper area. The senna-containing laxative should be discontinued and alternatives for managing LL’s constipation (e.g., increasing dietary fibre) should be discussed. Application of a topical barrier cream, such as zinc oxide 40%, should also be encouraged to facilitate skin healing. If senna-containing laxatives are used again in the future, administration should be timed such that bowel movements occur during the day and diapers can be changed promptly to reduce exposure time. Other nonpharmacologic strategies for managing DD described in the ABCDE mnemonic (Figure 1) should also be promoted. If LL’s condition fails to improve within seven days of implementing nonpharmacologic strategies and applying a topical barrier cream, referral for further evaluation is necessary.