History and exam
Key diagnostic factors
common
acute onset of rash in diaper area
Classic finding in irritant contact dermatitis.
erythema of convex surfaces in diaper area
Classic finding in irritant contact dermatitis.
sparing of skin folds
Classic finding in irritant contact dermatitis.
Other diagnostic factors
common
features of candidiasis
Shiny erythematous patches with satellite lesions in diaper area, folds of groin, neck, and axilla, and presence of oral candidiasis.
Diaper rash persisting >3 days is frequently associated with presence of Candida albicans.[1]
features of Staphylococcus aureus infection
Pustules, vesicles, bullae, denuded skin, and honey-colored crusting.
features of group A Streptococcus infection
Erythematous patch around vaginal and anal orifices.
uncommon
fussiness
Caregiver may describe fussiness or irritability with voiding, bowel movements, or diaper changes, due to pain from the diaper rash.
Risk factors
strong
young age (<2 years)
Younger children urinate more frequently and raise fewer objections when wearing a soiled diaper. Therefore, the irritants are allowed longer contact with the occluded skin.
One study of hospitalized patients found that skin breakdown was more likely in younger than older children.[5]
diarrhea
Hospitalized children with more episodes of diarrhea were more likely to experience skin breakdown. More frequent stools and time spent in a soiled diaper leads to diaper rash.[5]
underlying dermatologic disorder
Children with skin problems (e.g. dry skin, eczema, diaper dermatitis) on admission were significantly more likely to experience skin breakdown.[5]
infrequent diaper changes
Increased time in diapers will increase the time exposed to urine and fecal enzymes. Increased exposure to these elements leads to skin breakdown.
excess use of baby care products
Baby care products may expose the baby to potential irritants. Products with minimal additives should be used.
excess detergent
Detergents found in body soaps and laundry soap may irritate the skin. Products with minimal additives should be used, such as those described as fragrance-free or detergent-free.
excess wiping
Friction from caregiver's repeated wiping is a potential irritant.
plastic underpants
Occlusion of the diaper area by plastic will increase the moisture within the diaper, exacerbating the process that can lead to skin breakdown.
no diaper-free time
Time without diapers minimizes the time exposed to irritants used in diaper manufacturing and friction with the diapers themselves. There is also less time in contact with urine and fecal enzymes.
underlying skin infections
Underlying skin infections can be a cause of diaper rash and increase the risk of it being recalcitrant. These can be bacterial infections (S aureus or group A Streptococcus infections) and/or fungal infections (Candida infections).
weak
oral antibiotics
Oral antibiotics may lead to diarrhea and may also increase the risk of secondary fungal infection.[12]
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