OTCs Today
Daniel L. Krinsky, RPh, MS
Diaper dermatitis is an acute inflammation of the skin occurring in the region of the perineum, buttocks, lower abdomen, and inner thighs. Despite the perception that this condition is limited to infancy, it can and does occur in any population in which incontinence is present. The majority of diaper dermatitis cases appear in infants aged 2 years and younger.
Causes of diaper rash
Multiple factors can cause diaper dermatitis. Occlusion, moisture, microbes, GI tract proteolytic enzymes and bile salts, a shift from the normal acidic skin pH (pH 4.0–5.5) to a more alkaline pH, mechanical chafing, and friction can cause skin compromise and, in additive or synergistic ways, present as diaper dermatitis.
Skin left in contact with wetness for long periods becomes waterlogged or hyperhydrated, which plugs sweat glands, increases susceptibility to abrasion and frictional harm, and diminishes the barrier function of the stratum corneum in the diaper area.
Diaper dermatitis usually presents as red to bright red (erythematous), sometimes shiny, wet-looking patches and lesions on the skin. Lesions may appear dusky maroon or purplish on darker skin. Generally, diaper dermatitis occurs on the skin spaces covered by the diaper, but severe cases can spread outside the diaper area.
Self-treatment usually involves increased vigilance in keeping the infant dry and use of skin protectants in the diaper area. Self-treatment should be limited to uncomplicated diaper dermatitis.
Treatment
The goals of diaper dermatitis treatment are to relieve symptoms, rid the patient of the rash, prevent secondary infection, and prevent recurrences. The general treatment approach for diaper dermatitis is the use of nonpharmacologic therapy or a combination of pharmacologic and nonpharmacologic therapy.
Nonpharmacologic therapy plays an integral role in the treatment of diaper dermatitis and can be remembered through the mnemonic ABCDE: air, barrier, cleansing, diaper, and education. Nonpharmacologic therapy should reduce occlusion, reduce contact time of urine and feces with skin, reduce mechanical irritation and trauma, protect the skin from further irritation, encourage healing, and discourage the onset of secondary infection.
Pharmacologic therapy should protect the skin from further contact with urine and feces, soothe any discomfort caused by the lesions, encourage healing, and prevent the onset of secondary infection. Skin protectants are the only products considered safe and effective for use in diaper dermatitis without medical referral.
FDA has approved 17 ingredients—all skin protectants—for treatment of infant diaper dermatitis. The most common are zinc oxide, white petrolatum, lanolin, and calamine.
Skin protectant dosing and application are straightforward. The protectant is applied liberally to the skin in the diaper area and should be reapplied as needed and with every diaper change.
Diaper dermatitis that does not necessitate medical referral commonly improves dramatically within 24 hours of initiating such treatment.
What to tell your patients
Topical nonprescription antibiotic and antifungal agents are not appropriate to use for self-treatment of diaper dermatitis. If an infection is suspected, parents should seek medical advise.
Likewise, topical analgesics are not recommended because they can alter sensory perception in a population that often cannot communicate perceptual changes. Hydrocortisone is indicated for minor skin irritation, but it should not be used in diaper dermatitis without supervision by a health professional. Hydrocortisone can increase the risk of secondary infection via immune response suppression.
Some of the more common exclusions for self-care include lesions present for 7 days or more; frequent recurrence; presence of broken skin; oozing, vesicles, or pus at the lesion sites; and comorbid conditions.
Diaper rash is preventable through some proactive actions and easily managed if caught early. Pharmacists should remember this is not just a condition seen in infants, and as a health care provider, they have opportunities to counsel parents and caregivers on these important measures.