1.1.2.6 Napkin Dermatitis (classical)

Acute inflammatory cutaneous reaction (irritant contact dermatitis) in areas covered by the diaper. Disturbance of the epidermal barrier by lipases and proteases from urine and feces.

Diaper dermatitis is primarily an irritant contact dermatitis secondary to skin maceration through moisture and prolonged exposure to alkaline urine and feces under occlusion (diaper). Diaper dermatitis is usually observed in infants that constitutively have a poor (immature) skin barrier function. Diaper area is particularly prone to suffer disruption by damage (friction), irritation and secondary bacterial or fungal (Candida) infection.

Other potential incriminated factors include excessive heat, sweat retention, warm local environment and local irritant factors (soaps, detergents). Soaps can raise the skin pH which may also result in poor skin barrier function and an increased risk of percutaneous invasion by pathogens.

Secondary factors: Microorganisms, including bacteria (limited role) and Candida albicans, (identified in feces), as a causative fungal infection for severe napkin dermatitis (napkin candidiasis), and broad-spectrum antibiotics use.

Acute to subacute dermatitis. Well-demarcated, confluent erythema confined to the convex surfaces in contact with the napkin (upper thighs, genitalia, buttocks and lower abdomen). Skin folds often spared. Satellite lesions could be present. Chafing or frictional diaper dermatitis tends to involve the inner areas.

In the more severe form, napkin candidiasis may occur, where symptoms include intense erythema and edema involving mostly the diaper area spreading into skin folds with scaling and a scalloped margin.

Etiology: Frictional (chafing) dermatitis, irritant contact dermatitis, allergic contact dermatitis, and diaper candidiasis.

According to severity, napkin dermatitis has been classified as:

1. Mild: pink eruption, with scattered papules on the area covered by a diaper with or without scaling and/or dryness.

2. Moderate: Inflammation covering > 10% of the area covered by a diaper, with or without papules, edema or ulceration.

3. Severe napkin dermatitis secondary to bacterial or candida infection.

History, clinical features. KOH examination to exclude candidiasis. Therapy-resistant and persistent cases may correspond to other disorders: streptococcal infection, dermatitis or Langerhans cell histiocytosis.

• Reduce the degree of occlusion and maceration (change nappies [diapers] frequently, use highly-absorbent disposable ones).

• Protective agents, such as zinc oxide paste.

• Drying disinfectant dye solutions.

• Treat secondary candidal infections (topical antifungals [imidazoles]).

• If complicated by bacterial infection, treat with oral antibiotics (cloxacillin).

• Short-term mild topical corticosteroids (for moderate napkin dermatitis).

Preventive measures (parental advice on napkin care):

• Frequent diaper changes. Keep the skin under a diaper clean and dry.

• Protect Infant skin from irritants and prevent napkin dermatitis in the first year.

• Advise to wash with an emollient soap-free, fragrance-free liquid cleanser, or warm water.

• Avoid potential skin irritants (soaps, detergents perfumed products and alcohol/fragrance- containing products).

Use good-quality super absorbent napkins and frequent barrier preparations (cream, ointment or pastes) with ingredients that form a film and which protects skin from exposure to moisture.