On history

• The babies have itching and rash in the region of the diapers. The rash usually resolves in 3 days.
• In Candida dermatitis, the rash is very painful and takes a much longer time to resolve.
• In Staphylococcal diaper dermatitis, there is history of fever, pus drainage and lymph node infections.

On examination

• In irritant dermatitis, the skin is erythematous and scaly, often with papulovesicular and bulbous fissures and erosions. There eruptions can be patchy and confluent. The inguinal folds are often spared.
• Candida dermatitis appears as bright red eruptions with sharp borders and pinpoint satellites papules and pustules. There is oral thrush present. This is usually secondary to parenteral antibiotic therapy.
• In staphylococcus diaper dermatitis, there are thin walled pustules on an erythematous base (larger than those seen with Candida dermatitis). These pustules rupture rapidly producing scaling around the red base.

The diagnosis of diaper rash is made clinically. Laboratory testing can help us in excluding other diseases of the skin.

Blood tests may reveal an increased number of white cells in case of Staphylococcal and other infections. Gram staining of pustules can also reveal neutrophils and clusters of gram-positive bacteria.

Candidiasis is suspected when intertiginous areas are involved or when the rash fails to respond to symptomatic treatment. Potassium hydroxide (KOH) scrapings can show pseudohyphae in suspected cases of candidiasis.

The treatment of diaper rash consists of the following [7] [8].

• Water breathable diapers should be used. Furthermore, frequent changing of diapers promotes healing of the dermatitis.
• Gentle, thorough cleansing of the area with warm water and mild non-perfumed soap should be done.
• Application of lubricants and barrier pastes is helpful [9].
• Topical antifungal therapy and oral nystatin are used in case of Candida infection.
• Topical antibiotics are applied in case of staphylococcal diaper dermatitis.
• Avoiding excessive scrubbing and the use of high alkaline soap are necessary.
• Barrier creams (such as zinc oxide paste or petroleum jelly formations) decrease contact of urine and fecal content with the skin.
• Oral zinc can be used [10].
• The use of vitamin A & D ointment and Burrow solution is also helpful in promoting healing.

With the improvement of diaper hygiene, diaper rash usually resolves without any complications. Diaper rash due to Candida albicans may take up to 3 weeks to resolve.

The contributing factors for the development of diaper rash include the following.

• Diarrhea
• Frequent stools
• Allergic reactions
• Infrequent diaper changes
• Bad cleaning of the diaper area
• Failure to apply topical agents
• Air-tight diapers
• Heavy ammonia exposure
• Superabsorbent diapers
• Diapers with dyes

Every child usually has at least one episode of diaper rash in his or her life. The incidence of diaper rash is around 4-35% in the first 2 years of life. The peak incidence occurs at 7-12 months of age.

A decrease in incidence is seen after toilet training of child which occur at 2 years of age. Moreover, the incidence is lower in breast fed babies. The number of incidents are far greater than the cases reported. The cases of atopic dermatitis are more common in African American population.

Oral thrush is also associated with a higher incidence of diaper rash.

Diaper rash occurs due to interaction of a number of factors. These include moisture, friction, urine and feces, lack of air exposure, the presence of microorganisms and the presence of dye and irritant substances. The creases and folds of the skin lead to difficulty in cleaning of the diaper area and are hence more often involved.

Due to excessive hydration, there is softening of the stratum corneum of the skin. This leads to progressive break down of intercellular lipids. Since stratum corneum is a protective layer, this breakdown will lead to the entry of microorganisms in the skin.

Furthermore, when the fecal and urinary ammonia mix in the diaper, it will lead to decreased hydrogen ion concentration causing a further increase in the pH of the skin. This further augments the cycle of breakdown of the skin lipid layer.

Contrary to the popular belief, ammonia itself does not cause dermatitis. When the baby has diarrhea, excessive amounts of enzymes such as proteases and lipases are excreted in the stool. These fecal enzymes also increase the hydration of the skin and its permeability to bile salts, which also act as skin irritants. The alkaline urine causes activation of fecal lipases, ureases, and proteases which further increases the damage to skin [5] [6].

Superabsorbent diapers that contain certain dyes are suspected to cause allergic contact dermatitis. Secondary staphylococcus and streptococcus infections can also further complicate the irritant diaper rash. When the skin is immunocompromised, it will predispose to the development of Candida infections.

• Avoiding the use of air tight diapers.
• Avoiding the use of heavy alkaline soap.
• Education of the parents regarding use of diapers and cleansing of buttocks after diaper use.

Diaper rash or diaper dermatitis is an inflammatory condition of the skin that usually presents with itching and rash in region the diapers are worn [1]. Usually every baby has diaper rash once in his or her life time. Frequent stools and improper use of diapers can lead to repetitive episodes of diaper rash [2].

The high alkaline pH and excessive hydration of the skin lead to breaking of its lipid layer. The mixing of fecal protease and lipase also further increases the pH. In case of secondary bacterial infection, the rash is often accompanied by fever; whereas in case of Candida infection, oral thrush is also often present [3] [4]. Diaper rash usually resolves within 3 days.