| Basics | Clinical Manifestations | Diagnosis and Treatment |
| Infections | | | |
| Candidal diaper dermatitis (Fig. 2.18) | Candidal infection of skin, common
May be triggered by recent systemic antibiotic use, diarrhea, and oral thrush. In chronic, recurrent cases candida may be present in patient's GI tract | Bright “beefy” red, well-demarcated scaly patches, collarette of scale at edge, and characteristic satellite papulopustules
Unlike irritant diaper dermatitis, the inguinal fold is usually affected
Can also be seen in oral mucosa and other intertriginous areas | A KOH will be positive and show pseudohyphae and budding yeast
Topical anti-candida treatments including miconazole 2% cream, nystatin cream, or ketoconazole 2% cream. In resistant cases oral therapy with nystatin or fluconazole is required |
| Bullous impetigo (Fig. 2.19) | Infection with a toxin producing strain of Staphylococcus aureus that separates the upper layers of the epidermis
Moisture and warmth can promote bacterial growth; sometimes umbilicus is colonized with the S. aureus | Early: small vesicles that enlarge to 1-2-cm superficial bullae
Late: larger flaccid bullae, rupture easily leaving a collarette of scale, no thick crust, and usually no surrounding erythema
Favors diaper area in newborns but also seen periumbilical, face, trunk, and body folds | Gram stain: gram-positive cocci in clusters; bacterial culture + S. aureus
Treat with topical antibiotics (mupirocin 2% ointment or fusidic acid cream or ointment); oral antibiotics are used if there are systemic findings or not improving with topicals (cephalexin) |
| Inflammatory conditions | | | |
| Seborrheic dermatitis | Results from increased activity of sebaceous glands secondary to elevated hormone levels in early infancy | Salmon-colored scaly plaques with greasy yellow scale
Usually involves the inguinal folds and convex surfaces. Occasionally fissuring is seen
No satellite lesions
Typically eruption will also be present in other body folds, face, and/or scalp | Diagnosis is based on clinical recognition
Responds quickly to low-potency topical corticosteroid (hydrocortisone 2.5% ointment) and/or topical antifungals (ketoconazole 2% cream). Spontaneous clearance |
| Psoriasis (Fig. 2.20) | Psoriasis is overall rare in infancy; however, diaper dermatitis with dissemination is the most common presentation of psoriasis in children <2 yrs.
A positive family history of psoriasis may be present | Sharply demarcated confluent erythematous plaques, involve inguinal folds, typical scale of psoriasis may be lacking due to moisture in the diaper area
Typical psoriasis lesions may be present elsewhere | Psoriasis will take longer to clear than seborrheic dermatitis and will require a more potent topical corticosteroid (hydrocortisone valerate 0.2% or desonide 0.05% ointment) |
| Atopic dermatitis (Fig. 2.21) | Uncommonly seen in the diaper area, typically in the inguinal creases | Appears similar to irritant dermatitis (shiny, wrinkled eczematous plaques) but is more chronic and resistant to treatment
Is intensely itchy. Usually typical eczematous plaques are present elsewhere on body | Topical corticosteroids, frequent diaper changes, application of thick barrier ointment with each diaper change. Avoidance of harsh soaps and overuse of wipes |
| Jacquet dermatitis (Fig. 2.22) | Represents the severe end of the spectrum of irritant diaper dermatitis | A severe erosive eruption, well-demarcated papules, nodules, and punched-out ulcerations, typically on the perianal skin | Management is similar to irritant dermatitis, frequent changes, application of thick barrier ointment with each diaper change, low threshold for antimicrobial treatment if not improving |
| Other | | | |
| Langerhans cell histiocytosis (Fig. 2.23) | Rare disease characterized by infiltration of Langerhans cells into various organs of the body | In infants, typically presents as a seborrheic dermatitis-like eruption admixed with petechial and purpuric papules some with red-brown crusting. Fails to respond to treatment
Lesions can also be seen on the scalp and trunk
Can involve skin only or skin + other organ systems | A skin biopsy can confirm the diagnosis in suspected cases
Treatment depends on extent of extracutaneous involvement |
| Acrodermatitis enteropathica (Fig. 2.24A,B) | Rare condition caused by zinc deficiency that usually results from an inherited inability to absorb zinc; less often is acquired due to low levels of zinc in diet (or in maternal milk) or malabsorption from intestinal disease | Well-demarcated scaly plaques in the perineal skin and inguinal folds. Occasionally erosions, vesicles, and bullae. Older lesions become thick with drier scale. Typically, lesions are also present around the mouth and on hands and feet. Usually there is associated diarrhea and alopecia | Diagnosis is confirmed by detection of plasma zinc levels of <50 ug/mL and a low alkaline phosphatase
Responds quickly to zinc supplementation |