View
45
Download
0
Category
Tags:
Preview:
DESCRIPTION
journal
Citation preview
DOI: 10.1542/pir.16-4-142 1995;16;142-147 Pediatr. Rev.
Srisupalak Singalavanija and Ilona J. Frieden Diaper Dermatitis
http://pedsinreview.aappublications.orgthe World Wide Web at:
The online version of this article, along with updated information and services, is located on
Print ISSN: 0191-9601. Online ISSN: 1526-3347. Village, Illinois, 60007. Copyright © 1995 by the American Academy of Pediatrics. All rights reserved.trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove
andpublication, it has been published continuously since 1979. Pediatrics in Review is owned, published, Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
by Michael Martin on March 26, 2010 http://pedsinreview.aappublications.orgDownloaded from
FOCUS QUESTIONS
1. How does morphology interactwith distribution to facilitate diag-
nosis when dermatitis is confined
to the diaper area?
2. Which causes of diaper dermatitisare commonly associated with si-
multaneous manifestations outside
the diaper area?
3. Which clinical findings most reli-ably distinguish among the differ-
ent infections that may present as
diaper dermatitis?
4. How is irritant diaper dermatitisbest managed?
5. How is irritant diaper dermatitis
best prevented?
142 Pediatrics in Review Vol. /6 No. 4 April /995
ARTICLE
Diaper DermatitisSrisupalak Singalavanija, MD* and Ilona J. Frieden, MDt
EpidemiologyDiaper rashes are among the mostcommon skin disorders of infancy. Inone survey of 1089 infants, diaperdermatitis occurred in 50%; however,
only 5% had severe rash. The peakincidence of diaper dermatitis is be-
tween 9 and 12 months of age. Therelation between age and the fre-
quency of diaper dermatitis may re-sult from several factors, includingdietary changes from breast milk toformula milk and solid foods during
the first 12 months of life. Breastfed
infants have fewer diaper rashes thando formula-fed infants. The incidenceof diaper dermatitis is 3 to 4 timeshigher in infants who have diarrhea.
The frequency and severity of dia-per dermatitis are significantly lowerwhen the mean number of diaper
changes per day is eight or more,regardless of diaper type. Infants us-ing superabsorbent disposable diapershave a significantly lower frequency
and severity of diaper rash when
compared with infants using clothdiapers.
Diaper TypesThere currently are two types of dia-pering systems: reusable cloth diapers
*Minisfry of Public Health, Children’s
Hospital, Bangkok, Thailand.
tAssociate Clinical Professor, Departments ofDermatology and Pediatrics, University of
California, San Francisco, CA.
and single use (disposable) diapers.
Cloth diapers provide containmentthrough multiple layers of cotton fab-nc, usually aided by the use of plas-
tic or cloth overpants. Nearly all dis-posable paper diapers now contain an
absorbent gelling material within thecellular core.
Whether to use cloth or disposable
diapers is an issue of controversy and
intense emotion. Several studies havecompared the frequency of diaperdermatitis between cloth and dispos-able diapers, and they indicate thatsuperabsorbent diapers reduce theincidence and severity of diaper der-matitis, probably by keeping the skindrier, with a lower pH. Nevertheless,diaper choice for children whose dia-per dermatitis is not severe or recur-rent should be based on other consid-
erations, including cost, practicality,
and impact on the environment.
Pathogenesis of IrritantDiaper DermatitisBy the early l900s, ammonia wasimplicated as a causative agent of
diaper dermatitis. Because of asser-tions that diaper dermatitis was theresult of free ammonia created by theaction of a urea-splitting bacteria,‘ ‘ Brevibacterium ammoniagenes,’ ‘ orurine in the diaper, ‘ ‘ammoniacal
dermatitis’ ‘ became a synonym fordiaper dermatitis. This view prevailedfor many years, until the I 960s,when other investigators suggested
that diaper rash was not a single en-tity, but resulted from multiple etiobo-gies, including seborrheic dermatitis,reactive skin, systemic diseases, aller-
gens, primary irritants, and infections.The robe of ammonia as a cause of
diaper dermatitis fell into disreputeuntil the late 1980s when other inves-tigators demonstrated that urine, inthe presence of fecal urease, in-
creases the pH in the diaper environ-ment, and this increased pH, due toammonia, increases activation ofother fecal enzymes, particularly fe-cal lipases and proteases. The pres-ence of moisture in the diaper itself
increases skin wetness, transepider-mal water loss, and coefficient of skinfriction as well as susceptibility to
abrasion. The compromised skin.
thus, is exposed to a variety of bio-logic, chemical, and physical insultsthat may result in diaper dermatitis.
In addition to causing a primarydiaper dermatitis, Candida albicans
appears to play a role as a secondaryinvader of damaged skin. Even in theabsence of the typical morphology ofcandidab diaper dermatitis, C aihicanshas been recovered from the stool ofone third of infants who have had
diaper dermatitis for more than72 hours. Some authors have recom-
mended that all infants who havesignificant or long-standing irritantdiaper dermatitis be treated with an
anticandidal medication in addition to
other treatments.
Classification of DiaperDermatitisMany common and uncommon disor-ders can affect the diaper area(Table). Conceptually, these are bestdivided into three groups: 1 ) derma-toses rebated to diaper wearing;2) dermatoses aggravated by thewearing of diapers; and 3) dermato-ses in the diaper area (whether or notdiapers are worn).
DERMATOSES RELATED TODIAPER WEARING
The key to preventing irritant diaper
dermatitis is to keep the skin in thediaper area protected from urine andfeces. which act synergistically to
cause most cases of diaper dermatitis.This can be managed by increasingthe frequency of diaper changes andgently cleansing the skin.
The role of skin care during diaperchanges has not been studied care-
fully. It makes sense, however, thatthe skin be cleaned gently and rinsedwith warm tap water after urination
and a mild, nonperfumed soap (suchas Dove#{174})used to help remove resid-ual fecal material. In most cases,
commercially available diaper wipesare well-tolerated, but they probablyshould be avoided if dermatitis isrecurrent.
Barrier creams such as zinc oxidepaste as well as a number of propri-
by Michael Martin on March 26, 2010 http://pedsinreview.aappublications.orgDownloaded from
Pediatrics in Review Vol. 16 No. 4 April 1995 143
DERMATOLOGY
. Diaper Dermatitis
TABLE.DilferentialDiagnosisofDiaperDermatitis
DISEASE USUAL AGE MORPHOLOGY DISTRIBUTION DIAGNOSIS
1. Dermatoses Primarily Related to the Wearing of Diapers
Irritant contact Peak, 9-12 mo; Erythema ± scale; shallow Convexities-ie, buttock, Clinical
dermatitis rare before 1 mo ulcerations thigh, abdomen, andperianal area; spares I
creases
Candidal diaper Any age Beefy, red, scaly plaques Usually involves Clinical; KOHdermatitis with satellites, papules, and inguinal folds
pustules
Miliaria (prickly Any age Multiple discrete, sterile Also lesions on face, Clinical; history of fever,heat) vesicopustules or neck, axilla, arid groin sudden warm spell,
. erythematous papules . etc.
Granuloma gluteal 2-8 mo Reddish-brown to purplish Arises within area of Clinical and/or skininfantum nodules, 0.5-4 cm in preexisting diaper biopsy
diameter dermatitis
Pseudoverrucous Any age Multiple shiny, red, moist,
papules and flat-topped papules and/ornodules nodules
Diaper an d perianal area Clinical and/or skinbiopsy
2. Dermatoses Exaggerated by the Wearing of Diapers
Seborrheic 1-6 mo Well-circumscribeddermatitis erythematous patches or
plaques; occasionally“greasy scale”
Groin ±
foldsinvolvement of Clinical; involvement of
scalp, ears, axillae
Atopic dermatitis � 1 mo Erythema, papules, Convex surfaces; worst Clinical; other areaslichenification area may be adjacent
to diapershow atopic dermatitis;history of atopy
Psoriasis 6-18 mo Well-defined scaly plaques Convex surfaces, Clinical; recalcitrant toinvolvement of folds therapy; family history
(continued on page 144)
etary formulas such as Desitin#{174}mayhelp minimize urine and fecal contactwith the skin. Potentially toxic com-
pounds, such as baking soda and bo-nc acid, should be avoided becauseof the risk of percutaneous absorption.
Irritant diaper dermatitis, or so-called ‘ ‘chafing dermatitis,’ ‘ is themost common form of diaper derma-
titis. It is easily recognized by itsdistribution, with accentuation on theconvex areas, including the buttocks,lower abdomen, genitalia, and upperthigh and sparing of the creases (Fig-ure 1). It varies in severity frommild, with erythema with or withoutscale, to moderate, with more papulesor maccrated lesions. A severe ulcer-
ative form, known as ammoniacalulcers or Jacquet erosive dermatitis,is characterized by well-demarcated,punched-out ulcers or erosions that
have elevated borders (Figure 2).
Management includes more fre-quent diaper changes, and ultraabsor-bent disposable diapers should be
recommended if the dermatitis is re-current or particularly severe. A non-fluorinated, low-potency corticoste-
roid ointment or cream, such ashydrocortisone 1 %, should be appliedfour times daily with diaper changes.If the rash is severe or present morethan 72 hours, anticandidal agentssuch as nystatin, clotrimazole, or
ketoconazole also should be used.Thickly applied barrier creams may
be helpful as adjunctive therapy andafterwards to prevent recurrences.The fixed combination medicationsMycolog Il#{174}and Lotrisone#{174} should
not be used. The former contains tn-amicinolone 0.1 %, an intermediate-strength conticosteroid; the latter con-
tains betamethasone dipropnionate, avery potent topical corticosteroid.
Their potency is enhanced markedlyby the diaper’s occlusive properties,leading to a significant risk of atro-
phy, stniae, adrenal suppression, andCushing syndrome. lodohydroxyquineither alone or in combination with
hydnocortisone also should beavoided because of potential neuro-toxicity.
Candidal diaper dermatitis usuallypresents with beefy, red plaques thathave white scales and satellite pap-
ules and pustules, which almost al-ways involve the inguinal creases(Figure 3). It often develops after an
episode of diarrhea or use of oralantibiotics. Diagnosis is based on thecharacteristic clinical morphology.
KOH scrapings may demonstratepseudohyphae from a fresh papularor pustular lesion, but they may be
negative in bong-standing cases.
Treatment for candidiasis includes
by Michael Martin on March 26, 2010 http://pedsinreview.aappublications.orgDownloaded from
FIGURE 1. Irritant diaper dermatitis in a 9-month-old child.Note the sparing of the inguinal creases. FIGURE 2. ‘Atninoniacal’’ ulcers.
144 Pediatrics in Review Vol. /6 No. 4 April 1995
DERMATOLOGYDiaper Dermatitis
fl . � � � -
� TABLE. Continued
� DISEASE USUAL AGE MORPHOLOGY DISTRIBUTION DIAGNOSIS
� 3. Dermatoses in Diaper Area (Whether or Not Diapers Are Worn)
� Bublous impetigo Usually newborns, Vesicles, pustules, bullae, or Anywhere, but common Clinical, Gram stain, and
� but any age crusts at diaper and bacterial culture� possible periumbilical areas
� Langerhans cell Peak, 1-9 mo Discrete, yellow-brown scaly “Seborrheic Clinical plus skin biopsy.� histiocytosis papules, often purpuric, distribution’ ‘ on scalp, May have associated
� atrophic, or ulcerated neck, axilba. and anemia, lymph-� groin; usually involves adenopathy,� skin folds hepatosplenomegaly
� Acrodermatitis Weeks to months Sharply demarcated Peniorifical and acraJ Associated with diarrhea,
� enteropathica psoriasiform plaques, abopecia, irritability,
. vesicbes, and bublae serum zinc <50 mcg/
�. Congenital syphilis Usually at birth to Papubosquamous, reddish- Palms, soles, knees, Associated with low� 2-6 mo brown lesions; rarely, abdomen, and diaper birthweight,
� erosive or bulbous area hepatosplenomegaly,� anemia; dark field +
� syphilis serologies
� Molluscum Any age, usually Discrete umbilicated papules Anywhere Clinical
� contagiosum � I y
� Scabies 3-4 wk or later Papules, vesicles, burrows, Generalized, with Clinical; positive� nodules, and excoriations predilection at palms scraping for mites,
� and soles, genitalia eggs, or feces
� Hand-foot-and- Early childhood Discrete papules and/or Hands, feet, mouth, Clinical
� mouth disease vesicles and diaper area
� Genital warts Any age Verrucous papules Penineal and perianal Clinical� area
� Human � 3 mo Severe erosions and ulcers Penneal area, especially HIV risk factors,� immunodeficiency gluteal cleft serologies, associated
� virus (HIV) cytomegabovirus.
� herpes infection
L
by Michael Martin on March 26, 2010 http://pedsinreview.aappublications.orgDownloaded from
DERMATOLOGY
Diaper Dermatitis
FIGURE 3. Mild candidal diaper dermatitis.
Pediatrics in Review Vol. /6 No. 4 April /995 /45
general care and topical agents suchas nystatin, cbotnimazole, miconazole,or ketoconazole applied three to four
times daily. Hydrocortisone 1%cream or ointment may help decreaseerythema and inflammation and canbe applied at the same time. Oralnystatin should be used if oral thrush
or perianal candidiasis is present or ifrepeated bouts of candidab dermatitis
occur.
A psoniasiform id reaction mayoccur as a complication of a severecandidab diaper dermatitis, oftenshortly after therapy is initiated.Scaly papules and plaques, usuallyasymptomatic, rapidly develop on the
upper body, usually sparing the ex-tremities. The pathogenesis of thiseruption is not well understood. Al-
though such an eruption may suggestan underlying psoriatic or atopic dia-thesis, most infants who have the
eruption do not develop other skinproblems. The id reaction may persist
for days to weeks, and treatment withlow- to intermediate-potency topicalsteroids sometimes is necessary, de-
pending on the extent and severity ofdisease.
Miliania (prickly heat) is a surpnis-ingly rare cause of diaper dermatitis,possibly because the warm occlusiveenvironment of the diaper is ongoing.Miliania may be due to use of occlu-sive ointments or plastic pants or ac-company fever or sudden change inclimate. Multiple small enythematousvesicopustules or papules are present.The condition is self-limited; precipi-tating factors should be avoided.
Granuboma gluteab infantum is arare disorder characterized by dis-crete red to purple firm, painless nod-ules ranging in size from 0.5 to 4 cmin the diaper area. Lesions in otherintertniginous areas, such as the axillaand neck, also have been described.The etiology is not well understood;it probably represents an unusual in-flammatony response to long-standingirritation, Candida, or fluorinatedcorticosteroids.
The diagnosis often is based onclinical findings, but in severe casesskin biopsy sometimes is necessary
to confirm the diagnosis and differen-tiate it from granulomatous and neo-plastic processes. The histopathologyshows a nonspecific dermal inflam-
matory infiltrate composed of neutro-phils, lymphocytes, histiocytes, plasma
cells, and eosi-nophibs. Lesionsresembling Kaposisarcoma also have
been described.Treatment is
symptomatic be-cause this conditiontends to disappearspontaneously overa period of a fewmonths. Use of
mild topical or intra-lesional steroids hasnot changed the rateof improvement.
Penianalpseudoverrucouspapubes and nodules is an uncommoncondition characterized by 2- to
8-mm shiny. smooth, red, moist, flat-topped papules and nodules locatedin the perianal or suprapubic region.The condition originally was de-scribed as a reaction to irritation in
association with ureterostomies, butthe changes also may be seen in as-sociation with chronic fecal soiling or
diarrhea. The condition probably re-sults from chronic irritation similar tothat of Jacquet dermatitis.
Diagnosis is based on clinical find-ings, but histologic confirmation maybe necessary to differentiate it from
condyboma accuminatum, cutaneousCrohn disease, Langerhans cell histi-ocytosis, or granuboma gluteal infan-
tum. Therapy should be aimed at de-creasing the irritating factors, either
urine or liquid stool, and protectingthe skin with barrier creams such aszinc oxide paste.
DERMATOSES EXAGGERATEDBY DIAPER WEAR
Seborrheic diaper dermatitis is char-acterized by well-circumscribed ery-thematous and scaly plaques thathave flexural accentuation but no sat-eblite lesions. A major clue to thediagnosis is the presence of erythemaand scale in the scalp (cradle cap).face, axilba, retroauricubar area, andneck. The onset of this disease usu-
ally begins at 3 to 4 weeks but mayoccur up to I year of age.
The pathogenesis is unknown. The
diagnosis is made clinically, and thecondition can be treated with hydro-cortisone 1% cream or ointment ap-plied four times a day, adding an
imidazobe cream if the rash is severe.The lesions usually respond quickly
to treatment, and the prognosis isgood.
Atopic dermatitis often spares thediaper area, but infants who haveatopic dermatitis may have an in-
creased susceptibility to irritant dia-per dermatitis. When atopic dermati-tis does appear in the diaper area,
either acute dermatitis or chroniclichenification may be present, andStaphvlococcos aureus, either via
colonization or overt infection, oftenis present. Marked prunitus and a his-tory of atopic dermatitis help in mak-ing the diagnosis. Mild topical corti-costeroids are used in treatment, andoral antistaphybococcal antibioticssuch as erythromycin or dicboxacillin
may help in recalcitrant cases.Psoriasis is rare during infancy, but
may present in the diaper area. It is
characterized by well-demarcated,erythematous plaques, usually withinvolvement of the inguinal folds.
Unlike psoriatic lesions elsewhere,scales may be absent because of theconstant hydration of the area. Theeruption may be quite recalcitrant totherapy, and lack of response to treat-ment may be a clue to the diagnosis.
Treatment is similar to that used fortreating irritant dermatitis, but some-what more potent topical corticoste-roids, such as desonide 0.05%, maybe necessary.
DERMATOSES IN THE DIAPERAREA IRRESPECTIVE OFDIAPER WEAR
Langerhans cell histiocytosis (Letterer-Siwe disease), while rare, should be
by Michael Martin on March 26, 2010 http://pedsinreview.aappublications.orgDownloaded from
.‘‘.‘..,‘..f
. .�s. .rt� #{176}�
�
FIGURE 5. Deep gluteal cleft ulcerations were the
presenting manifestation of pediatric HIV injection.
FIGURE 4. Langerhan.v cell histioevtosis. Note ski,, atrophy.
(Courtesy of M. L. Williams, MD)
/46 Pediatrics iF, Review Vol. /6 No. 4 April /995
DERMATOLOGYDiaper Dermatitis
considered in any infant who has un-usually severe or recalcitrant diaperdermatitis. It is potentially fatal andusually affects young infants; how-ever, it can occur in toddlers and
older children. In addition to the dia-per area, the scalp and retroauricularareas commonly are involved. The
findings of purpuric papules, pete-chiae, deep ulcerations, or atrophy
are important clues to diagnosis be-cause none of these is found in themore usual forms of diaper dermatitis
(Figure 4). Other features includediarrhea, anemia, hepatosplenomeg-aly, lymphadenopathy, and bone in-
volvement. The skin should be biop-
sied to confirm the diagnosis.Acrodermatitis enteropathica (AE)
is caused by zinc deficiency; it canbe inherited as an autosomal reces-sive trait or be secondary to nutri-
tional zinc deficiency due to low zinclevels in breast milk or in preterminfants or infants who have severe
diarrhea and malabsorption. The on-set of symptoms usually occurs after2 months of age.
AE results in a periorificial andacral rash, usually with sharply de-
marcated, scaly, and crusted plaqueslocated around eyes, nose, mouth,anus, and genitalia. Other characteris-
tic clinical findings include alopecia,diarrhea, and irritability. The diagno-sis is confirmed by serum zinc levels
less than 50 mcg/dL. The diseaseresponds rapidly to treatment with
zinc supplements. Other conditionsthat can present with periorificiab der-matitis similar to that of AE include
biotin-multiple carboxylase deficiency
and cystic fibrosis.Staphylococcal pyoderma may
concentrate in the diaperarea, particularly in new-borns, due to coloniza-tion of the umbilicuswith S aureus. The erup-
tion is characterized bytiny vesicles and pus-tubes, honey-crusted ar-eas, or large flaccid bub-lae that rupture rapidly
and leave a red, moist,denuded area. Diagnosiscan be made clinically
and confirmed with aGram stain or culture ofa pustule or blister.Treatment consists ofadministering oral di-cloxacillin 12.5 to 25mg/kg per day or eryth-romycin 50 mg/kg perday for 7 to 10 days.
Congenital syphilis isa historically importantcause of diaper dermati-tis, and the recent increase in its mci-dence continues to make it importantin the differential diagnosis. Lesionsmay be present at birth or postna-tally. Although the most characteris-
tic lesions are symmetric desquama-tion of palms and soles orpapubosquamous eruptions. moist ar-
eas of eroded skin in the diaper area(as well as around the mouth andnose) also may occur. Other clinical
features, including anemia, hepato-splenomegaly, jaundice, and charac-
teristic bony changes, are helpful indiagnosing the condition. If moist,eroded, or bulbous lesions are present,spirochetes should be searched forvia dark field examination. A sero-logic test for syphilis will confirm the
diagnosis.Pediatric human
immunodeficiency
virus (HIV) infec-tion can have nu-merous cutaneousmanifestations, in-cluding severe dia-
per rashes.Thiboutot et al re-cently reported a
case of dissemi-nated cytomegabovi-
ral infection pre-
senting as aneruption in the dia-per area, with deep
erosions and ulcer-
ations. Eight of 23 infants who hadpediatric HIV infection in Romania
had diaper dermatitis, noted to bevery severe in some cases. One of
the authors (IJF) also has seen anat-risk infant who had an unusualerosive diaper dermatitis as the pre-senting manifestation of HIV infec-tion (Figure 5). HIV-infected infantswho have severe diaper dermatitisshould be evaluated carefully for evi-
dence of herpes simplex, cytomegalo-virus, and other infectious etiologies.
Conversely, HIV infection should beconsidered in infants who have un-usually severe diaper dermatitis, par-ticularly if it is erosive.
A number of other infections maypresent with a predominance of be-sions in the diaper area. These in-dude scabies, molluscum contagio-sum, hand-foot-and-mouth disease,and condyboma accuminatum.
SUGGESTED READINGBerg RW. Etiology and pathophysiology of
diaper dermatitis. Arc/i Dermatol. I 988:3:
75-98
Berg RW. Etiologic factors in diaper derma-
titis: a model for development of improved
diapers. Pediatrician. I 987: 14(suppl):27-33
Bluestein J. Furner BB, Phillips D. Granuloma
gluteal infantum: case report and review of
the literature. Pediatr Dermatol. 1990:7:
196-198
Burgoon CJ, Urbach F. Grover WD. Diaper
dermatitis. Pediatr Cliii North Aioi. I 965:8:
835-836Cooke JV. The etiology and treatment of
by Michael Martin on March 26, 2010 http://pedsinreview.aappublications.orgDownloaded from
PIR QUIZ
17. After staying with a baby sitter
over a weekend, a 6-month-old girl
develops a diaper rash. The girl
appears well. You note an erythem-
atous, slightly scaly eruption over
her buttocks, lower abdominal wall,
labia majora, and proximal thighs,
with sparing of the inguinal folds.
The remainder of her examination
is unremarkable. The most appro-
priate diagnosis is:
A. Candidal dermatitis.
B. Irritant dermatitis.C. Miliaria.
D. Psoriasis.
E. Seborrheic dermatitis.
Match each of the following sets of
clinical findings with the appropriate
infectious agent.
19. Flaccid bullae and pustules over
proximal thighs and lower abdomi-
nal wall.
20. Moist erosions in diaper area; des-
quamation of palms and soles.
21. Red, scaly plaques in inguinal
folds; satellite papules and pustules.
A. Candida albicans
B. Staphylococcus aureus
C. Treponema pallidum
18. A 5-month-old girl has a diaper
rash that has persisted for 1 month
despite two courses of nystatin.
The girl is otherwise healthy. An
erythematous, scaly rash is present
in the inguinal folds, behind the
ears, and over the scalp. The re-
mainder of her examination is un-
remarkable. The most appropriate
diagnosis is:A. Atopic dermatitis.B. Letterer-Siwe disease.
C. Psoriasis.
D. Psoriasiform id reaction.
E. Seborrheic dermatitis.
22. A previously well 6-month-old girlhas had an erythematous, slightly
scaly eruption over her buttocks,
lower abdominal wall, labia ma-
jora, and proximal thighs for the
past 2 days. The inguinal creases
are spared. Appropriate manage-
ment would include switching to
ultraabsorbent diapers, more fre-
quent diaper changes, and:
A. Coal tar ointment.
B. Desitin#{174} cream.
C. Mycolog Il#{174}cream.
D. Nystatin cream.
E. Triamcinolone cream (0.025%).
23. A parent can best prevent irritant
diaper dermatitis in a healthy
6-month-old infant by:
A. Changing diapers frequently.
B. Increasing dietary ascorbic acidcontent.
C. Switching from breast to
formula feeding.
D. Using cloth diapers in place of
disposable ones.
E. Using commercial diaper wipes
regularly.
Pediatrics in Review to Hold 1996Cover Art Co ntest: Works by C h lid ren!
In 1996, we plan to display a pieceof art by children on the covers ofour 1996 issues. Four pictures will
be chosen, and the cover artwork
will be changed quarterly.
Rules of the Contest
Pediatricians: Please have your
patients send art they would like
considered to:
1 . The contest will run from Janu-any through July 1995. (Winners
will be chosen in August 1995
for display in 1996. PRIZESwill be awarded to each winner!)
2. The theme of each submission:Draw a picture of you (ie, the
child/adolescent artist) doingyour favorite thing.
3. Qualification: The artist must beeither between the ages of a) 5
and 10 years or b) 1 1 and 15
years. (There will be two cate-
gories, by age, for submissionand judging.)
4. Requirements: The picture mustbe in color and be reproducible
to a size of 3 inches by 4
inches. FREE HINT TOARTISTS: Think Big! Smalldetails don’t show up as well.
Sydney Sutherland,
Editorial Assistant
Pediatrics in Review
do The Department of
Pediatrics, Box 777
University of Rochester Medical
Center601 Elmwood AvenueRochester, NY 14642
(716) 275-0170
Pediatrics in Review Vol. 16 No. 4 April 1995 /47
. . DERMATOLOGY� . �- Diaper Dermatitis
ammonia dermatitis of the gluteal regon of
infants. Am J Dis Child. l92l;22:481-492
Dixon PN, Warm RP, English MP. Role of
Candida albicans infection in napkin rashes.
Br Med J. 1969;2:23-27
Goldberg NS. Esterly NB, Rothman KF, et al.
Perianal pseudoverrucous papules and
nodules in children. Arch Dermatol. 1992;
I 28:240-242
Hara M, Watanabe M, Tagami H. Jacquet
erosive diaper dermatitis in a young girl
with urinary incontinence. Pediatr Dermatol.
198 1:8: 160-161
Jacobs AH. Eruptions in the diaper area.
Pediatr Cliii North Am. 1978:25:209-224
Johns AM, Bower BD. Wasting of napkin area
after repeated use of fluorinated steroid
ointment. Br Med J. 1970; 1:347-348
Jordan WE, Lawson KD, Berg RW, et al.
Diaper dermatitis: frequency and severity
among a general infant population. PediatrDermatol. 1986;3: 198 -207
Koblenzer PJ. Diaper dermatitis: an overview.
Clin Pediatr. 1973:12:386-392
Leibovitz E, Orlow 5, Lawrence R, et al.
Children of Romania: the AIDS legacy.
Children s Hospital Quarterls’. I 99 1;3Leyden JJ, Kligman AM. The role of micro-
organisms in diaper dermatitis. Arch
Dermatol. 1978;I 14:56-59
Longhi F, Carlucci G, Bellucci R, et al. Diaper
dermatitis: a study of contributing factors.
Contact Dermatitis. I 992:26:248 -252
Rebora A, Leyden JJ. Napkin (diaper)
dermatitis and gastrointestinal carriage of
Candida albicans. Br J Dermatol. 1981:105:
55 1-555Thiboutot DM, Beckford A, Mart CR, et al.
Cytomegalovirus diaper dermatitis. ArchDermatol. 199 1 ; 127:296-298
Wong LD, Brantly D. Clutter LB, et al.
Diapering choices: a critical review of the
issues. Pediatr Nursing. 1992:18:41-54
by Michael Martin on March 26, 2010 http://pedsinreview.aappublications.orgDownloaded from
DOI: 10.1542/pir.16-4-142 1995;16;142-147 Pediatr. Rev.
Srisupalak Singalavanija and Ilona J. Frieden Diaper Dermatitis
& ServicesUpdated Information
http://pedsinreview.aappublications.orgincluding high-resolution figures, can be found at:
Permissions & Licensing
http://pedsinreview.aappublications.org/misc/Permissions.shtmlits entirety can be found online at: Information about reproducing this article in parts (figures, tables) or in
Reprints http://pedsinreview.aappublications.org/misc/reprints.shtml
Information about ordering reprints can be found online:
by Michael Martin on March 26, 2010 http://pedsinreview.aappublications.orgDownloaded from
Recommended