diaper dermatitis

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DOI: 10.1542/pir.16-4-142 1995;16;142-147 Pediatr. Rev. Srisupalak Singalavanija and Ilona J. Frieden Diaper Dermatitis http://pedsinreview.aappublications.org the 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 and publication, 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.org Downloaded from

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Page 1: Diaper Dermatitis

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

Page 2: Diaper Dermatitis

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-

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Page 3: Diaper Dermatitis

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

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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

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Page 5: Diaper Dermatitis

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

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Page 6: Diaper Dermatitis

.‘‘.‘..,‘..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

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Page 7: Diaper Dermatitis

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.

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Srisupalak Singalavanija and Ilona J. Frieden Diaper Dermatitis

 

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