Persistent Diaper Dermatitis Could Be Sign of More Serious Skin Condition


Persistent or unusual diaper dermatitis may be a sign of a serious skin disease or systemic illness in infant patients.

Because rare and uncommon skin eruptions in the diaper area can appear to be a conventional rash caused by prolonged skin exposure to wetness, dermatologists should closely examine each referral they receive for diaper dermatitis and look for the warning signs of a more serious skin condition, according to Dr. Ilona J. Frieden.

"When pediatricians ask a dermatologist to see a patient with a diaper rash, it is usually an unusual one. Diaper rashes are common and most never require referral. Thus, if asked, dermatologists should always say 'Yes' to these referrals," said Dr. Frieden, director of pediatric dermatology at the University of California San Francisco Children's Hospital.

Among the unusual eruptions she discussed in her presentation at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation were psoriasis, granular parakeratosis, and clear cell papulosis. Diaper rash can also be a manifestation of a systemic illness such as group A streptococcal infection, Langerhans cell histiocytosis, a zinc or other nutritional deficiency, or an asymmetric periflexural exanthem.

Group A streptococcal infection can cause a perianal rash, but may also occur at other intertriginous sites. It is typically characterized by intense, bright-red colors; satellite lesions are usually absent. Treatment requires oral antibiotics, and repeat courses are sometimes necessary, noted Dr. Frieden.

Langerhans cell histiocytosis may present as persistent diaper dermatitis that may also occur in other sites, particularly the scalp, ear canal, and oral mucosa. Be on the lookout for petechiae, atrophy, or deep ulcerations, said Dr. Frieden; a biopsy is necessary to make a diagnosis.

Diaper dermatitis due to zinc deficiency is most commonly seen in preterm breast fed infants. Metabolic disturbances and cystic fibrosis can cause similar eruptions.

Asymmetric periflexural exanthem typically starts in a flexure, often at the axilla, but it can also begin in the posterior of the thigh, leading to confusion with diaper rash. It is characterized by small red papules at the periphery with a slightly dusky, scaly center, said Dr. Frieden.

"This condition can last for several weeks and may be misdiagnosed as a contact dermatitis or other dermatologic condition," she said. "Eventually, many cases begin to become bilateral and more generalized." The cause of this exanthema is not known.

An obvious tip for preventing diaper dermatitis, or decreasing its prevalence, is frequent diaper changes to minimize skin exposure to urine and feces. Barrier creams can also be helpful as a preventative measure, she noted.

"It is also important to note that the differential diagnosis of diaper rash during the newborn period differs from that of older infants in that the rash is less likely to be caused by an irritant and more likely to represent an infection or other condition," said Dr. Frieden.

Photo Courtesy: Dr. Ilona J. Frieden

Dr. Frieden reported having no relevant conflicts of interest. SDEF and this news organization are owned by Elsevier.

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