diaper rash

 i saw this case  in my clinic
3 month old girl 2 days history of rash on buttocks area,no diarrhea

DIAPER RASH

Risk Factors

• Infrequent diaper changes
• Waterproof diapers
• Improper laundering
• Family history of dermatitis
• Hot, humid weather
• Recent treatment with oral antibiotics
• Diarrhea
• Dye allergy
  
  
  General Prevention
  Attention to hygiene during bouts of diarrhea

  
  

  Pathophysiology

  • Fecal proteases and lipases are irritants.
  • Fecal lipase and protease activity is increased by acceleration of GI transit; thus a higher incidence of irritant diaper dermatitis is observed in babies who have had diarrhea in the previous 48 h.
  • Once the skin is compromised, secondary infection by C. albicans is common. 40–75% of diaper rashes that last >3 days are colonized with C. albicans.
  • Bacteria may play a role in diaper dermatitis through reduction of fecal pH and resulting activation of enzymes.
  • Allergy is exceedingly rare as a cause in infants.

  Etiology

  • Irritation to skin from prolonged contact with urine or feces (2)
  • Some have raised the possibility of contact allergy from the dye in disposable diapers (3).
    History

    • Onset, duration, and change in the nature of the rash
    • Presence of rashes outside the diaper area
    • Associated scratching or crying
    • Contact with infants with a similar rash
    • Recent illness, diarrhea, or antibiotic use
    • Fever
    • Pustular drainage
    • Lymphangitis

    Physical Exam

    • Mild forms consist of shiny erythema ± scale.
    • Margins are not always evident.
    • Moderate cases have areas of papules, vesicles, and small superficial erosions.
    • It can progress to well-demarcated ulcerated nodules that measure a centimeter or more in diameter.
    • It is found on the prominent parts of the buttocks, medial thighs, mons pubis, and scrotum.
    • Skin folds are spared or involved last.
    • Tidemark dermatitis refers to the bandlike form of erythema of irritated diaper margins.
    • Diaper dermatitis can cause an id (autoeczematous) reaction outside the diaper area
      Treatment

      Medication

      First Line

      • For a pure contact dermatitis, a low-potency topical steroid (hydrocortisone 0.5–1% t.i.d.) and removal of the offending agent should suffice.
      • If candidiasis is suspected or diaper rash persists, use an antifungal such as miconazole nitrate 2% cream, miconazole powder, econazole (Spectazole), clotrimazole (Lotrimin), or ketoconazole (Nizoral) cream at each diaper change (2)[B].
      • If inflammation is prominent, consider a very low-potency steroid cream such as hydrocortisone 0.5–1% t.i.d. along with an antifungal cream ± a combination product such as clioquinol-hydrocor-tisone (Vioform–hydrocortisone) cream (2)[B].
      • If a secondary bacterial infection is suspected, use an antistaphylococcal oral antibiotic or mupirocin (Bactroban) ointment topically.
      • Precautions: Avoid high- or moderate-potency steroids often found in combination steroid antifungal mixtures (2)[B].

      Second Line

      Sucralfate paste for resistant cases

      Additional Treatment

      General Measures

      • Expose the buttocks to air as much as possible (2).
      • Avoid waterproof pants during treatment (day or night); they keep the skin wet and subject to rash or infection.
      • Change diapers frequently, even at night, if the rash is extensive (4).
      • Superabsorbable diapers are beneficial (2,4)[B].
      • Discontinue using baby lotion, powder, ointment, or baby oil (except zinc oxide).
      • Disposable baby wipes contain substances that induce contact or irritant dermatitis, such as fragrance, benzalkonium chloride, and isothiazolinone or alcohol.
      • Apply zinc oxide ointment or other barrier cream to the rash at the earliest sign and b.i.d. or t.i.d. (e.g., Desitin or Balmex). Thereafter, apply to clean, thoroughly dry skin (2).
      • Use mild soap, and pat dry.
      • Cornstarch can reduce friction. Talc powders that do not enhance the growth of yeast can provide protection against frictional injury in diaper dermatitis but do not form a continuous lipid barrier layer over the skin and obstruct the skin pores. These treatments are not recommended.