Recent Advances in Diaper Dermatitis: Etiology and Treatment

Marty O. Visscher

Pediatr Health. 2009;3(1):81-98.

Abstract and Introduction

Abstract

Diaper dermatitis is a highly prevalent condition that causes discomfort and stress for patients and frustration for healthcare staff. Diaper technology has evolved to substantially lessen the severity of diaper dermatitis, but additional improvements are needed. Premature infants and incontinent adults are particularly at risk for developing diaper dermatitis and its potential consequences. Contributing factors include overhydration, irritants, friction, increased skin pH, diet, gestational age, antibiotic use, diarrhea and medical condition. Treatments aim to reduce hydration, provide a semipermeable 'layer' to facilitate skin barrier repair, shield the skin from irritants, deactivate specific fecal components and maintain skin surface contact. The published research on the effects of diaper dermatitis treatments is especially sparse. Controlled clinical trials are needed to provide definitive evidence for selection of effective treatments. This article discusses the incidence and etiology of diaper dermatitis in infants and adults. It provides the scientific basis for repair of diaper skin barrier damage and describes recent developments that will be available in the future.

Introduction

In addressing diaper dermatitis (DD), we encompass the most recent views about the skin structure, function and development with the foundation that the skin is an interface for primary care in any patient-caregiver interaction.^[1]

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Abstract and Introduction
Normal Skin Physiology
Epidermal Barrier Development
High-risk Patients: Premature Infant Skin
Significance: Incidence of Diaper Dermatitis
Etiology of Diaper Dermatitis
Treatment of Diaper Dermatitis
Future Perspective
Commentary
References
Executive Summary

Table 1. Relative Skin Compromise In Irritant Diaper Dermatitis
Skin condition score	Integrity		Erythemia		Rash
Skin condition score	Ulceration	Scaling	Spotty (macules)	Continuous	Papules	Edema
0.0
0.5		Dryness only	Very slight	Very slight
1.0		Slight	Slight	Slight
1.5		Moderate	Moderate	Moderate	Very slight	Very slight
2.0		Severe	Moderate-severe	Moderate-severe	Slight	Slight
2.5	Slight		Severe	Severe	Moderate	Moderate
3.0	Moderate				Moderate-severe	Moderate-severe
3.5	Moderate-severe				Severe	Severe
4.0	Severe
Percent coverage	< 10 10-50 > 50	< 10 10-50 > 50	< 10 10-50 > 50	< 10 10-50 > 50	< 10 10-50 > 50	< 10 10-50 > 50

Demonstrates the diaper rash grading scale and the associated description of skin condition used to quantify the severity of diaper dermatitis.
Data taken from reference 32.

Table 2. Surfactants Found in Skin Care Products and the Relative Irritancy Potential
Relative irritancy	Surfactants
High	Sodium lauryl sulfate
	Sodium dodecyl sulfate
	Sodium alkyl sulfate
	Sodium or potassium cocoate
	Sodium or potassium tallowate
	Sodium palmitate
	Sodium or potassium stearate
	Linear alkyl benzene sulfate
	Triethanolamine laurate
	Sodium olefin sulfonate
	Benzalkonium chloride
	Dodecyl trimethyl ammonium bromide
Moderate	Sodium ethoxylates
	Sodium laureth sulfate
	Ammonium laureth sulfate
Low	Sodium cocoyl isethionate
	Sodium alkyl glycerol ether sulfonate
	Sodium cocoyl sulfosuccinate
	Disodium stearyl sulfosuccinate

Table 3. Skin Protective Active Ingredients Under the US FDA Final Monograph
Ingredient	Allowed amounts (%)	Additional allowed labeling
Allantoin	0.5-2	*^‡
Aluminum hydroxide gel	0.15-5
Calamine	1-25
Cocoa butter	50-100	*^‡
Cod liver oil	5-13.56 (not to exceed 10,000 USP units of vitamin A and 400 USP units cholecalciferol)	*
Colloidal oatmeal	0.007 (minimum) or 0.003 (minimum) combined with mineral oil
Dimethicone	1-30	^‡
Glycerin	20-45	^‡
Hard fat	50-100	*^‡
Kaolin	4-20
Lanolin	12.5-50 15.5 with other skin protectants for diaper rash	*^‡
Mineral oil	50-100 30-35 with colloidal oatmeal	*^‡
Petrolatum	30-100	*^‡
Sodium bicarbonate	Not applicable
Topical starch	10-98
White petrolatum	30-100	*^‡
Zinc acetate	0.1-2
Zinc carbonate	0.2-2
Zinc oxide	1-25

*Temporarily protects minor cuts, scrapes and burns.
^‡Helps prevent and temporarily protects and helps relieve chaffed, chapped or cracked skin.
USP: US Pharmacopeia.

Box 1. Diaper Skin Management Scheme
Monitor skin condition
Examine at every diaper change or incontinent event
Assess patient for risk factors, including:
Frequent stooling Loose stools or diarrhea Diets or condition where digestive enzymes are not absorbed and are present in stool Conditions where bile salts are excreted Drug withdrawal Medications that change stool frequency or composition, including antibiotic therapy
Begin treatment at the first indication of slight erythema, dryness, rash or abnormal skin anywhere in the diaper area
Examine the skin for evidence of candidiasis or bacterial infection
Reduce hydration
Select and use absorbent products to wick away moisture from the skin surface Avoid diapers with plastic or nonbreathable outer sheet Minimize contact with water (urine and watery stools) Change frequently to minimize contact with irritants Insure that diaper fits properly (too tight increases skin occlusion and too loose minimizes absorption of fluids) Dry the skin surface after cleansing
Use gentle skin cleansing methods
Soft implements Avoid products with known irritants, fragrance and alcohol Minimize rubbing If topical creams are in place, remove only the soiled portion to minimize rubbing
Apply topical treatments to provide skin barrier recovery & prevent further damage
Treat with antifungal agent if candidasis is present Provide a semipermeable film/layer over damaged skin Provide a physical shield between skin and irritants Choose amount based on a balance of 'semipermeability' and physical shield Select product that stays in place and allows for ease of cleansing Use products that can bind or deactivate irritants (bile salts and enzymes) as indicated by patient condition
Monitor skin condition by noting area of involvement (% area covered) & severity of compromise (e.g., faint erythema, definite redness, intense redness, rash & bleeding)
Re-evaluate and modify plan if condition worsens or does not show improvement

Suggested procedures for the ongoing assessment and management of diaper skin condition.

Executive Summary

Diaper dermatitis is a common condition. The reported incidence rates vary depending upon patient demographics and specific study methods.
The majority of diaper rash is irritant contact dermatitis. Candida infection may be present.
Determination of the severity of diaper dermatitis and, therefore, the effectiveness of treatments is hampered by the lack of standardization assessment methods to consistently characterize and quantify the biological processes involved in irritant dermatitis.
Factors that influence diaper skin condition are overhydration, skin irritants, mechanical friction, skin pH, diet, age, gestational age, antibiotic therapy, diarrhea and medical condition.
Irritants disrupt the stratum corneum barrier structure, cause inflammation, increase permeability and increase keratinocyte proliferation. In response, the epidermis upregulates the formation of the stratum corneum, resulting in a defective structure, poor water handling and inadequate desquamation.
Reduction in diaper area humidity and skin hydration is the most important aspect of strategies for prevention and treatment.
Technology improvements, such as the introduction of disposable diapers with absorbent gelling materials and breathable outer sheets, have decreased the severity, but diaper dermatitis continues to occur.
Topical treatments for diaper dermatitis are based on strategies that have been shown to facilitate recovery from skin barrier compromise. They include the provision of a semipermeable 'layer' or 'film' to facilitate the repair of the stratum corneum barrierr, a physical shield to reduce/prevent contact with irritants, ingredients to deactivate specific fecal components and materials that remain in contact with the skin surface (i.e., are not removed with defecation).
Skin protectant products (barrier creams and moisture barriers) are not required to demonstrate effectiveness in controlled clinical trials prior to approval for use.
Published research on the effects of skin care products and diaper rash treatments among premature and high-risk infants and elderly incontinent subjects, particularly in clinical settings, is especially limited. All skin care products should be evaluated for the presence of irritating components prior to use in these populations.
Recent reports on the effects of topical oils, vernix caseosa, stratum corneum ceramides and skin surface pH on the development and restoration of epidermal barrier function may provide the basis for improved treatments for irritant diaper dermatitis. Further developments in assessment methodologies and in determination of the biological factors that impact response to treatment are warranted.

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Recent Advances in Diaper Dermatitis: Etiology and Treatment

Abstract and Introduction

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