Diaper rash

You are seeing a 6month old baby girl for a well child check. The mother mentions that the baby was recently seen at the ER and was diagnosed with a right ear infection  2 weeks back. She was started on amoxicillin and completed the course 2-3 days back. Around the same time mom notes that the baby was having runny stools when she was using pedialyte and having bowel movements  almost 7-8 times / day. When you examine the baby you note she has an erythematous rash involving her diaper area which extends into her skin folds, you also notice that there are smaller satellite lesions adjacent to the main rash. The baby gets really fussy as you examine the diaper site, but easily consoles once you bundle her up. You explain to mom what you think the rash is , start her on nystatin cream, update her shots, give anticipatory guidance and discharge them home.
1. Looking at the rash in the picture below what is the probable etiology? How do you differentiate it with other causes?
2. What are the risk factors present in the history which may have led to the infection?
3. What other exam should the resident have paid attention to ? 
4. What if treatment with nystatin fails?



Definition : Diaper rash/ Napkin rash/ Diaper dermatitis is a a spectrum of skin disorders of varying etiologies which have similar skin distribution. It may not necessarily be associated with wearing diapers.

Etiologies :
A) Infection :
1. Fungal :
- Candida albicans 
- risk factore : use of systemic antibiotics
- often seen with oral thrush
2. Grp. A Strep infections :

B) Inflammation
1. Seborrheic Dermatitis :
- often seen with cradle cap, involves inter-triginous areas
- inflammatory response to Pityrosprum ovale
2. Allergic contact dermatitis :
- new detergents, fragrances, dyes
- new topical medications
3. Granuloma gluteale infantum :
- chronic application of steroids
- rare

C) Irritant
1. Jacquet's irritant dermatitis
- erosive form, may be confused with HSV infection

Cradle cap in an infant

Granuloma gluteale

Jaquet's dermatitis

History ( things to note) :
- systemic antibiotic use
- acute on chronic diarrhea
- use of topical corticosteroids may cause modification of appearance of the rash, skin atrophy, increase risk for gluteale infantum
- frequent bathing and wiping may worsen irritation
- maternal nipple fungal infection

Physical exam :
- involves inter-triginous areas : GAS , candida, seborrheic dermatitis
- peri-rectal : GAS
- greasy erythema and scales : seborrhea
- well demarcated shiny erythematous patches : strep infection
- indurated red brown : granulomas
- DO NOT FORGET to examine
a) mouth - for thrush
b) scalp - for seborrhea
c) enquire about maternal breast health (if breast-feeding) to r/o nipple fungal infection

Treatment :
- skin care - gently wash, pat dry, do not rub or  wipe forcefully. Use mild soap.
- diaper free periods - air dry frequently
- barrier cream - zinc oxide
- suspect fungal infection - use nystatin cream / use ketoconazole, clotrimazole, econazole. In resistant cases, check for oral thrush, treat with oral nystatin. If still persists consider a course of fluconazole.
- lots of inflammation - ok to use low potency steroids for 1st few days ( stop once rash starts improving) --> do not want to risk skin atrophy or granulomas
- severe cases use sucralfate or cholestyramine to neutralize bile acids/ pepsin

OTC barrier creams with zinc oxide / petrolatum jelly

Myths :
- no differences in outcome noted in cloth diapers vs regular diapers
- talcum powder makes skin more dry
- rash is not because of unclean skin in fact is as a result of over aggressive cleaning

References :
1. google images
2. Textbook : 5 minute pediatric consult