1	The Poop on Diaper Dermatitis Bernard A. Cohen, M.D. Johns Hopkins Children’s Center Baltimore, Maryland dermatlas.org
2	my diaper dermatitis experience
3	Diaper Dermatitis-What is it? Any eruption in the area covered by diapers including… …those triggered by diapers …those worsened by diapers …those that are not related to diapers
4	Evolution of Diapers Initially diapers home laundered with harsh detergents 1930’s diaper services introduced Diaper = cotton rectangle + double layer and multi-ply or fiber filled center strip + safely pins + plastic pant
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6	Diapers-More History Disposable diapers-1960’s = top sheet + cellulose pulp core Superabsorbant diapers = core with absorbable gel material (absorbs 80X weight) Newer products with petrolatum emollient Disposable diapers = 1-2 % of nonbiodegradable waste in N America
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10	Irritant Diaper Dermatitis (those triggered by diapers) Most common cause 1905-first described by Jacquet 1970’s accounted for 20% of dermatology consults in children under 5 Disappeared with superabsorbancy Boys=girls 2 weeks-18 months Peaks @ 6-9 months
11	Jacquet Dermatitis
12	Diaper dermatitis-Pathognesis Susceptibility Ingestion of antibiotics Diarrhea Plastic diaper coveringàoverhydration, maceration Feces and urineàrise in pHàactivation of fecal lipases, proteasesàincrease in fungi, bacteriaàloss of normal barrieràdermatitis
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14	Diaper dermatitis-getting down and dirty! Role of urine Role of stool Skin wetness, pH Cloth diapers, fluff diapers, superabsorbant diapers
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16	Role of Urine Urineàincreased pH by breaking down urea in presence of fecal urease Results in increase in fecal protease, lipasesà hairless mouse model (Berg. Pediatr Dermatol 1986;3:1-2-6)
17	Role of Stool Proteases, lipases from infant fecesàirritant in vivo human model (Andersen. Contact Dermatitis 1994;30:152-8) Bile salts increase susceptibility to other irritants-hairless mouse model (Buckingham. Pediatr Dermatol 1986;3:107-112) Correlation between frequency of stools and frequency of DD (Jordan. Pediatr Dermatol 1986;3:198-207)
18	Role of Candidiasis, Staph Ferrazzini G, et al. Microbiological aspects of diaper dermatitis. Dermatology 2003;206:136-41 3 centers, 48 children, 28 with diaper derm Semiquantitative cultures for Candida, Staph aureus Candida higher in diaper derm, esp severe disease No difference in Staph aureus
19	Role of Diet Breast fed infants < than formula fed Lower colonization of stool in breast fed infants with ureas splitting organisms (more gram + in breast fed, mixed in formula fed) Lower pH and lower fecal enzymesàless irritation in breast fed (Berg. Pediatr Dermatol 1986;3:1-2-6)
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21	Rx-Identify Primary Trigger Diarrhea Malabsorption (eg. CF, liver disease), viral gastroenteritis, antibiotics, metabolic disorder, drugs, diet Change diaper Eliminate topical irritant product
22	Diaper Dermatitis-Rx Protective barrier Lubrication Treat inflammation Rx secondary infection Antipruritics Superabsorbant diapers
23	Novel Therapy Al-Waili NS. Clinical and mycologic aspects of topical application of honey, olive oil, and beeswax in diaper dermatitis. Clin Microbiolo Infect 2005;11:160-3. 11 infants with good clinical and mycological response Anecdotal reports of topical calcineurin inhibitors
24	Topical Antifungal Gallup E, Plott T. A multicenter, open-label study to assess the safety and efficacy of ciclopirox topical suspension 0.77% in the treatment of diaper dermatitis due to Candida albicans. J Drug Dermatol 2005;4:29-34. It was safe and it worked in this open-label study.
25	Role of Topical Steroids Avoid high potency products Avoid combination products eg. Greer’s Goo-Hydrocortisone Lotrisone (clotrimazole + beta- methasone dipropionate) Minimize length of rx, frequency of application
26	Diaper Dermatitis-Lotrisone Railan D, et al. Pediatricians who prescribe Lotrisone often utilize it in inappropriate settings…. Dermatology Online J 2002;8:3 Survey at AAP meeting 1999 of peds at least 2 years post training 23% used for diaper derm Few know potency rating
27	Other Primary Diaper Dermatoses Seborrheic dermatitis Infantile psoriasis Candidiasis Staphylocccal diaper dermatitis
28	Seborrheic Dermatitis
29	Disseminated Seborrheic Dermatitis
30	Postinflammatory hypopigmentation
31	Seborrheic Dermatitis Onset 3-4 weeks Resolution 3-4 months Asymptomatic-if itchy think atopic Atopic seborrhea Persistent-think immunodeficiency, infantile psoriasis
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33	Infantile Psoriasis Overlap with seborrheic dermatitis Persistent, difficult to treat Family h/o psoriasis Represents isomorphic phenomenon
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36	…those not related to diapers Traumatic-accidental/nonaccidental Infections-bacterial, viral, fungal Nutritional Autoimmune Hereditary Immunodeficiency Inflammatory Tumors
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38	Trauma Can the lesions be explained anatomically or physiologically Is the history consistent from time to time, caretaker to caretaker, with developemental level of child Shape of lesion Other clues (Blue light)
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41	….r/o organic dx
42	erosions at birth
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44	Infections Viral-Herpes simplex, varicella, zoster, molluscum, Human papillomavirus Bacterial-Staph, Strep, ecthyma gangrenosum Fungal-Candida, tinea, opportunistic infections, pityrosporum
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51	Failure to thrive and dermatitis at 1 month of age
52	Nutritional Dermatoses Zinc deficiency dermatitis-acrodermatitis enteropathica, zinc deficient breast milk, biotin deficiency, biotinidase deficiency, glucagonoma, citrullinemia and special diets, etc. Malabsorption-liver disease, cystic fibrosis, short gut syndrome Essential fatty acid deficiency
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56	Autoimmune Disorders Lichen sclerosis Linear IgA bullous dermatosis Epidermolysis bullosa acquisita Bullous pemphigoid
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59	Infiltrative Processes and Tumors Langerhans cell histiocytosis Inflammatory bowel disease (associated with distal colonic Crohn disease) Hemangiomas and other tumors of infancy
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62	Diaper Dermatitis Borkowski S. Diaper rash care and management. Pediatr Nurs 2004;30:46-70. Ferrazzini G, Kaiser RR, Hirsig Cheng SK, Wehrli M, Della Caru V, et al. Microbiologic aspects of diaper dermatitis. Dermatology 2003;206:136-41. Prasad HR, Srivastava P, Verma KK. Diaper dermatitis: ammonia. Indian J Pediatr 2003;70:635-7. Neville EA, Finn OA. Psoriasiform napkin dermatitis – a follow-up study. Br J Dermatol. 1975, 92:279–85. Sires UI, Mallory SB. Diaper dermatitis: how to treat and prevent. Postgrad Med. 1995, 98:79–86. Stein H. Incidence of diaper rash when using cloth and disposable diapers. J Pediatr. 1982, 101:721–3.
63	Seborrheic Dermatitis Cohen S. Should we treat infantile seborrheic dermatitis with topical antifungals or topical steroids? Arch Dis Child 2004;89:288-9. Skinner RB Jr, Noah PW, Taylor RM, et al. Double blind treatment of seborrheic dermatitis with 2% ketoconazole cream. J Am Acad Dermatol. 1985, 12:852–6. Yates VM, Kerr EI, Mackie RM. Early diagnosis of infantile seborrheic dermatitis and atopic dermatitis – clinical features. Br J Dermatol. 1983, 108:633–45.
64	Langerhans Cell Histiocytosis Chu T. Langerhans cell histiocytosis. Australas J Dermatol 2001;42:237-42. Esterly NB, Maurer HS, Gonzales-Crussi F. Histiocytosis X: a seven year experience at a children’s hospital. J Am Acad Dermatol. 1985, 13:481–96. Gianotte F, Caputo R. Histiocytic syndromes: a review. J Am Acad Dermatol. 1985, 13:383–404. Huang F, Arceci R. The histiocytoses of infancy. Semin Perinatol 1999;23:319-31. Roper SS, Spraker MK. Cutaneous histiocytosis syndromes. Pediatr Dermatol. 1985, 3:19–30.
65	Acrodermatitis Enteropathica Campo AG Jr, McDonald CJ. Treatment of acrodermatitis enteropathica with zinc sulfate. Arch Dermatol. 1976, 112:687–9. Danbolt N, Closs K. Acrodermatitis enteropathica. Acta Dermatol Venereol (Stockh). 1942, 23:127–69. Ghali FE, Steinberg JB, Tunnessen WW Jr. Picture of the month: acrodermatitis enteropathica-like rash in cystic fibrosis. Arch Pediatr Adolesc Med. 1996, 150:99–100. Gonzalez JR, Botet MV, Sanchez JL. The histopathology of acrodermatitis enteropathica. Am J Dermatopathol. 1982, 4:303–11. Perafan_Riveros C, Franca LF, Alves AC, Sanchez JA Jr. Acrodermatitis enteropathica: a case report and review of the literature. Pediatr Dermatol 2002;19:426-31. Sehgal VN, Jan S. Acrodermatitis enteropathica. Clin Dermatol 2000;18:745-8.