Rosen & Barkin's 5-Minute Emergency Medicine Consult (209 page)

DIAGNOSIS

Diagnosis often empiric based on appearance of rash

Child may cry with diaper changes or wiping diaper area or may be irritable.

• Irritant:
  
  • Beefy-red confluent patches with distinct borders at diaper edges, typically sparing skin folds
    
• Infectious:
  
  • Candida
    —demarcated erythematous rash with satellite pustules or papules, typically involves skin folds
    
  • Bacterial—superficial erosions with yellow crust and occasionally bullae
    
• Seborrheic diaper dermatitis:
  
  • Lesions with erythematous base and greasy yellow or gray scale
    
  • Infant will likely have similar lesions on other body surfaces, especially scalp.
    
• Atopic diaper dermatitis:
  
  • Similar appearance to irritant dermatitis, but lesions also on other body surfaces such as the face.
    
• Variations include:
  
  • Jacquet form—erosive variant with ulcers or erosions with elevated margins usually seen with persistent diarrhea or adult urinary incontinence.
    
  • Psoriasiform—erythema, silvery surface scales and spared skin folds; also likely to have similar lesions on other body surfaces.
    
  • Granuloma gluteale infantum—violaceous papules and nodules on the buttocks and in the groin with a self-limited course, resolving in weeks or months, often with residual scarring.
    

• Inquire about diaper-changing habits and urinary and fecal habits.
  
• Examine other body areas to identify associated rashes.
  
• Consider child abuse or neglect:
  
  • Child’s overall hygiene
    
  • Burns or other trauma
    

• Lab evaluation usually not necessary for management of diaper dermatitis.
  
• Bacterial cultures usually not indicated except in complicated cases.
  
• Skin surface scrapings with KOH prep and/or culture may help distinguish between
  Candida
  and atypical seborrheic dermatitis:
  
  • Look for budding yeast and/or pseudohyphae.
    

• Child abuse or neglect
  
• Infection:
  
  • Impetigo
    
  • Scabies
    
  • Herpes simplex
    
  • Varicella
    
  • Congenital syphilis
    
• Psoriasis
  
• Atopic dermatitis
  
• Seborrheic dermatitis
  
• Papular urticaria
  
• Bullous pemphigoid
  
• Epidermolysis bullosa
  
• Acrodermatitis enteropathica
  
• Acrodermatitis enteropathica–like eruption
  
• Langerhans cell histiocytosis
  

TREATMENT

The management of diaper dermatitis should include reducing moisture in the diaper area, minimizing contact with urine and feces and eradicating infectious microorganism

• Environmental adjustments:
  
  • Education of parents and caregivers is essential:
    
    • Cleanse skin frequently using cotton balls and water.
      
    • Wet wipes and talcum powders are not recommended.
      
  • Frequent diaper changes, up to q1h for neonates and q3–4h for infants and adults.
    
  • Gentle rinsing of affected area with warm water or saline.
    
  • Avoid harsh soaps or alcohol wipes.
    
  • Leave area uncovered as much as possible; allow time to air dry.
    
  • Highly absorbant diapers have less incidence of diaper rash than cloth diapers.
    
  • Cloth diapers are not recommended for patients with irritant diaper dermatitis.
    
  • New diapers that are “breathable” or contain top sheet of zinc oxide/petroleum and stearyl alcohol lining have been shown to decrease incidence.
    
• Barrier creams:
  
  • Many preparations available containing zinc oxide, petroleum, lanolin.
    
  • Should be applied after each diaper change and continued after rash resolves to minimize recurrence
    
  • A substantial negative relationship exists between barrier cream use and number of previous episodes of diaper dermatitis.
    
  • If
    Candida
    l infection present, apply over antifungal medication.
    
• Corticosteroids:
  
  • For moderate to severe cases not responding to other therapy
    
  • Should not be stronger than 1% hydrocortisone: Anything stronger can cause serious side effects.
    
  • Discontinue after 3–5 days.
    
• Antifungals:
  
  • Nystatin cream, powder, or ointment:
    
    • Expect improvement in 1–2 days.
      
    • Ointment best tolerated on macerated skin.
      
  • Clotrimazole applied topically after diaper change.
    
  • Miconazole applied topically after diaper change.
    
  • Lotion is preferred in intertriginous areas.
    
  • Cream should be applied sparingly to avoid maceration effects.
    
  • Ciclopirox applied topically after diaper change.
    
  • Generally continue 1–2 days after clearing
    
  • Antifungal agent also found to have some antibacterial activity and anti-inflammatory properties.
    
  • Consider oral agent if concurrent cutaneous or oral candidiasis is present or in recalcitrant case because stool may be colonized with
    C. albicans.
    
• Antibacterials:
  
  • Typically concurrent with other therapies if suspicion of bacterial infection
    
  • Mupirocin (Bactroban) applied after diaper changes
    
  • Systemic antibiotics rarely needed
    

• Ciclopirox 0.77% cream, gel, or suspension: Applied topically BID after diaper change
  
• Clotrimazole 1% cream: Applied topically BID after diaper change
  
• Hydrocortisone 0.5–1% topical cream: Applied BID
  
• Miconazole topical 2% cream: Applied BID after diaper change
  
• Miconazole nitrate 0.25% ointment: Apply after diaper change and bathing
  
• Mupirocin 2% ointment or cream (Bactroban): Applied topically 3–5 times daily after diaper changes (for infants >3 mo of age)
  
• Nystatin 100,000 U/g cream, powder, or ointment: Apply BID after diaper change
  

FOLLOW-UP

• Evidence of child abuse or neglect
  
• Evidence of sepsis
  

• Adalat S, Wall D, Goodyear H. Diaper dermatitis-frequency and contributory factors in hospital attending children.
  Pediatr Dermatol.
  2007;24(5):483–488.
  
• Adam R. Skin care of the diaper area.
  Pediatr Dermatol
  . 2008;25(4):427–433.
  
• Heimall LM, Storey B, Stellar JJ, et al. Beginning at the bottom: Evidence-based care of diaper dermatitis.
  MCN Am J Matern Child Nurs
  . 2012;37(1):10–16.
  
• Ravanfar P, Wallace JS, Pace NC. Diaper dermatitis: A review and update.
  Curr Opin Pediatr
  . 2012;24(4):472–479.
  
• Van L, Harting M, Rosen T. Jacquet erosive diaper dermatitis: A complication of adult urinary incontinence.
  Cutis
  . 2008;82(1):72–74.
  

CODES

691.0 Diaper or napkin rash

BASICS

• Penetrating injury:
  
  • Violation of the diaphragm by penetrating object (most commonly stab and gunshot wounds)
    
  • May involve any portion of diaphragm
    
  • Smaller defect compared with blunt injuries (more likely to be missed)
    
• Blunt injury:
  
  • Increased intra-abdominal or intrathoracic pressure is transmitted to diaphragm, causing rupture.
    
  • Usually due to motor vehicle crashes
    
  • Injuries are more commonly left-sided:
    
    • Left hemidiaphragm has posterolateral embryologic point of weakness.
      
    • Right hemidiaphragm is protected by liver.
      
    • Injuries are larger than with penetrating injury (frequently between 5 and 15 cm in length).
      
• Diaphragmatic defects do not heal spontaneously because of pleuroperitoneal pressure gradient:
  
  • May exceed 100 cm H
    ₂
    O during maximal respiratory effort
    
  • Promotes herniation of abdominal contents through rent in diaphragm and into chest