Work up for Langerhans cell histiocytosis:
- Referral to Pediatric Dermatology for biospy.
Is there concern for bacterial infection? Bullous impetigo with fluid-filled blisters or blister remnants? Folliculitis with pustules and erythema surrounding a hair follicle? Perianal erythema concerning for possible streptococci or S. aureus?
Is there concern for acrodermatitis enteropathica? Scaly, well demarcated erythema. Can be seen when infants are weaned from breast milk to cow’s milk formula.
If conservative treatment with appropriate diaper care has been attempted for at least 72 hours and diaper dermatitis does not fit any of the above descriptions, consider referral to Pediatric Dermatology.
Is there concern for seborrheic dermatitis? Erythematous, greasy, well demarcated patches and plaques. Can also be found on the scalp (“cradle cap”), face, ears, and neck.
Has the family been following best diaper care practices including applying barrier cream for >72 hours?
- <3 years old
- Rash in diaper area
- Fevers or other signs of systemic illness
- Known underlying dermatologic condition
Is there concern for candidal dermatitis? “Beefy” red rash involving inguinal creases, often with scaling at the margin and satellite papules or pustules? May have recent history of antibiotic use or concurrent oral thrush.
Is there concern for Langerhans cell histiocytosis? Scaly, erythematous papules and plaques that occur on the scalp, posterior ear folds, neck folds, and inguinal folds. Often confused for seborrheic dermatitis.
Treat seborrheic dermatitis:
- Diaper area: Low-potency hydrocortisone 1% crease twice a day or ketoconazole 2% cream once a day for one to two weeks, both accompanied with liberal use of zinc oxide barrier cream (e.g., Desitin, Triple Paste, Boudreaux's Butt Paste) or petroleum ointment (e.g., Vaseline, Aquaphor) with every diaper change.
- Cradle cap: Frequent application of emollient (vegetable oil, mineral oil, baby oil, petroleum) to scalp to loosen the scales and then gentle removal with a fine-tooth comb or soft brush. In severe cases, can recommend hydrocortisone 1-2.5% ointment once a day for one week or ketoconazole 2% cream or shampoo twice a week for two weeks.
History and Physical, including:
- Duration of symptoms.
- Associated symptoms such as diarrhea.
- Systemic symptoms.
- Current diapering practices including how the diaper area is cleaned and any topical treatments being used.
- Known exposures (e.g., scabies, Streptococcus, herpes simplex virus).
- Past medical history, including prior diaper rashes and outcomes.
- Recent medication use, including antibiotics.
- Family history (e.g., psoriasis, severe allergies).
Best Diaper Care Practices:
- Keep diaper dry and clean, changing it at least every 3 to 4 hours and promptly after it is soiled.
- When area is soiled, use gentle cleaning practices like a cloth or bath with warm water or gentle diaper wipes free of fragrance, alcohol, and other irritants.
- Allow diaper-free periods to expose the skin to air periodically throughout the day, if possible.
- Use a thick layer of zinc oxide barrier cream (e.g., Desitin, Triple Paste, Boudreaux's Butt Paste) or petroleum ointment (e.g., Vaseline, Aquaphor) with every diaper change. Can use the two together, applying a zinc-based cream followed by petroleum ointment.
- Barrier creams and ointments do not need to be completely removed with every diaper change.
- Ensure the right diaper size.
- Note: Talcum powder is not recommended due to risk of pneumonia and possible association with cancer. Other powders are not typically recommended because they can contribute to moisture retention, worsening the diaper rash.
Diagnose and treat acrodermatitis enteropathica:
- Measure serum zinc level.
- If low, <500mcg/dL, treat with oral zinc supplementation with 1 to 3 mg/kg divided two or three times daily of elemental zinc.
Is there concern for Jacquet’s erosive diaper dermatitis? Well-defined shallow ulcers or ulcerated nodules.
Treat irritant diaper dermatitis:
- Educate family on best diaper care practices and follow up if rash persists in 3 days.
Treat candidal diaper dermatitis:
- Clotrimazole (OTC 1%), miconazole (OTC 2%) or nystatin (Rx) three times a day followed by barrier cream until resolved.
Treat irritant diaper dermatitis:
- Educate family on best diaper care practices and follow up if rash persists in 3 days.
Work up and treat suspected bacterial diaper dermatitis:
- Obtain skin culture (can first screen with rapid strep test if strep is suspected).
- Mild: treat with topical mupirocin twice a day for 10 days.
- Moderate to severe: treat with amoxicillin for 10 days for group A beta-hemolytic streptococci. Select oral antibiotic based on culture if S. aureus is present.
