Diaper Dermatitis, Irritant and Candidal - Guidelines for Prescribing Topical Antifungals and Hydrocortisone

Description
  • A rash occurring under the covered area of a diaper

  • Caused by factors leading to compromised skin barrier:
    • Over-hydration
    • Friction
    • Prolonged contact with urine and feces, leading to increased skin pH, disruption of the stratum corneum, and maceration of the skin
    • Use of irritants
  • Rash may become secondarily infected with microorganisms such as Candida albicans.

  • Risk or aggravating factors:
    • Diarrhea or frequent bowel movements
    • Infrequent diaper changes
    • Formula feeding
    • Recent antibiotic use

  • Prevalent in ~30% of the infant population

  • Peak incidence at 9 to 12 months
Signs and Symptoms

Irritant Diaper Dermatitis (Images at DermNet NZ and Skinsight.com)

  • Rash is dusky red and shiny. 

  • Appears on buttocks and pubic skin with the creases/skin folds relatively spared.

  • Affects all areas where diaper covers.

  • In severe cases, leads to scaling paules and skin erosions.

  • Can lead to secondary candida infection if untreated.

Candidial Diaper Dermatitis (Images at DermNet NZ and Skinsight.com

  • Beefy red plaques.

  • Diaper dermatitis that has been present for at least three days (which increases the likelihood of secondary infection with candida).

  • Satellite papules, and superficial pustules at the margins of the inflammatory plaques.

  • Unlike irritant diaper dermatitis, candida often begins in the creases/skin folds and then extends out to the buttocks and pubic skin.

  • Excoriations are prominent.

  • Often painful - severe crying during diaper changes or when urinating or defecating.

  • Questioning may reveal a history of recent antibiotic use, or a bout of diarrhea, or a case of oral thrush.

Differential Assessment

Diaper dermatitis is diagnosed based on the presence of typical signs and symptoms (listed above). Rule out the following conditions that may present with similar signs and symptoms:

  • Atopic dermatitis - no rash in creases/skin folds and usually present in multiple locations with a history of itch or eczema.  Often spares groin area. (Refer to guideline for Atopic Dermatitis)

  • Seborrheic dematitis - other sites of seborrheic dermatitis are often present. Usually present only in the skin folds, including groin.  It is often asymptomatic (not itchy, unlike a diaper rash), and flaking and peeling skin is more common.

  • Impetigo - 1 to 2 mm fragile pustules and honey-colored, crusted erosions. (Refer to guideline for Bacterial Infections.)

  • Scabies - acute, widespread, pruritic dermatitis.  Lesions typically occur on the palm, soles or between the fingers.  Not a solid rash.

  • Langerhans cell histoiocytosis - severe rash. Red/orange or yellow/brown scaly papules, erosions, or petchiae.

  • Psoriasis - sharply demarcated erythematous scaly papules and plaques.  There may be a family history of psoriasis.  Lesions will typically be elsewhere on the body as well.  Lack of response to steroids or anti-fungals is another clue.

  • Child abuse - severe diaper dermatitis that appears “resistant” to treatment may be the result of neglect by the parent or caregiver.

  • Congenital syphilis - copper-colored, blisters, scaly lesions.

  • Miliaria - a heat rash that causes small, red papules with pruritus.  Can occur in the diaper area, but it will not present as a solid, continuous rash.

When to Refer

Infants with typical signs / symptoms of irritant or candidal diaper rash often do not require further investigation, however an assessment by the patient's primary care provider may be needed in the following situations:

  • Acute onset with pus, vesicles or ulceration.

  • Moderate or severe presentation, with or without systemic signs and symptoms.

  • Frequent recurrence of rash flare-ups, especially if there is not a period of no rash activity.

  • Secondary infection or co-morbid urinary tract infection.

  • Significant disruption of sleep or behaviour.
  • Condition has not resolved after 2 weeks of prescribed treatment.

  • Patient is immunosuppressed.
  • If unable to confirm diagnosis and symptoms / history suggestive of other conditions (See Differential Diagnosis) which require further investigation and supervised therapy.

Treatment

Mild diaper dermatitis usualy responds well to non-pharmaracological measures and regular use of topical barrier products. Topical hydrocortisone and antifungal products should be reserved for symptoms which are causing infant discomfort.

Non-pharmacological measures

  • Frequent diaper changes.  Change the diaper up to every 2 hours, or any time there is moisture or a bowel movement.

  • Expose diaper region to air as much as possible.

  • Wash diaper area with warm water alone, or with a mild soap and gently pat dry.  Unscented baby wipes can be used.

  • Avoid use of perfumed or lanolin-containing diaper wipes.

  • Try to avoid irritants (caffeine, citrus, or spicy foods) in mother's diet in breastfed infants.

  • Avoid feeding infant food that can cause diarrhea.

Over-the-counter drug options

  • Apply zinc oxide ointment (barrier and absorptive properties) , white petrolatum or other barrier cream after each diaper change.  Skin should be clean and thoroughly dried before application.

    • Zinc oxide should be given in the correct concentration:
      • 10-20%:  Use for prevention of diaper rash
      • 20-40%: Use for treatment of active episode

    • Petrolatum can be used as an effective barrier, but it does not have absorptive properties, so may be less effective during an active rash.
  • Avoid baby powders.  If inhaled, they may cause serious breathing problems.

  • Consider recommending hydrocortisone 0.5 % cream only if the rash is irritating the infant. Apply once or twice daily until symptoms resolve or for maximum of 14 days.  Do not use an ointment, as it will be under occlussion, thus increasing its potency and chance for side effects, such as skin atrophy.

OTC / Prescription drug options

Irritant Diaper Dermatitis

  • Consider a very low-potency steroid cream, such as hydrocortisone 1% cream. Apply once or twice daily until rash resolves; maximum of 14 days of use.

    • Note that although hydrocortisone 1% has recently been changed to OTC, it is still considered prescription if used under two years of age.
  • Continue with barrier therapy. Apply topical hydrocortisone first, wait five minutes, then apply barrier product.

  • Do not use hydrocortisone alone if candidal diaper dermatitis is suspected.

Candidal Diaper Dermatitis

  • A topical antifungal such as clotrimazole 1% cream, ketoconazole 2% cream, miconazole 2% cream, or nystatin  cream.  Apply cream twice daily, morning and evening, after diaper changes.  Continue use until rash resolves.  If not resolved or improving after 7 days, refer to patient's primary care provider.

  • If inflammation is prominent, consider adding a very-low-potency steroid cream, such as hydrocortisone 0.5-1% to be used along with the antifungal cream. Separate application of the hydrocortisone and antifungal by a few minutes.

  • Do not mix corticosteroid and antifungal creams prior to applying as this dilutes the concentration of active ingredients.

  • If using multiple products, application order is important:  Anti-fungal --> hydrocortisone --> barrier product, waiting 2-3 minutes between application.
Advice / Monitoring
  • Continue with the non-pharmacologic treatments after rash has resolved to prevent future flareups.

Assess Benefit

  • Symptoms should improve within 7 days. If not, refer to patient's primary care provider.  If symptoms have significantly improved, but not completely, another 7 days of treatment is reasonable. 

  • Looking for symptom reduction:
    • Inflammation: 80% decrease
    • Surface area involved: No progression
    • Spreading: None
    • Blister formation or oozing: None
    • Satellite lesion formation: None
    • Sleep disruption: Return to normal in 1-2 weeks

Assess Adverse Effects

  • Local effects - if symptoms worsen when hydrocortisone or antifungal therapy is initiated, stop therapy and refer to patient's primary care provider.
Products

Detailed information on contraindications, cautions, adverse effects and interactions is available in individual drug monographs in the CPS (e-CPS), Lexi-Comp, AHFS, www.drugs.com or other reliable drug monograph references. For comprehensive drug comparisons, see RxFiles charts (www.rxfiles.ca).
This information should be routinely consulted before prescribing.

 

DIAPER DERMATITIS

Hydrocortisone

1% TOPICAL CREAM (< 2 years of age)

 

Ketoconazole

2% TOPICAL CREAM


*Note: These are the prescription only products.  The OTC products, clotrimazole, miconazole and nystatin can also be used, but will not be eligible for the minor ailment assessment fee.
Prescribing and Billing Details
  • pseudoDIN: 00951091
    • Max of 4 claims per 365 days per patient

  • May prescribe sufficient quantity to treat for 7-14 days.  No refills.
    • If resolution not complete after 14 days, refer to patient's primary care provider.
    • Each episode of diaper dermatitis is to be treated as a distinct episode and re-assessed.
    • For help prescribing the proper quantity of topicals using finger-tip units, see: http://dermnetnz.org/treatments/fingertip-units.html

  • The OTC antifungals (nystatin, miconazole and clotrimazole) can be recommended; however, an assessment fee WILL NOT be paid in this case.  If they are given in conjunction with hydrocortisone 1% (a prescription only item), then an assesment fee will be paid.

  • Only products with an official indication from Health Canada for diaper dermatitis are considered for these guidelines.  Only the active ingredients in the "products" section are approved for pharmacist prescribing.  High-potency steroids are not approved.
Treatment Flowchart
Pharmacist Assessment Documents
References / Suggested Reading
1)  Compendium of Therapeutics for Minor Ailments (CTMA).  Diaper Dermatitis.
2)  Emedicine – Diaper dermatitis (Pediatrics: General Medicine). (free access – registration required)
3)  Dynamed Clinical Summary – Diaper Rash. (Subscription required)
4)  Hagemeier N.  Diaper dermatitis and prickly heat.  In Handbook of Non-Prescription Drugs, 16th ed. Chapter 36.
5)  Hughes D. Dermatitis, diaper. In 5-Minute Clinical Consult 2008.
6)  Horri K, Prossick T. Overview of diaper dermatitis in infants and children. In UpToDate Database. (Subscription required)

Prepared by medSask
Reviewed by Dr. L. Sandomirsky, Family Physician and Loren Regier, Pharmacist RxFiles Academic Detailing Program
Funded by the Saskatchewan College of Pharmacy Professionals.
Posted May 2010. Updated May 2017.