TELEDERMATOLOGY READER REPORT1
History
Chief complaint: diaper rash.
* A 9-month-old girl presents with a diaper rash that has been present for 3 weeks. She had an ear infection and was treated with amoxicillin, and her diaper rash started a couple of days later. It seems to be painful during diaper changes.
* Prior treatment: A&D ointment, cornstarch powder without improvement.
* Prior biopsy: none.
* Skin history: no history of similar rashes; no history of other skin disease.
* No other significant laboratory/study findings.
IMAGE QUALITY ASSESSMENT
Fully satisfactory.
TELEDERMATOLOGY IMAGING READER REPORT
One image was provided that shows erythematous patches and thin plaques with scattered erosions in the perineum (Figure 1).
INTERPRETATION OF IMAGES
Lesion A
The red patches and mild erosions are present on the concave surfaces of the buttocks and perineum, characteristic of an irritant diaper dermatitis.
RECOMMENDATIONS
Skin Care and Treatment Recommendations
The parents should be instructed to use a thick barrier paste such as 40% zinc oxide with every diaper change. Gentle diaper hygiene should be initiated. Low-potency topical corticosteroids may also be used for a short duration.
RECOMMENDED FOLLOW-UP
Type of Visit
Teledermatology visit in 3-4 weeks if needed (Roman & Jacob, 2014); otherwise, follow up with primary care provider as needed.
CLINICAL PEARL
Rashes in the diaper area are very common in infants and toddlers and stem from many etiologies including infectious, inflammatory, and neoplastic. The most common cause is irritant diaper dermatitis (Stamatas & Tierney, 2014). Irritant diaper dermatitis is caused by skin being in contact with urine and feces and therefore is typically worst on the convex surfaces of the skin. The intertriginous folds are usually spared except for the perianal skin, which can also be involved. It presents with erythema and sometimes erosions. If prolonged, papules and nodules or deeper erosions and ulcers may develop (Coughlin et al., 2014).
The cornerstone of treatment is protection of the skin from contact with urine and feces. This requires frequent diaper changes, gentle cleansing, and use of barrier pastes on the skin. Best diapering practices should include changing the diaper as soon as it is known to be soiled. In most cases, disposable diapers are more absorbent than cloth diapers and therefore have a lower chance of being associated with irritant diaper dermatitis. Cleansers instead of soaps or detergents are also preferred. If possible, those with neutral or acidic pH should be used. Barrier pastes should be applied at every diaper change to maintain a thick layer of protection for the skin from contact with urine and feces. Similarly, air-drying or avoidance of diapers all together also speeds healing but is not often practical for families.
Low-potency topical corticosteroids (Classes 6 and 7) are used for their anti-inflammatory effect. They can be used safely on the buttocks and perineum of even young infants twice a day for up to 2 weeks. Some severely inflamed cases may require longer treatment, although monitoring for corticosteroid side effects is then indicated.
If irritant diaper dermatitis persists longer than 3 days, colonization and overgrowth of Candida are common (with or without topical corticosteroid therapy), and antiyeast medications can be helpful. In the acutely inflamed state, medications in an ointment formulation are better tolerated than creams or gels and are easier to use than powders. These can be used twice daily and covered with barrier paste until erythema has resolved.
REFERENCES