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My baby got dat rash or is it Thrash? Scott Carney.

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Presentation on theme: "My baby got dat rash or is it Thrash? Scott Carney."— Presentation transcript:

1 My baby got dat rash or is it Thrash? Scott Carney

2 Diaper Dermatitis Prevalence Represents 10 to 20 percent of all skin disorders evaluated by the general pediatrician Represents 10 to 20 percent of all skin disorders evaluated by the general pediatrician Of those seen 1:4 is diagnosed with Diaper dermatitis Of those seen 1:4 is diagnosed with Diaper dermatitis From million outpatient visits From million outpatient visits

3 Epidemiology Peak frequency 9-12 months Peak frequency 9-12 months Risk Factors: Risk Factors: Poor hygiene (infrequent diaper changes) Past history of dermatitis Diarrhea Thrush Toilet training

4 Path to pain… Trifecta of factors that lead to dermatitis: Trifecta of factors that lead to dermatitis: Increased skin hydration Chemical irritation Friction

5 A littles good a lots mo betta Increased hydration Increased hydration More liquid feces and urine leads to increased breakdown of stratum corneum Increases risk of frictional trauma, penetration of irritants and microbes

6 Its the pee right? Its gotta be the pee.. Study of 26 infants with diaper dermatitis found that high ammonia level on intact skin had no effect compared with those without dermatitis Study of 26 infants with diaper dermatitis found that high ammonia level on intact skin had no effect compared with those without dermatitis

7 But…. Fecal bacteria produce urease Fecal bacteria produce urease Degrades urine to ammonia Degrades urine to ammonia Increases stool pH Increases stool pH Reactivates fecal enzymes protease and lipase Reactivates fecal enzymes protease and lipase Increases breakdown further of stratum corneum Increases breakdown further of stratum corneum

8 Other risk factors Diet: Diet: Breast fed children have decreased incidence of DD likely due to a lower stool pH from Breast feeding Breast fed children have decreased incidence of DD likely due to a lower stool pH from Breast feeding Antibiotic usage: Antibiotic usage: Patients with chronic antibiotic usage have increased risk of antibiotic associated diarrhea and increased risk of altered stool flora increasing risk for Candidal infection

9 Clinical features: Wide range of presentations Wide range of presentations Asymptomatic erythema to painful scaling papules and superficial erosions Asymptomatic erythema to painful scaling papules and superficial erosions Skin folds are spared Skin folds are spared Traditionally involves convex areas of diaper areas Traditionally involves convex areas of diaper areas Including the buttocks, lower abdomen, genitalia, and upper thighs Including the buttocks, lower abdomen, genitalia, and upper thighs

10 Pretty straightforward right? Not so fast, spectrum extends beyond classical diaper dermatitis to more severe forms including Not so fast, spectrum extends beyond classical diaper dermatitis to more severe forms including Tidewater dermatitis Tidewater dermatitis Jacquet's erosive dermatitis Jacquet's erosive dermatitis Granuloma gluteale infantum Granuloma gluteale infantum

11 Differential Dx: Allergic Contact Allergic Contact Intertrigo Intertrigo Atopic Derm Atopic Derm Seborrhea Seborrhea Langerhans Langerhans Psorias Psorias Child Abuse Child Abuse Zinc deficiency Zinc deficiency Biotin deficiency Biotin deficiency Herpes Herpes Scabies Scabies Candida Candida Bacterial infection Bacterial infection Syphillis Syphillis

12 Tidewater/Lucky Luke/Diaper Dye Dermatitis Erythema and scaling at the diaper margin due to friction and cycles of wetness and dryness Erythema and scaling at the diaper margin due to friction and cycles of wetness and dryness Also thought to be due to rubber components of diaper Also thought to be due to rubber components of diaper

13 Tidewater Dermatits

14 Jacquet's erosive dermatitis Well-demarcated papules, nodules, and punched-out ulcerations in the perineal region Well-demarcated papules, nodules, and punched-out ulcerations in the perineal region

15 Granuloma Gluteale Infantum Reddish-purple nodules in the inguinal folds, scrotum, buttocks, and medial thighs Reddish-purple nodules in the inguinal folds, scrotum, buttocks, and medial thighs Presents within 2-9 mo age Presents within 2-9 mo age Associated with use of steroid creams and chronic Candidal infections. Associated with use of steroid creams and chronic Candidal infections.

16 Oh Candida! Thought to have increased liklihood if it has persisted for > 3 days due to previously mentioned factors. Thought to have increased liklihood if it has persisted for > 3 days due to previously mentioned factors. Beefy red plaques, satellite papules, and superficial pustules Beefy red plaques, satellite papules, and superficial pustules Does not spare folds Does not spare folds Typically associated with oral thrush (52%) Typically associated with oral thrush (52%) In patients treated with abx for 10 days found to have 10x increased risk In patients treated with abx for 10 days found to have 10x increased risk

17 Oh Candida!

18 Sebhorrea Sebhorrea Salmon colored, well- demarcated scaling plaques especially in inguinal folds Salmon colored, well- demarcated scaling plaques especially in inguinal folds Greasy scaling lesions elsewhere Greasy scaling lesions elsewhere Appears by 3-4 weeks resolves by 3-4 mo. Appears by 3-4 weeks resolves by 3-4 mo. Intertrigo Intertrigo Moist sharply demarcated erythema in folds with minimal scale No satellite lesions

19 Sebhorrea Intertrigo

20 Langerhans Hematologic/oncologic disorder Hematologic/oncologic disorder Present during infancy or early childhood Present during infancy or early childhood Red/orange or yellow/brown scaly papules, erosions, or petechiae most commonly in the groin, intertriginous regions, and scalp Red/orange or yellow/brown scaly papules, erosions, or petechiae most commonly in the groin, intertriginous regions, and scalp

21 Langerhans

22 Zinc Deficiency Aka Acrodermatitis Enteropathica Aka Acrodermatitis Enteropathica Typical in breast fed patients that are not supplemeneted with vitamins Typical in breast fed patients that are not supplemeneted with vitamins Erythema, peeling of skin in multiple areas including hands, face, feet and nail changes Erythema, peeling of skin in multiple areas including hands, face, feet and nail changes

23 Zinc Deficiency

24 Management Education, Education, Education Education, Education, Education Prevention is key! Prevention is key! Frequent diaper changes Frequent diaper changes Gentle cleansing, avoiding harsh soaps/frequent cleaning Gentle cleansing, avoiding harsh soaps/frequent cleaning Barrier protection Barrier protection Antifungals/Anti-inflammatories Antifungals/Anti-inflammatories

25 Wave of the future… Disposable diapers in place of cloth diapers have led to a decrease in incidence due to their super absorbant nature Disposable diapers in place of cloth diapers have led to a decrease in incidence due to their super absorbant nature New diapers provide continuous administration of zinc oxide/petroleum to skin New diapers provide continuous administration of zinc oxide/petroleum to skin

26 Keep it clean… Removal of diaper as soon as it is soiled/wet to prevent interaction of enzymes Removal of diaper as soon as it is soiled/wet to prevent interaction of enzymes Removal should be with a soft cloth and water to avoid removal of stool only and not barrier cream Removal should be with a soft cloth and water to avoid removal of stool only and not barrier cream Avoid baby wipes that contain alcohol as they may increase drying out. Avoid baby wipes that contain alcohol as they may increase drying out.

27 Barriers Work to prevent overhydration of skin Work to prevent overhydration of skin Reduces transepidermal loss of water and repels further water from entering skin. Reduces transepidermal loss of water and repels further water from entering skin. Disadvantages to using barriers are mostly due to the difficulty in removing them Disadvantages to using barriers are mostly due to the difficulty in removing them Ways to avoid: Ways to avoid: Use of mineral oil to soften paste Use of mineral oil to soften paste Cornstarch instead of talcum powder to reduce frictional injury. Cornstarch instead of talcum powder to reduce frictional injury.

28 Barrier cream

29 Antifungals Indications: Indications: Satellite lesions Confirmation with KOH slide Present for at least 3 days Nystatin, ketoconazole, miconazole all equally effective

30 Steroids Treatment limited to three to five days 2x daily and only to treat severely inflamed irritant diaper dermatitis due to increased absorbtion Treatment limited to three to five days 2x daily and only to treat severely inflamed irritant diaper dermatitis due to increased absorbtion Only the lowest potency, nonhalogenated topical corticosteroids should be prescribed; over-the- counter 1% Hydrocortisone percent cream or ointment is often sufficient. Only the lowest potency, nonhalogenated topical corticosteroids should be prescribed; over-the- counter 1% Hydrocortisone percent cream or ointment is often sufficient.

31 Antibiotics Topical only Topical only Only for secondarily infected. Only for secondarily infected. Mild: Mupirocin 2x daily Mild: Mupirocin 2x daily Avoid: Avoid: Neosporin/Bacitracin due to increased allergic likelihood to neomycin Neosporin/Bacitracin due to increased allergic likelihood to neomycin

32 The End


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