Clinics in Dermatology (2015) 33, 477482

Diaper (napkin) dermatitis: A fold

(intertriginous) dermatosis
Yaln Tzn, MD a,, Ronni Wolf, MD b , Sleyman Balam, MD a , Burhan Engin, MD a
Department of Dermatology, Cerrahpaa Medical Faculty, Istanbul University, stanbul, Turkey
a
b
Dermatology Unit, Kaplan Medical Center, Rehovot, Israel, affiliated with the School of Medicine, Hebrew University and
Hadassah Medical Center, Jerusalem, Israel

Abstract Diaper (napkin) dermatitis is an acutely presenting inflammatory irritant contact dermatitis of
the diaper region. It is one of the most common dermatologic diseases in infants and children. In the
past, the disease was thought to be caused by ammonia; however, a number of factors, such as friction,
wetness, inappropriate skin care, microorganisms, antibiotics, and nutritional defects, are important.
Diaper dermatitis commonly affects the lower parts of the abdomen, thighs, and diaper area.
Involvement of skin fold regions is typical with diaper dermatitis. At the early stages of the disease, only
dryness is observed in the affected area. At later stages, erythematous maceration and edema can be
seen. Secondary candidal and bacterial infections can complicate the dermatitis. In the differential
diagnosis of the disease, allergic contact dermatitis, intertrigo, psoriasis, atopic and seborrheic
dermatitis, and the other diseases should be considered. Causes of the disease should be determined and
eliminated primarily. Families need to be informed about the importance of a clean, dry diaper area and
the frequency of diaper changes. The use of superabsorbent disposable diapers has decreased the
incidence of the disease. Soap and alcohol-containing products should be avoided in cleaning the area.
In some cases, corticosteroids and antifungal agents can be administered. If necessary, antibacterial
agents and calcineurin inhibitors can also be beneficial.
2015 Elsevier Inc. All rights reserved.

Diaper dermatitis is an acute, inflammatory skin reaction that
occurs in the diaper area. This term includes skin reactions
caused by direct exposure of the skin to diapers; however,
dermatologic disorders (such as bullous impetigo, acroder-
matitis enteropathica, and so on) that occur particularly
around the diaper region are considered as subgroups of this
definition as well.1
Diaper dermatitis is the most common dermatologic
disease of infancy. It is seen mostly in infants between 9 and
12 months of age but also may be seen in adults using
incontinence pads and those with urinary incontinence.1,2
The prevalence of this disorder has been estimated to be
Corresponding author.
E-mail address: Yalcintuzun@gmail.com (Y. Tzn).
between 7% and 35%. Recently, the use of superabsorbent
disposable diapers had reduced this frequency.3 No vari-
ability between different ethnic groups is seen.
The best clinical criterion for the diagnosis of diaper
dermatitis is the location of the lesions. Affected regions
include the genitals, the buttocks, thighs, and the lower part
of the abdominal area.4
Etiology
In the past, it was widely believed that ammonia was the
prominent factor for diaper dermatitis. Ammonia is produced
by fragmentation of urea in urine with the aid of bacterial

http://dx.doi.org/10.1016/j.clindermatol.2015.04.012
0738-081X/ 2015 Elsevier Inc. All rights reserved.
478
enzymes. It has been determined that the amount of ammonia
on the skin and the mornings first diaper of infants is the same
for affected and unaffected infants. Erythema can be observed
when ammonia is applied only to the damaged skin. All of
these show that the main factor responsible for diaper
dermatitis is not limited to ammonia. Many factors other
than ammonia are involved in the etiology of diaper dermatitis.
The primary cause of diaper dermatitis is prolonged and
increased exposure to wetness against the skin.5
Friction
Friction between the skin and clothes is an important
trigger in diaper dermatitis but is not the sole factor.6 Friction
damages epidermal barrier functions, which allows easier
penetration of irritants. This hypothesis is supported by the
predilection of diaper dermatitis to occur in areas with the
closest contact with the diaper such as the convex surfaces of
the genitalia, the thighs, the buttocks, and the waistline.7
Wetness
Increased skin hydration occurs in diaper areas, which
makes skin surfaces more fragile and therefore increases the
risk of friction. The skins protective barrier function is
damaged by friction, which makes the skin more susceptible
to microorganisms.8
Urine and feces
We can say that ammonia is not the primary cause of
diaper dermatitis; however, it has an important role as an
aggravating factor for the damaged skin. Other urinary
degradation products also may play a role in diaper
dermatitis etiology. In one study, a sample of urine kept
below 37C for 18 hours was applied to newborn skin, after
which development of dermatitis free of pH and ammoniacal
concentration, was observed. 7 Epidermal permeability
function is more severely affected by urine than water.9
It is known that feces have an irritant effect on skin.
Bacterial enzymes in feces degrade urea and release
ammonia. Increased pH levels in the diaper area activate
fecal proteases and lipases.10 These enzymes in the diaper
area are the most important irritant agents for skin. Severe
erythema and deterioration in the integrity of the skin
develops after contact with these enzymes. Children fed
cow's milk have many urease-positive bacteria in their feces,
which raises the risk of diaper dermatitis in these children.3
There is a correlation between diaper dermatitis and the
volume of defecation. Intestinal passage is faster in patients
Y. Tzn et al.
with diarrhea. As a result, the number of enzymes increases
in diaper area and the frequency of diaper dermatitis rises.3
Inappropriate skin care
The use of liquid soap and talcum powder can cause
diaper dermatitis. The other important factor causing diaper
dermatitis is infrequent diaper changes.3,7,11
Microorganisms
The role of microorganisms in the pathogenesis of diaper
dermatitis has been considered; however, any significant
difference between the bacterial growth in infants with or
without diaper dermatitis has not been demonstrated.
Penetration of bacteria increases when the stratum corneum
is damaged. 7 The role of Candida infection in the
pathogenesis is more prominent than that of bacterial
infection. Several reports indicate that the presence and
level of Candida infection is important for the clinical
demonstration of diaper dermatitis.
Atopic dermatitis can affect the diaper area. The presence
of atopic dermatitis may cause or exacerbate diaper
dermatitis. Patients with atopic dermatitis have increased
Staphylococcus aureus colonization in this area. Other
infectious agents such as herpes simplex virus type 1,
dermatophytes, and cytomegalovirus infections can also
trigger diaper dermatitis.5
Antibiotics
The use of broad-spectrum antibiotics can play a role in
the etiology of diaper dermatitis. This condition is related to
colonization of Candida infection in the genital area.7,12
Nutritional defects
Zinc and biotin deficiency can lead to diaper dermatitis.1
Clinical findings
Irritant diaper dermatitis is the most common dermato-
logic disease of infancy.2 This condition is not observed
within the first 3 weeks of infancy. The disease usually starts
between the third and twelfth weeks. It is characterized by
erythema on the convex sides of the hips, mons pubis,
scrotum, and the lower part of the abdomen, areas with the
Diaper (napkin) dermatitis: A fold (intertriginous) dermatosis
Fig. 1 Erythema in convex sides of the hips, mons pubis, and the
lower part of the abdomen.
most contact with diapers (Figure 1). Skin folds are not
affected typically. In the early stages, the irritation consists of
erythema, light maceration, and edema; the progression of
lesions increases maceration. Erosion and ulceration may
develop at the advanced stage.13 At this stage, secondary
infections due to Candida albicans and bacteria can develop
(Figure 2).
Papules and pustules can be seen beyond the edge of the
erythematous areas (ie, satellite lesions). Another form of
irritant contact dermatitis situated on the edge of the diaper
Fig. 2 In the same infant as in Figure 1, later-stage secondary
infection due to bacteria.
479
can be seen due to adhesives used to hold the diaper in
place. In this type, asymmetric lesions are important for the
correct diagnosis. Additionally, a rare clinical condition of
primary irritant dermatitis is described as having herpetiform
lesions. In this type, vesicles and pustules occur after
erosions. There is no pathologic finding due to herpes
simplex virus infection.7
Jacquet erosive diaper dermatitis is the more severe
clinical form of irritant contact dermatitis. This condition is
characterized by crater-like erosive erythematous nodules.10
It is more common in children with chronic diarrhea.3
The severe clinical form of diaper dermatitis is granuloma
gluteale infantum. This clinical condition is rare and
characterized by purple-brown nodules in the diaper area.
These nodules are asymptomatic and settle especially on the
inner part of the thighs, perianal region, and lower part of the
abdomen. The pathogenesis of the disease is unknown;
however, fluorine-containing strong corticosteroids are
thought to be the cause.14 Patients need no treatment due
to spontaneous recovery. Differentiation from neoplastic
disease is important.
Differential diagnosis
The differential diagnosis of diaper dermatitis is shown in
Table 1.
Allergic contact dermatitis
Allergic contact dermatitis is considered uncommon
in children younger than 2 years of age due to their immature
immune systems. This disease can develop due to some
agents applied to the skin, such as paraben, lanolin, or
neomycin, and the elastic bands around the edges of
cloth diapers.5 The lesions usually begin with vesicle
formation. Later, the vesicles rupture and eczematous lesions
occur. Also, flexural involvement is important for allergic
contact dermatitis.15
Table 1 The differential diagnosis of diaper dermatitis
Allergic contact dermatitis
Intertrigo
Candidal diaper dermatitis
Psoriasis
Atopic dermatitis
Seborrheic dermatitis
Congenital syphilis
Acrodermatitis enteropathica
Multiple carboxylase deficiency
Langerhans cell histiocytosis
Primary herpes simplex virus infection
Bullous impetigo
480
Intertrigo
Intertrigo refers to the well-defined redness of the folds.
Heat, humidity, and sweat retention are the triggering factors.
Secondary candidal infection may cause satellite papules
and pustules.16
Candidal diaper dermatitis
Candidal infection is the most common complication of
diaper dermatitis. 3 Satellite papules and pustules are
accompanied by erythematous and well-defined plaques.
Inguinal folds are impaired as opposed to the areas affected
by irritant contact dermatitis. Broad-spectrum antibiotic
therapy or diarrhea can be found in the medical history.
Oral mucosal involvement is also noted in these infants. The
diagnosis can be confirmed by smear and culture.5,17
Psoriasis
A rare clinical manifestation of psoriasis is diaper
dermatitis. There are erythematous, sharply demarcated
plaques in inguinal folds and on the buttocks. Scaling of
the psoriatic plaques is not observed due to the humidity of
the diaper area. It is a difficult diagnosis; however, observing
psoriatic plaque and nail involvement elsewhere may suggest
the diagnosis. Clinical response to treatment is slower than
with other diseases.3,5,15,18
Atopic dermatitis
Infants with atopic dermatitis are prone to irritant contact
dermatitis. The clinical appearance is similar to irritant
contact dermatitis; however, unlike irritant contact dermati-
tis, atopic dermatitis is more resistant to treatment and there
is severe itching. Sites of predilection of atopic dermatitis
may be helpful for differential diagnosis. Also, a family
history of atopy is helpful.3,5,19
Seborrheic dermatitis
Infants with seborrheic dermatitis develop erythematous
plaques with fine, greasy scales in the diaper area. These
generally form at the third or fourth weeks of life.18 The
lesions, involving the scalp, ears, and face, are helpful in
making the diagnosis. Generally, these asymptomatic lesions
respond to topical steroids.3,5
Y. Tzn et al.
Congenital syphilis
Congenital syphilis is not a common disease; however, it
should be considered.7
Acrodermatitis enteropathica
Acrodermatitis enteropathica is a rare autosomal recessive
disease in which intestinal zinc-binding ligands are absent,
leading to zinc deficiency. An erythematous plaque mim-
icking diaper dermatitis may be a clinical manifestation of
acrodermatitis enteropathica. Characteristic clinical symp-
toms of the disease include periorificial and acral dermatitis,
alopecia, and diarrhea.19,20 Response to zinc supplementa-
tion is very good.21
Multiple carboxylase deficiency
Multiple carboxylase deficiency is one reason for skin
eruptions on diaper area. At the same time, it must be considered
in patients with facial seborrheic dermatitis.7
Langerhans cell histiocytosis
Langerhans cell histiocytosis is a severe disease seen in
children younger than 3 years of age. The diaper area, scalp,
and retroauricular area are the most commonly affected
areas. At presentation, the lesions can be seen as inguinal
erythema mimicking diaper dermatitis.22 Clinical lesions
resistant to local treatments are important in the diagnosis of
Langerhans cell histiocytosis.3,5
Primary herpes simplex virus infection
Diaper dermatitis may be secondarily affected. Primary
herpes simplex virus infection in the diaper area can
be manifested by red spots or grouped vesicular skin
eruptions. The diagnosis is made by a Tzanck smear and
viral culture.3,5
Bullous impetigo
Bullous impetigo most commonly affects neonates. It is
characterized erythematous blister and surrounding redness
in the diaper area.3,5,13,16
Diaper (napkin) dermatitis: A fold (intertriginous) dermatosis
Histopathology
Histopathologic evaluation shows nonspecific findings,
such as epidermal spongiosis and dermal inflammation.7
Treatment
The most important step in the treatment of diaper
dermatitis is the detection and elimination of the etiologic
factors causing the disorder. In this way, both the treatment
of the disease and prevention of recurrence can be provided.
Families should be informed about cleaning the diaper area,
the frequency of diaper changes, and use of care products
applied in these areas. The infants diet should be questioned,
as it may have a role in the development of diaper
dermatitis.3 The diaper area should be kept clean and dry
by avoiding moisture and friction.
Diapers
The frequency and intensity of diaper dermatitis decrease
when superabsorbent disposable diapers are used.23 These
diapers can absorb water up to 80 times their own weight and
thus can protect the diaper area from moisture and friction.24
They also help to maintain the normal pH of the diaper area.
Another current consideration is breathable disposable
diapers with micropores. These diapers simply provide
selective permeability against water. Preventing the prolif-
eration of candidal infections in the diaper area is another
important feature. About a 50% reduction in the frequency of
diaper dermatitis was observed with use of these diapers.3,17
Disposable diapers containing zinc oxide/petrolatum and
stearyl alcohol compounds seem to reduce the frequency of
dermatitis. The compounds in these diapers are released to
the skin in a controlled manner.3,25
The most important preventive factor for diaper dermatitis
is frequent diaper changes. Prolonged exposure to urine and
feces will cause irritation. It is recommended that diapers be
changed every hour for newborns and every 3 to 4 hours for
older infants. If possible, the child should be left with no
diaper for a certain time to keep the area dry.3,7
Cleaning and care
Cleaning of the diaper area should be implemented
correctly. Cleansers containing soap and alcohol are not
recommended. Washing often disturbs the barrier layer of
the skin. The area should be gently cleaned without
overusing lotions and creams, including oil in the water.
This process should be repeated after each defecation.
481
Barrier creams should be used after cleaning. These creams
prevent penetration of irritants by repairing the lipid
layer of the skin. For this purpose, preparations such as
zinc oxide, dimethicone, lanolin, and petrolatum can be
chosen. Also, soap and alcohol-containing products should
be avoided.3
Powders can be used to prevent moisture and decrease
friction. Corn flour can be used for this purpose, but talcum
powder is not recommended.3,5
Medical treatments
Diaper dermatitis can occur despite appropriate care and
cleaning. In such cases, various treatments can be imple-
mented for unresponsive diaper dermatitis.
Protective barriers
Occlusive agents, such as zinc oxide (Lassars) paste, has
its proponents, as do petrolatum agents.
Corticosteroids
Corticosteroids can be used in cases unresponsive to other
treatments; however, only low- to mid-potency steroids may
be used in the diaper area.3,5,7 Long-term use of topical
steroids is not indicated, just as potent topical steroids should
be avoided.
Antifungal agents
C albicans plays a crucial role in the etiology of diaper
dermatitis. In dermatitis lasting longer than 3 days and in the
presence of clinical signs suggestive of candidosis, antifun-
gal agents should be added to the treatment. Nystatin,
miconazole, fluconazole, and clotrimazole are topical agents
that can be used. The success rate of topical agents is high,
and oral antifungal agents are rarely needed.3,5,9,16,17
Antibacterial agents
In the presence of bacterial superinfection or when yellow
crusts are observed in patients with atopic dermatitis,
antibacterial therapy should be considered. Besides its
antibacterial activity, mupirocin is also effective against
Candida spp. The use of systemic agents may be required if
bullous impetigo is present.
482
Calcineurin inhibitors
Steroid-related side effects are not observed with the use
of tacrolimus and pimecrolimus; however, the data for
calcineurin inhibitors are limited for use in the treatment of
diaper dermatitis.3,26
Others
A mixture of honey, olive oil, and beeswax is said to be
useful in the treatment of diaper dermatitis.27 Also, topical
application of sucralfate may improve the barrier function of
the skin, and this application may then be effective in the
treatment of diaper dermatitis. 28 The use of tar is
controversial due to its possible carcinogenic effects; in
some countries, tar is used in combination with zinc oxide.17
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