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What types of dermatitis are most common in babies?



1. Primary irritant diaper dermatitis:

It is characterized by confluent and shiny erythematous lesions, which vary in intensity over time. It can be manifested by erythematous papules ( which cause a reddening of the skin ) associated with edema (swelling) and mild desquamation. It usually affects the regions in contact with the diaper, and the folds are normally spared. The most affected areas are the convex surfaces of the buttocks, the thighs, the lower abdomen, the pubic region, the labia majora, and the scrotum.

 



2. Candidiasis:

It is considered the main complication of dermatitis. If they occur simultaneously, the erythema worsens and there are satellite lesions in pustules ( small inflammatory tumor) or papules ( red pimple on the skin, without pus or serosity, which dries in a short time).

When the erythema starts to improve, the skin shrinks and looks like papyrus. In children under the age of four months, the first manifestation is mild perianal (around the anus) erythema.

There is a more severe form of dermatitis due to the continuity of the lesion, associated with aggravating factors such as topical irritants and fungi. It is characterized by firm, raised papules, dark red or violet in color, which appear before the vesicle-erosive-ulcerative stage. Ulcerations are oval or rounded, shallow and with a crateriform appearance. It occurs mainly on the buttocks, upper thighs, and may look like the following photo.

 



After regression, this type of dermatitis can cause atrophy (roughness) and hyperpigmentation (darkening of the skin). It usually affects children over the age of six months. In boys, ulcers can affect the glans and urinary tract, leading to discomfort and dysuria (difficulty urinating).

The most common form is primary irritative diaper dermatitis. It originates from the combination of several factors: prolonged skin contact with urine and feces, which causes maceration and a rise in skin pH, high temperature, hyper-hydration of the stratum corneum (which makes it more susceptible to friction by the diaper ), chemical irritation. In some cases, superinfection by bacteria and Candida albicans may occur, the latter being facilitated by the use of oral antibiotics.


What are the epidemiological data on the occurrence of diaper dermatitis?

Primary irritant diaper dermatitis is rare in the immediate neonatal period, increases in incidence during the first month of life, and has a peak prevalence between the 9th and 12th month. In Western countries it is around 25-50%. 


A clinical history

Primary irritant diaper dermatitis is characterized by shiny erythema with a varnished appearance that, in prolonged chronic situations, evolves into wrinkled skin with a parchment appearance, with fine scaling. It characteristically affects the convex areas, which are the areas most in contact with the diaper: labia majora, scrotum, inner and upper thighs, lower abdomen and buttocks. Saves the creases. It is also known as W-shaped dermatitis.

 

Irritant dermatitis of the diaper area
 

Primary irritant contact dermatitis


There are less common morphological variants

  • Tidal dermatitis: band erythema confined only to the margins of the diaper in the area of ​​the abdomen and thighs. It results from the constant friction that occurs at the edge of the diaper in the area of ​​the abdomen and thighs.
  • Jacquet's erosive dermatitis: severe condition of irritative dermatitis, associated with intense maceration, manifested by eroded papules and nodules.    
     

Irritant dermatitis of the diaper area


Differential diagnosis

A diaper rash can also be a diagnostic sign of a systemic disease, another more diffuse dermatosis that is exacerbated in this area, or a local infection.


However, there may be other causes for diaper dermatitis:

It should be distinguished from other skin changes that can also affect this area of ​​the body:

1) Frictional or frictional dermatitis (eg caused by improperly sized or overly tight diapers....)

2) Contact dermatitis - of allergic origin -: caused by the rubber or plastic of diapers, or by some previous treatments. Caused by contact with other products or irritating stimuli to the skin - diarrhea for example, which alone is sufficient to trigger and maintain diaper rash, or other irritating products (eg cleaning wipes)

3) Candida-type fungal dermatitis: shiny erythema affecting the folds, with pustular “satellite” dots on the edges of the lesions. When this happens, the typical appearance is bright red lesions, bright, with the presence of satellite pustules on the edges of the lesions and possibly scaling in the peripheral region. Dermatitis complicated by candidiasis, unlike simple diaper dermatitis, usually affects folds too!

4) Seborrheic dermatitis: erythema with yellowish desquamation, which can affect other areas of the body (scalp, eyebrows...)

5) Atopic dermatitis: more often affects other parts of the body.

6) Bacterial infection: superficial eruptions and/or yellowish crusts

7) Miliaria rubra or sudamine: red dots due to heat, etc...


Candidiasis of the diaper area

It is one of the most frequent causes of dermatitis in the diaper area. Unlike irritative dermatitis, it primarily affects the folds.

Initially, confluent pinkish papules with superficial scale are observed. In the more advanced form, bright red erythema is seen, with peripheral desquamation and satellite papulopustules.


Diaper area dermatitis - wet lesions (Candida albicans infection)


Diaper area mixed dermatitis

Often several pathologies affect the diaper area simultaneously, which modifies the characteristic morphological pattern of each one of them. For example, Candida albicans superinfection of primary irritant dermatitis or seborrheic dermatitis often occurs; an inflammation in the diaper area can precipitate psoriasis in this same area in genetically predisposed children.


Allergic contact dermatitis

Allergic reactions to diaper components, namely to decorative dyes, glues and elastic compounds, as well as to components of topical applied in the area or at a distance, have increased in frequency (6). It should be suspected when eczema lesions are observed that do not respond or relapse/aggravate after appropriate treatment. Sometimes these are “talking lesions” because they draw the contact area. The suspicion can be confirmed with epicutaneous or contact evidence.


Granuloma gluteal infantum

They are hard, painless, erythematous-brown nodules in the diaper and buttocks area. There is usually a previous history of dermatitis in the diaper area treated with potent steroids.





Other dermatoses located here may pose differential diagnosis problems, such as: seborrheic dermatitis , psoriasis , atopic dermatitis , impetigo , folliculitis, miliaria rubra, scabies , acrodermatitis enteropathica and others. Other rarer entities are Langerhans cell histiocytosis, chickenpox/herpes, bullous epidermolysis, congenital syphilis, mastocytosis, chronic bullous dermatosis of childhood.

 

 

Catarina Vilela - Nurse