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A 7-week-old boy with painful erosions on his buttocks
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Marissa J. Perman
Scarlett Boulos
A 7-week-old boy presented with a 3-week history of a worsening diaper rash. He started with bright red patches on his buttocks that were treated with nystatin powder to empirically treat candidiasis. The area initially had mild improvement for a few days, but then the areas continued to worsen and break down.
Patient presented with punched-out, eroded and ulcerated papules and small plaques on the exposed surfaces of his medial thighs and buttocks, sparing the folds.
Source: Boulos S
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The patient had frequent stools, and his diaper was changed often. His parents had noticed that he was especially fussy when he urinated or had a bowel movement as well as during diaper changes. His parents used regular diaper wipes to clean the area, scented baby soap and various barrier creams. The parents felt the most helpful treatment was petroleum jelly. The patient was otherwise healthy and developing normally. The diaper rash led to a concern for milk allergy, and his parents were directed to try a new dairy-free formula, which he was not taking as well. His family history was notable for asthma and eczema in his father.
On exam, the patient had punched-out, eroded and ulcerated papules and small plaques on the exposed surfaces of his medial thighs and buttocks, sparing the folds. He also had mildly dry skin. No other significant findings were noted on physical exam.
Case Discussion
Jacquet’s erosive diaper dermatitis (B) is a severe form of irritant diaper dermatitis (IDD), which typically develops between ages 3 weeks and 2 years with an increased prevalence between ages 9 and 12 months. IDD has become less common in developed countries with the use of disposable, super absorbent diapers.
Risk factors associated with the development of IDD include infrequent diaper changes, diarrhea, antibiotic use, and intestinal anomalies. Constant moisture and friction in the diaper area disrupt the stratum corneum, which provides a protective barrier from irritants. Urine not only contributes to the moisture, but it also increases the environmental pH with the decomposition of urea in the presence of fecal urease. In addition, fecal lipases, proteases and bile salts produce further erythema and barrier disruption.
IDD initially presents with erythema on the exposed, convex surfaces of the diaper area, sparing the folds and suprapubic area in boys. The rash can become more extensive to include the creases and scrotum and more inflammatory with yeast colonization. In some more severe cases, the erythematous plaques can become shiny with a wrinkled surface. Jacquet’s erosive diaper dermatitis is distinguished by its well defined, punched out erosions and ulcers on exposed surfaces.
When evaluating patients with suspected IDD, it is important to gather information about cleansers, moisturizers, barrier creams, diaper wipes, or any other product that is used in the diaper area to eliminate potential irritants. The etiology of chronic urine or fecal leakage should be determined and, if possible, corrected. Treatment is based on gentle skin care, frequent diaper changes with superabsorbent disposable diapers, and mild, rarely medium-strength, topical steroids twice daily followed by a barrier cream or ointment. A barrier cream or ointment should be used with every diaper change, maintaining a thick layer on the skin surface. Many diaper wipes contain multiple preservatives and fragrances, which serve as irritants and potential allergens. They should not be applied to open skin. It is best to recommend either soft cloths to wipe the area or wipes with minimal preservatives and no fragrances. Once the chronic irritant is removed, the lesions generally will spontaneously resolve within days to weeks.
The differential diagnosis of IDD includes other more severe forms of Jacquet’s erosive diaper dermatitis including granuloma gluteale infantum and pseudoverrucous papules and nodules, allergic contact dermatitis, diaper candidiasis and acrodermatitis enteropathica.
Granuloma gluteale infantum is a rare presentation of severe IDD in infants with oval red-brown and purple nodules in the diaper area, rarely involving the folds. The long axis of the lesions tends to follow the skin lines. There is usually a history of chronic diaper dermatitis, treated with multiple topical therapies including fluorinated steroids.
Pseudoverrucous papules and nodules is another form of severe IDD that presents in infants as dome-shaped, shiny, red or white papules on the groin area or around enterostomal openings. The lesions can be mistaken for condylomata clinically. The condition is related to skin irritation from leakage around stomas, chronic incontinence or diarrhea due to malabsorption, short gut syndrome, or surgical repair of imperforate anus or Hirschsprung disease.
Allergic contact dermatitis (ACD) can develop in the diaper area after about age 6 months due to exposure to fragrances, preservatives and dyes. ACD presents with eczematous, dry, red plaques with vesicles and edema in the corresponding areas exposed to the allergen, although involvement can extend beyond the areas of exposure. The affected areas tend to be itchy. Treatment is based on avoiding possible allergens and low to medium potency topical steroids.
Candidal diaper dermatitis is caused by Candida albicans, and it presents beginning around age 6 weeks but can occur at any age with beefy red patches and plaques in the perineum including the creases with satellite papules and pustules. This condition is associated with chronic moisture, history of antibiotic use, or diarrhea. The patient should be examined for oral thrush with white patches on the buccal mucosa. Treatment consists of topical antifungal treatment and barrier products or occasionally oral antifungal therapy if the oral mucosa is involved.
Acrodermatitis enteropathica (AE) is a rare presentation of zinc deficiency, which can be acquired or recessively inherited. This condition presents in an infant with red-orange scaly, crusted plaques on the perioral area forming a “horseshoe” shape on the cheeks and buttocks. The acral areas of the fingers and toes can also be involved and nails can be dystrophic. Patients can be especially irritable, have diarrhea, hair loss, and recurrent infections especially with C. albicans. If this diagnosis is suspected, a serum zinc level and alkaline phosphatase should be checked. Zinc is a cofactor of alkaline phosphatase, so it can concomitantly be low. AE is treated with oral zinc supplementation.
While diaper dermatitis has several etiologies, the exam findings, distribution and history can help direct further workup, diagnosis, and treatment options. With several potential irritants and allergens in skin products, it is important to educate parents regarding gentle and appropriate skin care to help prevent further skin irritation and discomfort.
- References:
- Eichenfield LF, et al. Neonatal and Infant Dermatology. 3rd ed. London: Elsevier; 2015.
- Klunk C, et al. Clin Dermatol. 2014; doi:10.1016/j.clindermatol.2014.02.003.
- Paller AS, et al. Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence. 5th ed. London: Elsevier; 2016.
- Shin HT. Pediatr Clin North Am. 2014; doi:10.1016/j.pcl.2013.11.009.
- For more information:
- Scarlett Boulos, MD, is a pediatric dermatology fellow at The Children’s Hospital of Philadelphia. She can be reached at bouloss@email.chop.edu.
- Marissa J. Perman, MD, is an attending physician at The Children’s Hospital of Philadelphia.
Disclosures: Boulos and Perman report no relevant financial disclosures.