Review

Infections and skin diseases mimicking diaper dermatitis

Dirk Van Gysel, MD, PhD

Department of Pediatrics, O. L. Vrouw

Hospital, Aalst, Belgium
Correspondence
Dirk Van Gysel, MD, PHD
Department of Pediatrics
O. L. Vrouw Hospital
Moorselbaan 164
B-9300 Aalst, Belgium
E-mail: dirk.van.gysel@olvz-aalst.be

Abstract
Diaper dermatitis is a common condition that often prompts parents to seek medical
attention. Irritant diaper dermatitis is by far the most common cause, but numerous
potentially serious diseases can present with changes of the skin in the diaper area. The
differential diagnosis can include psoriasis, metabolic disorders, rare immune diseases and
infection. Clinical examination can be helpful in distinguishing the underlying cause.
General screening laboratory tests, as well as select testing when a specific condition is
suspected, can be used to challenge or confirm the putative diagnosis.

Funding: The author received financial

support for the research, authorship and
publication of this article from The Procter
& Gamble Company.
Conflicts of interest: None.

Introduction
Although diaper dermatitis is a very common problem
in infants and young children, a range of other conditions may present in the diaper area and may be mistaken for a simple rash. Any diaper dermatitis that
does not resolve with standard treatments must be evaluated for underlying disease. A rash may be related to
a common disease (such as atopic dermatitis) that does
not often occur in the diaper area, or may be caused
by a rare disease (such as acrodermatitis enteropathica).
Diseases that mimic diaper dermatitis
Select types of infection, and systemic and dermatologic
disorders that may resemble diaper dermatitis are outlined in Tables 1 and 2, respectively. Patients with these
conditions require additional evaluation through a range
of tests in order to ensure a correct diagnosis and the provision of appropriate treatment.13
Diagnostic tests

10

History and clinical examination, including both the

clinical features of eruptions in the diaper area and
accompanying signs outside the diaper area, can be helpful in distinguishing the underlying cause of the diaper
dermatitis.
International Journal of Dermatology 2016, 55 (Suppl. 1): 1013

In addition, available laboratory tests can be used to

challenge or confirm the putative diagnosis. Blood and
urine analyses may involve a general screening, including
complete blood cell counts, and liver and renal function
tests. Screening may also be conducted on an individual
basis when a certain condition is suspected. Screening
processes may include:
measurement of serum zinc levels, tryptase, biotin and
biotinidase activity, ammonia;
analysis of organic acids in plasma and/or urine;
serologic testing for syphilis (rapid plasma reagin [RPR]
or Venereal Disease Research Laboratory [VDRL] tests)
on serum, and
polymerase chain reaction (PCR) for syphilis, human
papillomavirus (HPV), herpes simplex virus (HSV),
human immunodeficiency virus (HIV) and enterovirus.
Other evaluations may include:
culture of skin lesions for Staphylococcus aureus or
Group A streptococcus;
potassium hydroxide preparation and/or fungal culture
of skin scrapings for candida;
microscopic examination of scrapings from linear
lesions in suspected scabies;
Tzanck smear of blisters or pustules; multinucleated giant
cells indicate a viral infection such as herpes simplex;
dark-field microscopy for direct visualization of Treponema pallidum, and
epicutaneous patch testing.
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Van Gysel

Skin diseases mimicking diaper dermatitis

Review

Table 1 Infections mimicking diaper dermatitis with specific clinical features and diagnostic tests
Infection

Clinical features

Diagnostic tests

Candida napkin
dermatitis

Consider in any irritant diaper dermatitis that persists for

>3 d
Bright red erythema with irregular border with involvement
of the folds and satellite pustules; sometimes thrush
Neonates with congenital cutaneous candidiasis may
present with characteristic macerated areas of erythema in
the anogenital region
Easily ruptured, large, flaccid bullae, leaving erosions and
honey-colored, crusted plaques in the diaper area
In neonates often colonization of the umbilicus with
Staphylococcus aureus
Painful, itchy, bright red, perianal rash with well-defined
margins and thin mucoid exudates
Diffuse erythema that blanches with pressure, with numerous
small (12 mm) papular elevations, giving a sandpaper
quality to the skin; the rash is most marked in the skin folds
of inguinal areas
Hemorrhagic vesicles or pustules that evolve into necrotic
ulcers with a tender erythematous border
Usually occurs in patients who are critically ill and
immunocompromised
Most commonly caused by Pseudomonas aeruginosa;
however, EG-like lesions have been observed in patients
with other bacterial and fungal infections
Intensely pruritic eruption consisting of red papules, pustules
and excoriations on the lower half of the buttocks and male
genitalia (scrotum, penile shaft, glans)
Similar lesions in other sites of predilection
Intense itching in family members
Often heavy involvement of the palms and soles in young
children and infants
Anogenital warts

Potassium hydroxide slide preparations of the skin:

pseudohyphae

Bullous impetigo4

Perianal streptococcal
disease5
Scarlet fever

Ecthyma
gangrenosum (EG)6

Scabies7

Human papillomavirus
(HPV)
Herpes simplex virus
(HSV)8
Human
immunodeficiency
virus (HIV)

Hand, foot and mouth

disease9

Painful crops of papular, vesicular or pustular lesions

Severe recalcitrant erosive napkin dermatitis with deep

gluteal cleft ulcerations
Early HIV infection: flu-like symptoms, followed by painless
swelling of lymph nodes; painful ulcers in the mouth and
esophagus; digestive symptoms such as nausea and
vomiting, diarrhea, lack of appetite and weight loss; dry
cough
Advanced HIV infection: opportunistic infections
Red macules and small, blister-like bumps on the buttocks
and (less commonly) genitalia
Small, oval, graywhite papules and vesicles on an
erythematous base on the palms of the hands and feet
Red macules that progress into small vesicles on the
buccal mucosa and tongue
Increasing numbers of atypical cases with widespread
lesions

Grams stain: Gram-positive cocci

Bacterial culture of blister fluid: S. aureus

Cultures obtained from swabs of the perianal area: Group A

b-hemolytic streptococcus
Characteristic triad: rash, perioral pallor and strawberry
tongue
Rapid strep test, throat culture, ASO titer
Grams stain of fluid from the central hemorrhagic pustule or
bulla
Cultures obtained from swabs of the lesion
Skin biopsy: edema, epidermal necrosis and Gram-negative
rods on tissue Grams stain

Microscopic examination of skin scrapings from linear

lesions: demonstration of the mite, ova and/or feces

PCR for HPV detection using primers targeted to the viral

capsid L1 gene, which can detect numerous HPV types
PCR for HSV detection
Tzanck smear: multinucleated giant cells
Viral culture
HIV-1 DNA PCR
Exclude associated cytomegalovirus or herpes infection

PCR for Coxsackie A16 and Coxsackie A6 viruses

ASO, antistreptolysin O; PCR, polymerase chain reaction.

In patients in whom the rash is atypical and unconfirmed by standard screenings, a skin biopsy with histologic examination may be necessary.
2016 The International Society of Dermatology

In conclusion, diaper dermatitis is a common problem in infants. Any persisting diaper dermatitis should
be further scrutinized for underlying disease. Clinical
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Van Gysel

Skin diseases mimicking diaper dermatitis

Table 2 Systemic and dermatologic disorders mimicking diaper dermatitis with specific clinical features and diagnostic tests
Disorder

Clinical features

Diagnostic tests

Atopic dermatitis (AD)10

AD usually spares the diaper area

If present: similar to IDD
More typical lesions elsewhere on the body
Pruritus
Family history of atopy
Well-circumscribed erythematous papules and plaques with
greasy yellow scale, most prominent in the inguinal folds
Similar lesions in other skin folds (axillae, antecubital
fossa, and popliteal fossa), in the scalp and the face
affecting the forehead, eyebrows and post-auricular area
Sharply demarcated brightly erythematous, intertriginous
plaque in the diaper area
Occasionally: persistent sharply demarcated scaly lesions
Typical scaly lesions in other parts of the body; nail
abnormalities; family history of psoriasis
Similar to IDD
Appears in areas exposed to the offending agent and
therefore usually sharply demarcated
Spares the inguinal folds
Sharply demarcated, ivory atrophic patches involving the
vulvar and perianal skin (figure-of-eight distribution)
In boys: sharply demarcated, ivory sclerotic area on the
foreskin, resulting in phimosis; occasionally: ivory sclerotic
aspect of the glans penis with urethral meatal stenosis
Periorificial and acral eczematoid or psoriasiform lesions
Associated symptoms: alopecia; failure to thrive; diarrhea;
eye and eyelid abnormalities (blepharitis, conjunctivitis,
keratitis, ectropion, symblepharon, amblyopia)
AE-like syndrome: zinc deficiency caused by insufficient
intake/supplementation or malabsorption (e.g. cystic
fibrosis, Crohns disease)
Clinical zinc deficiency can occur even when serum zinc
level is normal
Periorificial and acral erythematosquamous eruptions
Associated symptoms: vomiting and failure to thrive;
lethargy; seizures; hypotonia, and dehydration
Multiple red/orange or yellow/brown edematous, crusted,
and eroded papules and plaques healing with dry crusts
and a collarette of scale
Most commonly in the groin
Similar lesions in the seborrheic areas
Systemic manifestations of the disease (anemia,
thrombocytopenia, hepatosplenomegaly,
lymphadenopathy, bone lesions)
Tense pruritic vesicles and bullae in a cluster of jewels
configuration on the lower abdomen and anogenital region
Lesions in the mouth, which may precede the skin lesions:
vesicles, erosions, ulcerations
Eye lesions: burning sensation, secretion

None

Infantile seborrheic
dermatitis11

Psoriasis12

Allergic contact
dermatitis13

Lichen sclerosus14

Acrodermatitis
enteropathica (AE)15

Methylmalonic acidemia
(MMA)16
Langerhans cell
histiocytosis (LCH)17

Linear immunoglobulin
A (IgA) disease18

Any child with widespread seborrheic dermatitis, diarrhea

and failure to thrive should be evaluated for Leiners
disease

Biopsy: acanthosis, parakeratosis and orthokeratosis, loss

of the granular cell layer and the formation of spongiform
pustules and parakeratotic microabscesses

Epicutaneous patch testing: positivity for topically applied

products, chemicals in or constituents of applied products,
baby wipes, or diapers
Occasionally biopsy: thinned epidermis with acanthosis and
elongation of the rete pegs; hyalinized upper dermis with a
band of lymphocytes below this region

Plasma levels of zinc: <60 lg/dl

Zinc level in either lymphocytes (<50 lg/10 cells) or
granulocytes (<42 lg/10 cells)

Analysis of organic acids in plasma and/or urine: high

levels of methylmalonic acid, methylcitrate, propionic acid,
and 3-OH propionic acid
Skin biopsy: dense infiltrate of histiocytes in the superficial
dermis and epidermis; positive CD1a and/or CD207
(Langerin) staining of lesional cells
Systemic evaluation includes abdominal ultrasound, chest
radiograph and skeletal radiograph survey with additional
testing for specific scenarios17

Skin biopsy: subepidermal blister formation

Immunofluorescence: linear IgA deposition along the basal
membrane zone

IDD, irritant diaper dermatitis.

examination, which should consider both the clinical

features of eruptions in the diaper area and accompanying signs outside the diaper area, is important for identifying the cause. However, extra laboratory tests or a
skin biopsy may be necessary to confirm the putative
diagnosis.
International Journal of Dermatology 2016, 55 (Suppl. 1): 1013

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