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This document discusses several common skin conditions that occur in infants and children wearing diapers. It describes infantile perineal protrusion, which presents as a soft tissue protrusion in prepubertal girls. It also covers diaper dermatitis, the most common pediatric dermatological condition. Diaper dermatitis has multiple causes, including prolonged skin wetness and contact with urine/feces. The main types are irritant and candidal diaper dermatitis. Treatment focuses on keeping the skin dry and using topical steroids for a short period. The document also briefly mentions other less common conditions like miliaria rubra and granuloma gluteale infantum that can occur in the diaper area
This document discusses several common skin conditions that occur in infants and children wearing diapers. It describes infantile perineal protrusion, which presents as a soft tissue protrusion in prepubertal girls. It also covers diaper dermatitis, the most common pediatric dermatological condition. Diaper dermatitis has multiple causes, including prolonged skin wetness and contact with urine/feces. The main types are irritant and candidal diaper dermatitis. Treatment focuses on keeping the skin dry and using topical steroids for a short period. The document also briefly mentions other less common conditions like miliaria rubra and granuloma gluteale infantum that can occur in the diaper area
This document discusses several common skin conditions that occur in infants and children wearing diapers. It describes infantile perineal protrusion, which presents as a soft tissue protrusion in prepubertal girls. It also covers diaper dermatitis, the most common pediatric dermatological condition. Diaper dermatitis has multiple causes, including prolonged skin wetness and contact with urine/feces. The main types are irritant and candidal diaper dermatitis. Treatment focuses on keeping the skin dry and using topical steroids for a short period. The document also briefly mentions other less common conditions like miliaria rubra and granuloma gluteale infantum that can occur in the diaper area
known as infantile pyramidal protrusion, infantile perineal protrusion (IPP) is a benign condition that occurs almost exclusively in female prepubertal girls. It appears as a pyramidal, soft-tissue, tongue-like, smooth, or velvety pink protrusion. It is usually located in the midline just anterior to the anus. IPP is usually asymptomatic, but painful defecation has been reported. It occurs in three settings: constitutional, functional (after constipation, diarrhea, or other irritant exposure), or associated with lichen sclerosus et atrophicus. Often, IPP is misdiagnosed as condyloma acuminatum, hemorrhoids, or as a sign of trauma. Conservative management is indicated. Spontaneous resolution as well as resolution following high-fiber diet to relieve constipation has been noted.35,36 DIAPER DERMATITIS. Diaper dermatitis, like hand dermatitis, denotes a group of region- specific dermatoses. Diaper dermatitis is one of the most common dermatologic conditions in infants and children, noted in approximately 1 million pediatric outpatient visits each year.45 With the advent of superabsorbent disposable diapers in the last decade, severe forms of diaper dermatitis have diminished in incidence. Irritant and candidal diaper dermatitis comprises the vast majority of diaper dermatitides in diaper-wearing individuals of all ages. The etiology of diaper dermatitis is multifactorial. The initiating factor is prolonged and increased wetness to the skin. This leads to increased frictional damage, decreased barrier function, and increased reactivity to irritants. Other interrelated etiologic factors include contact with urine and feces, fecal proteolytic and lipolytic digestive enzymes, increased skin pH, and superinfection with Candida and, less commonly, bacteria.46
Irritant Diaper Dermatitis. By far the most common
type of diaper dermatitis is irritant diaper dermatitis. This dermatitis occurs in any person who wears diapers, regardless of age. Irritant diaper dermatitis appears as erythematous, moist, and sometimes scaly patches on the convexities of the genitalia and buttocks, beginning in areas in closest contact with the diaper. Shallow erosions are sometimes present on the convex surfaces. It can be asymptomatic or tender. Candida Diaper Dermatitis. (See Chapter 189). Candida diaper dermatitis is the second most common type of diaper dermatitis and presents with bright red erythematous, moist papules, patches, and plaques that tend to involve body folds as well as convex surfaces. Satellite lesions are very characteristic. Oral thrush can be associated. Candida from intestinal flora frequently contaminates any type of diaper dermatitis present for greater than 3 days, and Candida levels increase with the clinical severity of the dermatitis.47 Miliaria Rubra (Heat Rash). (See Chapter 84.) Miliaria rubra tends to occur at sites where plastic components of the diaper cause occlusion of eccrine ducts of the skin. It is also seen in the folds of the neck and upper torso, and is particularly common when there is a rapid shift to warm weather, and the child is overdressed. Pseudoverrucous Papules and Nodules. Pseudoverrucous papules and nodules occur in the diaper and perianal areas in patients of any age with exposure to prolonged wetness. Children who wear diapers due to chronic urinary incontinence are prone to this type of dermatitis for example. Infantile Granular Parakeratosis. Infantile granular parakeratosis represents an idiopathic form of retention keratosis in diaper-wearing infants. There are two clinical patterns: bilateral linear plaques in the inguinal folds and erythematous geometric plaques underlying pressure points from the diaper. A thick, flake-like scale is present in both forms and is characteristic. Therapeutic responsiveness to topical agents is ambiguous; however, spontaneous clearance after months to 1 year appears to be the rule.48 Jacquet Erosive Dermatitis. Jacquet erosive dermatitis is an uncommon, severe diaper dermatitis that can occur at any age. It is characterized by welldemarcated, punched-out ulcers, or erosions with elevated borders. Prolonged contact with urine and feces under occlusion leads to this condition.49 It is seen less commonly since the advent of superabsorbent disposable diapers. Granuloma Gluteale Infantum. Granuloma gluteale infantum is an uncommon condition characterized by reddish purplish nodules of different sizes (0.53.0 cm) occurring on the convexities of the diaper area in 2- to 9-month-old infants. It arises within preexisting diaper dermatitis. Biopsy shows dense dermal infiltrates of lymphocytes, plasma cells, neutrophils, and eosinophils, but no true granulomas. It appears to be an unusual reaction to the usual irritant factors, candidal infection, and, in some cases, topical steroid use in the diaper region.49 Treatment consists of avoidance of irritants, use of barrier pastes, and avoidance of topical steroids. Resolution occurs over several months. Dermatoses Not Etiologically Related to Diaper Wearing. Seborrheic dermatitis, atopic dermatitis, psoriasis (Fig. 107-14), bullous impetigo, acrodermatitis enteropathica, scabies, hand-foot-andmouth disease, herpes simplex infections, and Langerhans cell histiocytosis are conditions that occur in the diaper region but are not primarily due to the wearing of diapers and should be considered in the differential diagnosis. Skin biopsy is indicated to rule out Langerhans cell histiocytosis (see Chapter 147) if nonhealing erosions or petechiae are seen in the diaper area (Fig. 107-15). Treatment of Diaper Dermatitis. The treatment of diaper dermatitis is outlined in Table 107-8.50 Irritant diaper dermatitis and Candida diaper dermatitis (or a combination of both) comprise the vast majority of diaper rashes. Candida is more likely to complicate diaper rash if present for more than 3 days. Education of parents and primary care physicians should include instructions regarding the use of topical steroids in the diaper area. Because of greatly increased percutaneous absorption of steroids from moisture and occlusion from diapers, topical steroid use in this anatomic region should be limited to a short course (37 days) of hydrocortisone (1% or 2.5%) ointment. This is effective in nearly all cases when a topical steroid is needed. Similarly, use of the combination products containing steroids, such as nystatin plus triamcinolone, and clotrimazole plus betamethasone dipropionate, should be avoided due to increased risks of steroid atrophy and hypothalamicpituitary axis suppression when used in the diaper area. Last, parents will be reassured by the fact that even the most problematic diaper dermatitis will resolve when toilet training is achieved, and diapers are not worn.