Resident Rounds Part III. Case Report: Diaper Dermatitis Presenting as Pustules
September 2014 | Volume 13 | Issue 9 | Features | 1153 | Copyright © September 2014
Ann R. Tucker BA,a Ashley N. Emerson MD,a Julie P. Wyatt MD,b Robert T. Brodell MDc
aUniversity of Mississippi Medical Center, Jackson, MS
bDivision of Dermatology, Department of Otolaryngology and Communicative Services,
University of Mississippi Medical Center, Jackson, MS
cDivision of Dermatology, Department of Otolaryngology and Communicative Services, University of Mississippi Medical Center, Jackson, MS and University of Rochester School of Medicine and Dentistry, Rochester, NY
Diaper dermatitis is the most common dermatologic disorder of infancy. Its cause can often be determined clinically based on the clinical
presentation. Primary diaper dermatitis is associated with irritants and spares the deep skin folds. Secondary diaper dermatitis is most
often caused by Candida yeast overgrowth and typically presents as a well-defined area of beefy red erythema covering the diaper area
and including the deep folds of skin with hallmark satellite pustules. Other causes include seborrheic dermatitis, psoriasis, acrodermatitis
enteropathica, allergic contact dermatitis, Langerhans cell histiocytosis, and, in the setting of a primarily pustular eruption, bacterial folliculitis.
A simple potassium hydroxide preparation (KOH) can confirm the diagnosis of candida diaper dermatitis and guide proper treatment.
A 3-month-old infant presented with a two-week history
of worsening “diaper rash.” He presented with a primarily
pustular eruption involving the lower abdomen,
upper thighs, intertriginous zones, and genitalia, with only
mild, background erythema without clearly definable borders.
Super-absorbent disposable diapers had been used since birth.
Zinc oxide paste was utilized with diaper changes for the two
weeks since the rash appeared. This failed to produce any improvement.
A potassium hydroxide preparation (KOH) from a
pustule revealed budding yeast and pseudophyphae. A diagnosis
of candida diaper dermatitis was made. Treatment with
topical ketoconazole cream twice daily, continued use of superabsorbent
diapers, and continued application of zinc oxide
paste resulted in a 90% improvement within two weeks.
Diaper dermatitis is the most common dermatologic disorder of
infancy in the United States. More than one million cases are diagnosed
each year.1 A wide variety of factors may contribute to
the development of this condition, including exposure to moisture,
biochemical irritants, and changes in skin pH associated
with exposure to excreta.2 Primary diaper dermatitis is considered
to be a non-allergic dermatitis with the etiology arising from
an impaired barrier function of the skin and external irritants3;
however, Candida should be suspected as the causative agent in
dermatitis lasting for greater than 3 days.3,4
Candidal diaper dermatitis is a clinical diagnosis with a classic
presentation including a sharply marginated zone of confluent, beefy red erythema on the upper thighs, lower abdomen, genitals,
and unlike irritant diaper dermatitis, it involves the genital
creases and skin folds. Satellite pustules are often present and
are virtually pathognomonic for this condition.3 While primarily
pustular candidal intertrigo presenting in neonates has been
discussed in the literature,5 this atypical presentation has rarely
been reported in infants. Seborrheic dermatitis must also be
considered in diaper dermatitis of infancy. This diagnosis is
suggested when erythematous, scaly papules and plaques with
a yellow greasy scale occur in association with papulosquamous
rashing on the scalp, cheeks, chest, and flexural areas.
Isolated intertriginous seborrheic dermatitis can be difficult to
distinguish clinically from other forms of diaper dermatitis.6 Since seborrheic dermatitis is associated with the presence of
pityrosporon yeast, it often responds to the same topical antifungal
treatment as Candidal dermatitis.
A stepwise approach is recommended when a pustular rash is
present that is limited to the diaper area. First a KOH should be
performed. Most cases with this presentation will demonstrate
budding yeast and pseudohyphae, confirming the diagnosis of
atypical Candida diaper dermatitis.5 These patients should be
treated with an azole topical antifungal cream to attack the Candida
yeast, which is the primary pathophysiologic basis for this
condition. It is also prudent to use super-absorbent disposable diapers
and barrier creams to limit irritation to skin made even more
sensitive by barrier damaging effects of this infection. Systemic
antifungals are rarely required. Of course, complete clearing of
diaper dermatitis is often difficult until children are toilet-trained.