Diaper Dermatitis

Managing incontinence is the principal urogenital hygiene challenge in infants. Global diapering practices vary: disposable paper diapers are used widely in Western industrialized countries; typically, cloth is used in the developing world.

Prolonged genital skin contact with urine and feces can cause irritant dermatitis on the vulva, the perineum, and the buttocks of the diapered skin (diaper rash). The etiology is multifactorial (Fig. 1) (1-6). In brief, prolonged contact with urine increases skin wetness and skin pH, making the skin vulnerable to damage by friction and local irritants. Wet, occluded skin has a higher coefficient of friction and is more vulnerable to damage from abrasion (6,7). Urinary ammonia, however, is not a primary irritant, as once thought (8,9). Ammonia produced by bacterial action on urea increases the local pH; this, in turn, disturbs the normal acid mantle of the skin, impairs skin barrier function (10), elevates the activity of fecal enzymes that compromise skin integrity (2,5,10), and reduces the acid inhibition of microbial pathogens that cause secondary infections on the compromised skin. Accelerated gastrointestinal transit also raises fecal enzyme activity resulting in more frequent diaper dermatitis after bouts of diarrhea (11).

The etiology of irritant diaper dermatitis provides a scientific basis for recommending the use of barrier preparations and superabsorbent diapers to maintain drier skin and limit the effects of urine and feces (12-15). These recommendations are supported by clinical evidence of efficacy in reducing rash (16-24). Figure 2 illustrates representative results for diapers. However, such products are not always available or affordable in many regions of the world. To limit contact with skin and contact with urine and feces, frequent diaper changes and good perineal hygiene are recommended as a general practice, regardless of the mode of diapering.

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