Napkin Eczema

Diaper Dermatitis — Inflammatory skin condition affecting the diaper area in infants and sometimes in incontinent adults.

Etiology & Pathogenesis

Primary cause is irritant contact dermatitis due to:
  • Moist environment inside the diaper
  • Prolonged exposure to urine and feces → increased skin pH → activates fecal enzymes (protease & lipase) → skin barrier damage
  • Friction from diapers
  • Ammonia formation from urine breakdown
Secondary infection may complicate:
  • Candida albicans (most common superinfection)
  • Bacterial infection (Staphylococcus, Streptococcus) less common

Risk Factors

  • Infrequent diaper changes
  • Diarrhea
  • Recent antibiotic use (predisposes to Candida)
  • Use of plastic/occlusive diapers
  • Atopic skin / sensitive skin

Clinical presentation

  • Erythema, maceration, scaling in diaper area
  • Skin folds usually spared in irritant dermatitis, but:
    • Candida involvement → affects skin folds with satellite pustules
  • May present with:
    • Vesicles, erosions in severe cases
    • Painful, itchy rash
    • Satellite papules/pustules → suggest fungal infection
      • notion image

Investigations

  • Clinical diagnosis based on history and examination
  • KOH test if Candida infection suspected
  • Consider bacterial culture if pustules, crusting, or non-responsive cases

Management

General Care
  • Frequent diaper changes every 2-3 hours
  • Keep area clean and dry
  • Use breathable diapers
  • Gentle cleansing (avoid wipes with alcohol/perfume)
  • Expose area to air when possible
Pharmacologic
  • Barrier creams: zinc oxide, petroleum jelly every diaper change
  • Topical low-potency corticosteroids (hydrocortisone 1%) short-term for inflammation
  • Antifungal cream if Candida infection suspected (nystatin, clotrimazole 1%, miconazole 2%)
  • Antibacterial ointment if secondary bacterial infection present (mupirocin 2%, fusidic acid 2%)