Most diaper rashes have to do with impairment of skin integrity rather than any specific bacterial or fungal infection. Urine and stool acidity (the latter seen in diarrhea) and chronic wetness coupled with a warm barrier environment are all factors proposed as causes of diaper dermatitis (diaper rash). However, sometimes a superficial skin infection is a factor in diaper rash. The most common infectious cause of diaper rash is Candida albicans (yeast, a fungus).
Such a diaper rash can begin with softening and breakdown of the tissue around the anus. The infected area is red and elevated, and fluid may be visible under the skin. Small, raised infected red bumps (satellite pustules) appear at the periphery of the rash. These satellite pustules are characteristic of Candida diaper rash and allow yeast diaper rash to be easily distinguished from other types of diaper rash such as a contact (irritant) diaper rash. Yeast diaper rash can appear on the thighs, genital creases, abdomen, and genitals.
Another distribution characteristic of C. albicans diaper distribution is its likelihood to be found in the creases of skin (for example, in the skin folds where the legs join with the pelvis). Generally, contact diaper rash does not involve these regions since the overlapping skin "protects" the area from exposure to noxious irritants.
A Candida skin infection can come from the upper gastrointestinal tract, the lower gastrointestinal tract, or exposure from a care provider. A Candida diaper rash can be accompanied by Candida infection of the mouth (thrush). A breastfeeding infant with a thrush infection may inadvertently infect the mother's nipple/areola area. If such an infection is suspected, simple topical medications may be prescribed by her doctor.
It goes without saying that wearing a diaper is the major contributing factor. Cotton underwear is much better suited to breathing and preventing the environment in which yeast thrive -- dark, warm, and moist skin surfaces. Cloth diapers and nonabsorbent disposable diapers both contribute to a favorable environment for yeast growth.
Many specialists believe that a yeast infection in the infant's mouth (thrush) is a risk factor for the development of yeast diaper dermatitis.
Recent use of oral antibiotics may also encourage the overgrowth of intestinal yeast.
One-fourth to one-half of babies experience diaper rash. Of these, 15%-50% are due to yeast infections. Yeast infectiondiaper rashes tend to decrease as children get older and end when the infant stops using diapers. The air exposure afforded by underwear lessens the establishment of an infection on macerated skin surfaces. This explains the tongue-in-cheek opinion of pediatricians that a quick cure for diaper rash (contact or infectious) is successful toilet training.
If few C. albicans organisms are present, they may not be significant. However, symptoms are aggravated with more extensive infection. One study noted C. albicans was present in 37%-40% patients with diaper rash, suggesting that C. albicans infection from the gastrointestinal tract plays a major role in diaper rash. Another study noted that 30% of healthy infants and 92% of infants with diaper rash had C. albicans in the stool. This reveals a definite relationship between Candida colonization of the stool and diaper dermatitis.
However, such information does not reveal the entire picture. The actual presence of C. albicans in the stool in and of itself is not the entire story since a majority of healthy adult intestinal tracts are colonized by C. albicans. These generally asymptomatic (having no symptoms) adults may also develop groin Candida infections should they become immune compromised or suffer from extremely poor hygiene. Several studies have shown promising results of lessening the incidence and severity of Candida infection when probiotics (for example, yogurt with "active cultures") are taken whenever antibiotics are necessary.
Antibiotic use can lead to increased growth of Candida species. Thus, the fact that the use of commonly prescribed antibiotics such as amoxicillin increases the risk of developing diaper rash is not surprising. Amoxicillin use in infants decreases the number of bacteria and increases the number of C. albicans.
A yeast caused diaper rash is not painful. The characteristic bright red area of skin in the groin and around the anus, including the intertriginous region (the deep folds of skin where the legs attach to the child's torso), is characteristic of a yeast infection diaper rash.
Careful examination of the diaper region for the characteristic diaper rash described above allows for rapid diagnosis and treatment. Supportive evidence for a yeast diaper rash diagnosis would be the presence of an oral yeast infection (thrush). Laboratory testing and/or examination by a dermatologist is rarely necessary.
The primary treatment for Candida diaper rash involves antifungal topical treatment and decreasing moisture in the diaper area. Nystatin (Mycostatin), clotrimazole (Lotrimin), and miconazole (Micatin, Monistat-Derm) are topical over-the-counter (nonprescription) treatments of equal strength for treating Candida diaper dermatitis. Occasionally, other prescription antifungal creams, such as ketoconazole (Nizoral cream) and econazole (Spectazole) may be necessary. How long treatment should last has not been completely defined, although typically the cream or ointment is applied at each diaper change until the rash is resolved, usually in 4-7 days.
Because of the intestinal reservoir of Candida species in most patients with yeast diaper rash, some doctors recommend oral antifungal medications in addition to topical creams. No study has definitively answered the question of whether oral antifungal medications are helpful.
Some dermatologists and pediatric infectious disease specialists point out that the effectiveness of these topical creams has been waning over the last few years. An alternative oral medication (fluconazole [Diflucan]) taken once a day for 2 weeks can be very effective. Many pediatricians will initially recommend one of the topical medications for ease and simplicity and use fluconazole if topical treatment is not effective.
Some studies have indicated that preventing diaper rash may be done by applying barrier creams like zinc oxide (A+D Ointment, Desitin, Diaparene) or petroleum jelly (Vaseline, Aquaphor) to the diaper area after bathing. These products may help to decrease the ambient moisture in the diaper area after bathing or changing a diaper. Gentle cleaning to minimize skin breakdown may also be helpful. Air exposure (for example, no diaper) is also therapeutic.
There are several approaches that will be helpful in eradicating and preventing a yeast infection in the diaper area.
Diaper rashes decrease to the extent that diapered skin can have an environment closer to that of undiapered skin. The less time that infants wear diapers, the less the chance that they develop a diaper rash. However, the need to wear diapers must also be considered.
Disposable diapers are associated with fewer cases of yeast diaper rash than cloth diapers. Disposable diapers have absorbent gelling materials that draw moisture away from delicate skin surfaces. Infants who wear breathable disposable diapers developed significantly fewer diaper rashes of any type than infants who wore standard, non-breathable disposable diapers in a series of clinical trials.
An evaluation of past clinical studies conducted before and after the introduction of absorbent gelling materials in diapers confirms that the use of these materials has been associated with a definite reduction in the severity of diaper rash. Survival of Candida colonies was reduced by almost two-thirds in the breathable diaper-covered sites compared to the control sites.
Betamethasone dipropionate is a fluorinated high-potency topical corticosteroid that is formulated with clotrimazole in the brand-named product Lotrisone. This product is frequently used inappropriately in intertriginous (diaper regions where deep folds of skin overlap) areas. Such potent corticosteroids have no role in the treatment of a Candida diaper rash. The absorption of such a highly potent steroid may produce multiple (and potentially severe) side effects.
Prevention and the above-described therapies yield an excellent prognosis for a yeast infection in the diaper area. The naturally recurrent nature of a yeast infection in the diaper area should not be interpreted as a failure of parenting skills. Sometimes it just happens.
Topical therapy, including barrier creams and disposable diapers, decreases the incidence and extent of yeast diaper rash. Frequent diaper changes with the superabsorbent disposable diapers create an environment that does not let yeast thrive. Cleaning that is gentle and minimizes skin breakdown can help as well. Air exposure is also helpful.
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