Clotrimazole and betamethasone dipropionate cream for diaper rash

The emergency physician's role in this disease is to make a proper diagnosis, to educate the caregivers, and to treat any acute complications that have occurred due to an untreated rash.

Irritant contact dermatitis, miliaria, and intertrigo often can be treated nonmedically through changes in diapering practices.

The emergency physician should advise the parent to keep the skin in the diaper area as dry as possible. This may entail more frequent diaper changes to limit the amount of time the skin is exposed to urine and feces. Caregivers should change diapers frequently, as often as every 2 hours or sooner if the diaper is wet and/or soiled. [16, 17, 18] Expose the skin under the diaper to open air as much as possible throughout the day.

Types of diapers

Switching to a disposable brand of diapers containing superabsorbent gelling material may also be helpful. Superabsorbent disposable diapers contain an absorbent gelling material (AGM) that wicks away moisture. Studies suggest that these diapers are associated with less-severe diaper rashes. Conventional disposable diapers were not found to be superior to reusable cloth diapers. A Cochrane Review did not find definitive evidence to support or refute the use and type of disposable diapers for prevention of diaper dermatitis. [19]  Tight-fitting diapers should be avoided.

The following newer types of diapers have been devised, which further reduce the incidence of diaper rash:

• A disposable diaper that continuously administers a topical petrolatum formulation to the skin has been shown to reduce the severity of diaper rash significantly compared with a conventional disposable diaper.

• Breathable disposable diapers have been shown to reduce the incidence of candidal infection by 38-50% and to also reduce the survival of Candida colonies by two thirds. The prevalence of diaper rash in this study was inversely related to the breathability of the diaper.

• Another innovation is the insertion of a water impermeable but vapor permeable membrane within diaper layers. This selectively permeable membrane allows the water vapor to escape, but prevents urine leak, and thus keeps the skin dry. In a study, this diaper has been shown to reduce the incidence of severe and mild diaper dermatitis by 39% and 18%, respectively.

Topical agents

The use of barrier creams, such as zinc oxide paste or petroleum jelly, is recommended to minimize urine and fecal contact with the skin. [20] Other useful creams include vitamin A & D ointment and Burow solution.

The principal functional effects of damage to the stratum corneum will be, firstly, an increase in the outward permeation of water, known as transepidermal water loss (TEWL), and secondly, an increase in the inward permeation of a wide variety of potentially harmful molecules and microbes. Barrier preparations work in 2 ways, either by providing a lipid film over the surface of the skin and/or by providing lipids that can penetrate into the stratum corneum, simulating the effects of normal intercellular lipids.

Effective treatment of diaper rash with bufexamac (Parfenac) lipid ointment has been reported in one study. Application of 2% eosin is effective in treating diaper area dermatitis.

Some have claimed that topical application of vitamin A ameliorates diaper dermatitis. In a Cochrane Database Systematic Review, a review studying the use of topical vitamin A for the treatment of napkin dermatitis there was no evidence to support or refute the use of topical vitamin A preparations. [21] For the prevention of napkin dermatitis, no evidence suggested that topical vitamin A alters the development of napkin dermatitis. Further, randomized, controlled trials are required to determine whether topical vitamin A is efficacious in treating or preventing napkin dermatitis.

Topical sucralfate has been reported effective for erosive irritant diaper dermatitis in a patient with chronic diarrhea.

Cornstarch can reduce friction, and talc powders that do not enhance the growth of yeast can provide protection against frictional injury in diaper dermatitis, but it does not form a continuous lipid barrier layer over the skin and obstruct the skin pores. These treatments are not recommended.

Topical cholestyramine ointment may be a safe and efficacious treatment option for perianal irritation due to bile acids and high output stools.

White soft paraffin BP is not really recommended for routine use. It is exceptionally occlusive when compared with other emollients and is, therefore, less than ideal for continuous use, since complete occlusion can prevent the recovery of damaged stratum corneum.

Two clinical trials have demonstrated that an ointment containing dexpanthenol, Bepanthen Ointment (Roche Consumer Health, UK), can help prevent and treat IDD.

Some formulations also contains lanolin, which is one of the most physiological emollient constituents currently available, containing many of the lipid groups present in the human stratum corneum and having the advantage of permitting water exchange.

Oral zinc was found to be helpful in one study.

Parents should be taught how to clean the diaper area. Excessive scrubbing should be avoided. Instead, urine can be rinsed away with warm tap water, and feces can be removed with warm water and mild nonperfumed soap.

A clinically controlled trial was completed by Adam. [6] It compared the use of infant wipes and the traditionally recognized as the golden cleansing practice, water and wash cloth. The result was in favor of the infant wipes because water has a polar nature that limits its ability to remove lipophilic substances from the skin and because water is incapable of any pH buffering action. A similar study was completed by Ehretsmann et al. [22]

Lipases and proteases in feces mix with urine and cause an alkaline surface pH, which has an irritant effect on nonintact skin. Newer formulations of wipes that include pH buffers can help restore the pH balance. Advise parents that wipes should be free of soap, essential oils or other fragrances, and harsh detergents that can irritate the skin. [23]

Cornstarch should not be used due to the irritant effect of its content on skin.

Soap has a high PH, which has a negative impact on the skin, and it contains calcium and magnesium salts, which can leave irritant precipitates on the skin and should be avoided. These should be replaced by syndet synthetic detergents, which are less irritating.

If changing in diapering practice is followed, irritant contact dermatitis, miliaria, and intertrigo should resolve very quickly.

If a mild, irritant, noninfected dermatitis is found, a cream may be all that is needed. The following are recommended:

• A cream containing zinc oxide will be appropriate.

• An ointment is a thicker barrier with petrolatum and offers more protection.

• A severe diaper rash requires aggressive treatment. A paste is the topical agent of choice. Pastes are thicker, contain petrolatum, higher concentrations of zinc oxide, karaya powder in some, moisturizers, and other additives to aid in protection, prevention, healing, and comfort.

• It is suggested with some of these products to cover the paste with a thin layer of petroleum jelly so that the paste does not stick to the diaper or to prevent opposing skin surfaces from sticking together.

For the typical irritant dermatitis or intertrigo, a nonfluorinated, low-potency corticosteroid ointment or cream (ie, 1% hydrocortisone) can be prescribed for no longer than 2 weeks. The following are recommended:

• The ointment or cream should be applied to the affected areas 4 times daily with diaper changes.

• The parent should be advised to avoid fixed combination medications, such as Mycolog II or Lotrisone. The steroids in these compounds are too potent to be safely used in the occlusive diaper environment. Usage can cause skin atrophy, striae, adrenal suppression, and Cushing syndrome.

If candidal infection is suspected, topical ointments or creams, such as nystatin, clotrimazole, miconazole, or ketoconazole can be applied to the rash with every diaper change. The following agents are recommended:

• Combination antifungal-steroid agents, such as Mycolog II or Lotrisone, should not be used because the high steroid concentration in the occlusive diaper area might cause Cushing syndrome. A review studied the use of a combination product of miconazole and hydrocortisone preparation and compared it with a combination product of nystatin/benzalkonium chloride/dimethicone/hydrocortisone preparation, both were found to improve the appearance of diaper dermatitis.

• If oral thrush or perianal candidiasis is present or if repeated bouts of candidal dermatitis have occurred, oral nystatin should also be prescribed.

• Ciclopirox was used and studied for the treatment of candidal diaper dermatitis and was found to be safe and effective. [24]

• A 2013 study examined the efficacy and safety of sertaconazole cream (2%) in diaper dermatitis candidiasis and concluded that sertaconazole cream may be considered a new alternative for diaper dermatitis candidiasis treatment. [25]

For mild bacterial infections, a topical antibiotic ointment (ie, bacitracin) should be prescribed. The following should be considered:

• More severe infections caused by gram-positive organisms and anaerobes can be treated with a broad-spectrum oral antibiotic (ie, amoxicillin/clavulanate, 40-mg amoxicillin component/kg/d for 7-10 d).

• Impetigo can be treated with dicloxacillin 12.5-25 mg/kg/d or erythromycin 50 mg/kg/d for 7-10 d.

• Congenital syphilis can be treated with 1 dose of IM penicillin G 50,000 U/kg.

In the case of granuloma gluteale infantum, recovery seems to be slow (several months), but complete. The following measures are recommended:

• Low potency topical steroids may accelerate resolution in some patients.

• Management of this disease is beyond the scope of emergency care.

• Referral to a dermatologist for management and long-term follow-up care is recommended.

Table. Skin Care Ingredients Found in Diaper Rash Creams, Ointments, and Pastes (Open Table in a new window)

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