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Diaper Dermatitis

Diaper Dermatitis
By Brian T. Maurer

Brian T. Maurer has practiced general pediatrics as a Physician Assistant for thirty years.

I once heard the late Dr. Sydney Hurwitz (author of Clinical Pediatric Dermatology and a pediatric dermatology professor at Yale) speak to a group of pediatricians on common skin conditions in children.  At the time he emphasized that Lotrisone (clotrimazole/ betamethasone diproprionate cream) had absolutely no place in the treatment of diaper rash.  He cited a report of a young child who had developed major systemic side effects secondary to continued applications of Lotrisone to the diaper area.  Dr. Hurwitz actually advocated that the drug be banned from use in the pediatric age group for that reason.

Applying such a potent steroid preparation under an occlusive dressing (e.g., the diaper) only enhances the systemic absorption of the drug.

For these reasons, I refrain from using Lotrisone in young children.

In healthy infants with recalcitrant diaper dermatitis, I believe that in most cases the underlying problem is either:
(1) an irritant diaper dermatitis,
(2) a contact diaper dermatitis (from the perfume in the particular brand of disposable diapers—worth inquiring if the parent switched brands at some point), or
(3) perhaps even a reaction to the steroid component of Lotrisone.

When faced with this scenario, I generally advise that parents:

Brian Maurer’s Approach to Diaper Dermatitis

(1) Avoid using disposable wipes (even the hypoallergenic kind).  Instead, cleanse the diaper area with a warm wet washcloth, using a mild skin cleanser like Cetaphil if necessary;

(2) Start Aveeno sitz baths 2 to 3 times daily to soothe the area (for more details on Aveeno bath go to pdf below)

(3) Dry the diaper area with a hairdryer on low setting; then

(4) Apply a barrier ointment with each diaper change, such as Vaseline petroleum jelly, Calmoseptine ointment, Balmex ointment, Desitin, or Boudreau’s Butt Paste (you gotta love that name).

(5) Temporary use of cloth diapers without plastic pants may also help.

If all else fails, a mixture of Maalox and cornstarch powder dabbed on to the diaper area with each change usually works to improve the rash in a few days.  

Printable Version of Brian Maurer's Protocol:  Download Maurer’s Diaper Dermatitis

Head Lice: Wet Combing

German scientists examined 304 children at five primary schools that reported persistent head lice infestations. First, a researcher examined their scalps, parting the hair at five places where eggs or lice are often found. Then a different investigator, unaware of the results of the first test, examined the same children, this time wetting the hair with conditioner and running a fine-tooth comb from the scalp to the end of the hair.  The results appear in the March issue of The Archives of Dermatology.

This short NY Times article is a good jumping off place.

Peanut Allergy: Oral Desensitization

"A medically supervised daily dose of peanuts may help children with peanut allergies greatly increase their tolerance to the food, according to two new studies that raise the possibility of a cure for this potentially life-threatening condition.

The findings, presented on Sunday at a meeting of the American Academy of Allergy, Asthma and Immunology in Washington, suggest that a treatment for peanut allergy may be developed in two or three years, said Dr. Wesley Burks, the chief of the division of pediatric allergy and immunology at Duke University Medical Center, who helped conduct the research."  From NY Times article, March 16, 2009 -- see Full Article. 

This is an interesting article, but is really "old wine in new bottles."  Sulzberger experimented with oral desensitization over 50 years ago.  It is likely that American Indians have done this for hundreds if not thousands of years (see Wayne Winterrowd's fine piece:  "The Baleful Weed.") There is a fascination with Peanut Allergy.  It is far rarer than one thinks but has a strangely compelling aura. See Extraordinary Nutty Delusions.

Here is the abstract of a recent review of oral desensitization from PubMed:

Beyer K, Wahn U. Oral immunotherapy for food allergy in children. Curr Opin Allergy Clin Immunol. 2008 Dec;8(6):553-6.
Children's Hospital Charité, Humboldt University, Berlin, Germany.
kirsten.beyer@charite.de

PURPOSE OF REVIEW: Food allergy is a common disease in childhood. Natural tolerance development is frequent, but some children with cow's milk or hen's egg allergy and the majority of children with peanut allergy will remain allergic until adulthood. Within the last several years, the usefulness of oral immunotherapy has been investigated in food allergic patients. This review covers the most recent findings. RECENT FINDINGS: In cow's milk and hen's egg allergy, controlled trials have been conducted in children, showing that oral immunotherapy, in general, has been successful and safe. Moreover, rush protocols have been developed allowing desensitization in a short period of time. Although side effects are frequent, allergic reactions seem to be controllable by antihistamines, steroids, or epinephrine. For peanut allergy, the first results look promising and detailed data will be available shortly. SUMMARY: Several studies have shown that oral immunotherapy is a promising approach, especially in patients with severe and persistent food allergy. Side effects are frequent but seem controllable. So far, treatment protocols have been performed in highly supervised research settings. Until more experience is gained from larger long-term studies, oral immunotherapy should not be tried in clinical practice settings.