Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Diaper Rash, Primary Irritant
DIAPER RASH, PRIMARY IRRITANT
Erythema, scaling, or ulceration of skin in the diaper area.
I. Etiology
A. Prolonged contact of urine and feces with the skin can lead to maceration and chemical irritation (from urea and intestinal enzymes).
B. Consider neglect, carelessness, or sensitivity from contact reactions to plastic, rubber, disposable diapers, and laundry products.
C. Conversely, it can be the result of too enthusiastic bathing and inadequate rinsing, resulting in dry skin (xerosis).
II. Subjective data
A. Reddened diaper area
B. Sores in diaper area
C. Baby itchy, uncomfortable; cries when voiding
D. Baby irritable
E. History of change in or use of inappropriate laundry products, change in diapers (disposable), change in family situation, strong odor of ammonia
F. Detailed history of treatment used
G. History of recent antibiotic use
H. History of diarrhea
I. Oral lesions (thrush)
III. Objective data
A. One or a combination of the following will be present in the diaper area generally over convex contact areas and sparing flexural folds:
1. Erythema
2. Papules
3. Vesicles
4. Ulcerations
5. Burned or scalded appearance
B. Check urethral meatus in circumcised male; ulceration is frequently present.
C. Inspect entire child.
1. Intertriginous areas may be irritated if general hygiene is poor.
2. Legs and heels may be affected from contact with wet diapers.
3. Eczema or other skin disease may be present.
IV. Assessment: Differential diagnosis
A. Candidiasis: Beefy red, shiny; sharply demarcated borders with satellite lesions (see protocol for identification and treatment, p. 253).
B. Atopic dermatitis: By detailed history and involvement of other areas (e.g., chest, face, neck, extremities)
C. Allergic contact dermatitis (sensitivity to disposable diapers, laundry products): By detailed history
D. Psoriasis: Scaling papules and plaques with inflammation; often a positive family history
E. Child abuse: Scalded skin, bruising, or signs of neglect
V. Plan: Treatment is determined by type of lesions—oozing, infected, or dry. If it is dry type, wet it; if it is wet type, dry it.
A. Mild, erythema only: Apply a barrier cream or ointment:
1. Desitin
2. Vaseline
3. Dyprotex
B. Erythema, papules: Hydrocortisone 1% cream, 3 times a day for maximum 2 weeks
C. Intense erythema, vesicles, ulcerations
1. Polysporin cream or bacitracin ointment tid
2. Burow’s solution: Apply compresses for 20 minutes tid.
D. Ulceration of meatus
1. Polysporin cream tid or
2. Garamycin cream tid
E. Corticosteroids should not be used indiscriminately. Begin with the mildest corticosteroid. If nonresponsive, increase potency to Aclovate 0.05% or Synalar 0.01%. Do not order refills.
VI. Education
A. Prevention primary concern
B. Frequent diaper changes
1. Wash diaper area at each change with tepid water or cotton soaked with Balneol or Cetaphil lotion.
2. Use a mild, nonperfumed soap, such as Dove.
3. Do not use packaged wipes.
C. Apply petroleum jelly to penis of circumcised male at each diaper change.
D. Omit diapers as often as possible.
E. Use plastic pants for social occasions only.
F. Do not use cornstarch; it can be metabolized by microorganisms.
G. Use Caldesene medicated powder on a routine basis.
H. Cloth diapers
1. Diaper service is generally acceptable.
2. Home laundering
a. Use mild soap (e.g., Ivory Snow).
b. Do not use bleach, fabric softeners in wash, or softener sheets in dryer.
c. Put through rinse cycle twice.
d. Use vinegar—1 oz/gal of water—in final rinse.
I. Disposable diapers
1. Disposable diapers may be helpful because the gel material absorbs the moisture, keeping the skin dry.
2. Switch to another brand if sensitivity is suspected.
3. Fold plastic away from body.
4. Tear small holes in plastic to decrease humidity in diaper area.
J. Diet
1. Increase fluids.
2. Include cranberry juice if child is 12 months of age or older— changes pH of urine, making it less irritating.
3. Exclude all other juices.
4. Do not add any new foods.
K. Monitor for sensitivity to topical agents: Erythema, edema, scaling, itching.
L. Wet dressings cool and dry skin.
M. Use soft, clean cloth for compresses. Moisten and reapply every 10 minutes.
VII. Follow-up
A. Call if no improvement in 2 days or immediately if rash is worse.
B. If ulceration of meatus, check for full stream when voiding.
C. Call if any question of sensitivity to topical agents
VIII. Complications: Secondary bacterial infection
IX. Consultation/referral
A. Failure to respond to treatment after 10 days
B. Any question of neglect