Etiopathogenics of Dermatitis in the Diaper Area

Dermatitis of the Diaper Area

It is an acute inflammatory reaction that affects the region of the pelvis that is covered by the diaper, often in children under 2 years old (frequent onset between the 1st and 2nd month of life).  Its pathophysiology involves some factors, among them the one that stands out the most is the prolonged occlusion of the skin by the diaper, with little protection and consequent maceration of the epidermis.  The wet epidermis is more susceptible to damage caused by friction in the diaper, which makes the skin vulnerable, making it more permeable to irritants and microorganisms present in urine and feces. The inflammation induced by chemical and frictional irritation promotes greater penetration agents, thus enabling secondary infection by microorganisms such as Pseudomonas, Candida albicans, Enterococcus faecalis and Proteus [4] .

It is known that the term “diaper dermatitis” refers to a set of dermatoses in the region covered by the diaper, which may extend to other regions if there is no adequate treatment.  Regardless of the etiological agent or cause of diaper dermatitis, what becomes crucial is prevention, through proper hygiene of the site, frequent diaper change and, if possible, changing the disposable diaper for a tissue or diaper with superabsorbent technology, aiming at a quick regeneration of epithelial tissue [1].

It is necessary to consult a specialist, because the use of ointments, creams, oils, soaps and medications without proper medical advice can cause allergic reactions and worsen the irritation to the injured area. It is worth pointing out that the risk of being affected by this disease is not altered by socioeconomic conditions, race and sex, but by correct and balanced hygiene after physiological eliminations. Also, after sweating excessively or remaining for a considerable time wearing the same diaper [1].

The skin changes in this dermatosis are triggered by a series of mechanisms, which the main is the prolonged contact or irritation by urine and feces, the maceration caused by the heat and humidity of the region. The prolonged contact of the epidermis with the diaper wet with urine increases both the permeability of the skin to irritants and the pH of the environment, thus intensifying the activity of fecal proteases and lipases, which are the major irritants and responsible for the manifestations [5].

Dermatitis can become a serious infection when, due to the pH alterations in the area, bacteria or fungi proliferate, favored by the appropriate culture medium that the region becomes.  It increases the injury to the epidermis, the organism’s first structural defense, and the invasion of microorganisms in deep layers, including the bloodstream, in severe cases.  Thus, it is essential to have appropriate dermatological follow-up in age groups that use diapers, whether elderly or infants, in order to avoid preventable discomforts [1].

Primary Irritative Nappy Area Dermatitis

Primary irritant diaper dermatitis is the most frequent type of diaper area dermatitis.  Thus, it demands greater concern and care. This dermatitis is a source of significant discomfort, as wearing a diaper promotes increased heat and humidity in the area. As a result, there is wear and tear on the skin, which becomes more susceptible to inflammation due to continued contact with physiological eliminations.  This humid, hot and injured environment, in contact with urine and feces, provides predisposition for secondary infections by  Pseudomonas, Candida albicans, Enterococcus faecalis, Proteus, Staphylococcus and Streptococcus.

The use of creams, ointments or any substance without the prescription of a specialist can worsen the clinical condition. It is notorious that it is a dermatitis triggered by a wide range of factors, which initially affects the level of the stratum corneum. This corresponds to the outermost layer of the epidermis, where there is an abundance of keratin and dead cells responsible for protecting the skin against friction, impact, abrasions, among other agents mentioned previously [1].

During the worsening of dermatitis in the primary diaper region, it is essential to identify some factors: 1. Diapers: The diaper, due to the evolution of the protection and quality of the material, has little relationship with the development of irritative dermatitis.  In developed countries, the decrease in the frequency and severity of diaper dermatitis is mainly due to the encouragement of using better materials in the manufacture of diapers [6]. 2. Feces / Urine: The existence of several aggravating factors is discernible, such as ammonia, which is a product of the decomposition of urea, carried out by bacteria.  Ammonia as a single agent does not cause dermatitis, but if the skin is previously  injured, the chances of starting the inflammatory process increase. In addition, this substance provides an increase in local pH, and this change in the diaper area activates fecal lipases and  proteases.  These enzymes are protagonists in the pathophysiology of dermatitis. Feces largely contain these digestive enzymes that wear down and irritate the skin barrier when there is prolonged contact of the skin surface with the diaper. Diarrhea illustrates this fact. In the literature, there is a substantial relationship between bile acids and the appearance of dermatitis [7].

3. Friction: The child movements, the friction between two areas of the skin and between the skin and the diaper act as predisposing factors for the development of a form of dermatitis on shapely regions such as the genitals, thighs, known as the “W” region [8].

4. Hydration: Hyperhydration of the skin is a clinical situation that can be generated by the release of urine, by fever, and by the formation of a hot and humid environment.

This combination of factors favors friction by movement and the development of secondary infections [9].

5. Temperature: With the blocking of perspiration by the skin located in the area surrounded by the diaper, there is an increase in local temperature and, consequently, in vasodilation and risk of inflammation. It also functions as a culture medium for the proliferation of microorganisms.

6. Chemical irritants: Deodorants, soaps, oils, preservatives, talc, ointments, herbal baths, lotions may potentialize irritation. Some drugs can be irritating when excreted, and can also affect the motility of the intestinal flora, so they must be evaluated and checked in the diagnosis of dermatitis [1].

7. Microorganisms: Dermatitis in the diaper area, like any skin lesion, may be associated with a secondary infection resulting from a vulnerable state of the skin’s defense barriers. Superinfections by Candida albicans and Staphylococcus aureus, by bacteria such as Pseudomonas, Streptococcus, Proteus, Enterococcus faecalis are quite common, and in cases of infant dermatitis with more than three days of evolution, contamination by Candida Albicans is frequent [10].

Fecal bacteria possibly have a relationship (in conjunction with Candida albicans) in the production of rash. It is noteworthy that Candida produces keratinases which enable it to penetrate the epidermal barrier and that evidence shows that infection with C. albicans is prominent in the development of epithelial lesions [6].