Pharmacologic Therapy

Protectants

Protectants form an occlusive barrier between the skin and moisture from the diaper. Cream and ointment preparations are effective in providing a sufficient barrier in mild, irritant, and noninfected diaper rashes. For more severe cases, a paste is the topical agent of choice. Pastes are thicker and often contain additional ingredients (petrolatum, mois-

turizers) to help decrease discomfort and promote healing. Zinc oxide is one of the most commonly used topical protectants. In addition to forming an effective barrier against moisture, it has astringent and antiseptic properties that provide added symp-

tom relief.

Protectants are generally applied to the affected area after every diaper change and can be discontinued when the rash resolves. Other available protectants that can be used alone or in combination for the safe and effective treatment of diaper rash include white petrolatum, Vitamins A & D, lanolin, and topical cornstarch. Many agents contain a combination of occlusive and protective agents such as Triple Paste and Cal-moseptine.

Topical Steroids

Because of the increased permeability of their skin, infants are at risk for excessive absorption and toxicity from the use of topical steroids. Although these agents are effective in decreasing inflammation and relieving pruritus, steroid use in infants for the treatment of diaper dermatitis should be limited to only the low potency prepara-tions.39

A thin layer of hydrocortisone cream (0.25-1%) applied twice a day for no more than 2 weeks is an appropriate treatment regimen. The use of higher potency steroids or use extending beyond 2 weeks should be at the discretion of a physician only.

Antifungals

Diaper rashes lasting longer than 48 to 72 hours are at increased risk for the development of fungal infections. These complications are most frequently caused by Candida albicans and will require treatment with a topical antifungal363 (See Fig. 65-6.)

Candidiasis Diper

FIGURE 65-6. Candidiasis: diaper dermatitis. Confluent erosions, marginal scaling, and "satellite pustules" in the area covered by a diaper in an infant. (From Wolff K, Johnson RA. Cutaneous fungal infections. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. 5th ed. New York: McGraw-Hill, 2005: 721.)

FIGURE 65-6. Candidiasis: diaper dermatitis. Confluent erosions, marginal scaling, and "satellite pustules" in the area covered by a diaper in an infant. (From Wolff K, Johnson RA. Cutaneous fungal infections. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. 5th ed. New York: McGraw-Hill, 2005: 721.)

Adverse events with the use of topical antifungals are generally limited to local irritation at the site of application.

Nystatin, clotrimazole, and miconazole creams or ointments applied two to four times daily with diaper changes have all shown to be effective in the treatment of candidal diaper rash. Although some of these products are available over-the-counter, parents and caregivers should be advised to initiate treatment with antifungal agents only after physician recommendation.

Antibacterials

If conventional treatment fails, unresolved diaper rash can also lead to secondary bacterial infections. Staphylococcus aureus and streptococcus are the most likely pathogens responsible for these infections and require treatment with systemic antibiotics.37'38 While • topical protectants may be used as an adjunct in treatment, suspected bacterial infections should always be referred to a physician for accurate diagnosis and

the selection of an appropriate antibacterial regimen. Figure 65-7 shows a useful algorithm for the effective treatment of diaper dermatitis.

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