When Is Diaper Rash not Just A Rash?
Diaper dermatitis is common and is usually easily treated. However, just like many other things in life, it can also get complicated. There are several scenarios that every parent, as well as providers, should be aware of in which a rash IS not a simple diaper rash. As we stated in a previous post, diaper rash as a clinical entity accounts for between ten and twenty percent of the in-office complaints that we see in children under 2 years of age. Even though it is called diaper rash and is found mainly in the diaper-covered areas of the infant, there are situations in which the rash goes beyond these areas. In such instances as well as in others with more severe clinical features, medical intervention is both necessary and urgently needed.
Below are four variants of complicated diaper rash that need medical intervention.
Candida Diaper Dermatitis:. The hallmark of candida diaper dermatitis is the red beefy raised areas of skin (the medical term is plaques). Other clinical characteristics are the presence of some superficial pustules that look as if they have pus in them. Also to aid in clinical diagnosis, one looks for satellite lesions. Essentially, with candida, it is a phenomenon whereby there will be some spots that are located away from the main area where the rash is present. It looks as if they are satellites thrown far away from the main bulk of the lesions. of the constant contact, that ensues when a child sits in a wet or stool-soiled diaper for a prolonged period. Chemicals from urine and feces irritate the wet skin, thus putting the top layer of the skin under chemical pressure. Eventually, the skin breaks out and the rash develops. As one may expect, candida diaper rash usually is preceded by a chemical diaper dermatitis often times due to urine irritation of the area. The disease process transitions into candida as soon as the skin folds start getting involved. Normal chemical irritants do not affect the skin folds. Although we diagnose this infection clinically without any lab tests, a laboratory scraping usually stained with KOH in the lab shows the candida components. Treatment is with topical (skin-applied) antifungal cream. On rare occasions, the infant's candida infection persists.That gets your provider thinking and trying to expose or eliminate conditions like Type 1 diabetes and chronic mucocutaneous candidiasis.
Impetigo is Secondary Infection from Staphylococcus aureus (or S. pyogenes): This is a bacteria found literally everywhere. It has a subspecies that lives on the human skin and it also has some multi-drug resistant subspecies called MRSA. Impetigo is a common, itchy and fast-spreading (read contagious) skin infection. I have treated many children in the past with impetigo on other parts of their body. These are usually teens. Unfortunately, infants can have impetigo as a complication of a diaper rash. They have raised 2mm lesions that are fragile, may have some pus and do look like honey crusts when eroded. Some children have more serious infections called bullous impetigo where the lesions are much larger and rupture easily. The diagnosis is usually confirmed with laboratory testing of the pus. Treatment is with antibiotics. If the infant is under two months, we may decide to treat her as an inpatient because they are very delicate at this age and may be at a high risk for developing septicemia (bacteria multiplying in their blood). Furthermore, if the infant looks ill, has symptoms of being tired, not acting herself, or crying excessively or if she has a fever, further testing needs to be done along with immediate treatment.
Perianal excoriation due to streptococcus:. Infections in the area covered by diapers can indeed get complex. This infection in the area around the anal opening is caused by group A streptococcus infection. The area looks red and inflamed. There is a sharply demarcated area of redness and other parts of the diaper area may also be red. When this has been around for a while, the child may develop perirectal fissures and blood-streaked stools. Fissures are notorious for causing pain on stooling so this may be an indication if your child has distress doing " number 2". Treatment is with antibiotics after a thorough examination by the provider.
Herpes Simplex Virus Infection. Some infants develop vesicles, papules or pustules caused by HSV virus. HSV is known to be sexually transmitted so is an infant develops herpetic lesions, this is a red flag for potential child abuse. Such cases are not common but do occur. If it is suspected, we initiate an investigation of child sex abuse and this includes both the law enforcement agents and child protective services. Herpes is treated with antiviral agents, but more pertinent is the safety of the child from a potential abuser. As we have seen, there can be serious complications of diaper rash that require more detailed management and treatment. It is important that parents understand the need to seek medical attention whenever they notice things unusual with their child. Second guessing and "watching it for a while" may not always be the best decision though reasonable at times.
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Omega Pediatrics Difference: At Omega Pediatrics in Roswell, Georgia we understand the challenges that parents face when their children develop symptoms late in the day or after hours. Many pediatric offices are closed after 4 pm however we are open every weekday up to 9 pm for walk-ins and we have telemedicine via evisits for our known patients. Our clinic is one of the easily accessible pediatric primary care clinics in Roswell and Alpharetta. We provide pediatric primary care to families in the North Fulton area and we have families that live in Sandy Springs, Johns Creek, Duluth and Cumming.
Immunizations after-hours: One advantage of switching to Omega Pediatrics for your child’s primary care is that you can bring your child in for immunization after regular business hours. We provide this service because we have the passion for what we do and we want to be a comfortable and convenient service, not the ordinary pediatric doctor’s office.