Showing posts with label Diaper Dermatitis. Show all posts
Showing posts with label Diaper Dermatitis. Show all posts

Wednesday, February 13, 2013

Newborn with Erosive Diaper Dermatits

Abstract:  5 week old girl with an erosive diaper dermatitis since day 2.
HPI:  The patient was born at 3200 grams to a P2G2 opioid-addicted mother who was on Suboxone (buprenorphine and naloxone) maintenance.  The infant is feeding well and gaining weight and the mother seems attentive.  At day 2 her mother noted the process seen below.  The child is bottle fed and had originally been on Enfamil but was switched to Nutramagen.  Treatment to date has been with a panoply of creams:  Neomycin (!), Desitin, clotrimazole.  The mother relates that stools seem unremarkable.

O/E:  There is a nodulo-ulcerative napkin dermatitis.  No other skin lesions are noted.


Clinical Photo:


Lab:  A culture was done and was negative.  KOH not done.

Diagnosis:  Jacquet-type Nodulo-ulcerative Diaper Dermatitis in an infant with possible narcotic abstinence syndrome (see reference).

Questions:
How many of you have seen a similar case of Jacquet’s Disease in an neonate?  What local care would you recommend?  Any work-up at this point?  Are you aware of the narcotic abstinence syndrome and if so have you seen an erosive napkin dermatitis like this?

My approach at this time is to try the alpha tocopherol, keep diaper changes simple, consider cloth diapers for 1 – 2 weeks.  KOH prep will be done.  If response is not favorable consider biopsy or admission to hospital for care.

One Month Follow-up:
The baby was treated in the following way, as recommended by Dr. Julianne Mann from Pediatric Dermatology, OHSU, Portland, Oregon:

1. Absolutely NO diaper wipes at all.  Have mom get a large pack of rectangular cotton makeup remover pads.  Have her apply mineral oil to the cotton pad and use this to clean the baby's bottom.  When she is away from home OK to have her use a damp cotton cloth (I tell parents to pack several damp soft cotton washcloths in a ziplock in their travel diaper bag).

2. With every diaper change, have mom liberally apply a thick barrier paste after cleaning the baby's bottom.  We have had the best luck with a compounded butt paste that our local pharmacy mixes up because we suspect that preservatives in OTC diaper pastes may also play a role with the dermatitis.  We do 25% corn starch, 25% zinc oxide, and 50% petrolatum and dispense one pound.

3. I emphasize the importance of stopping everything else that they've been using.  Most parents whose baby's butt looks like this have been desperately trying everything, including doing things like vinegar or baking soda soaks and trying a different cream almost daily.  I tell them the goal is to simplify.  KEEP IT SUPER SIMPLE!
Thank you, Lili!!


Reference:

[Effectiveness of topical acetate tocopherol for the prevention and treatment of skin lesions in newborns: a 5 years experience in a 3rd level Italian Neonatal Intensive Care Unit].  Manzoni P, Gomirato G.  Minerva Pediatr. 2005 Oct;57(5):305-11.
Divisione di Neonatologia e TIN Ospedaliera, Ospedale S. Anna, Azienda Ospedale OIRM-S. Anna, Turin. paolomanzoni@hotmail.com
Abstract:  Neonates in NICU (especially when premature) are particularly prone to skin damage by action of external aggressive conditions such as chemical, physical, infectious, radiant, mechanical and iatrogenic factors. Strategies for avoiding disruption of the skin barrier are thus highly needed in such patients.
METHODS: We evaluated the effectiveness of a acetate tocopherol (AT) ointment for topical use in 21 neonates admitted to our NICU and affected by neonatal abstinence syndrome with severe diaper exulcerative and erosive erythema with ulcer and granulation tissue at the bottom of the lesion (group A), and compared them to 19 matched neonates affected by the same condition and treated with a commonly used skin ointment (emollient type, water-in-oil category) (group B). For all newborns we calculated: the dermatological severity score (using a clinical score from 0 to 9 points according to the increasing severity of the lesions) at time 0, 4 and 7 days; the mean days for achieving complete recovery; the rate of therapeutical failures.
RESULTS:  Mean score at day 0 was 7.8 in group A vs 7.9 in group B (P=0.35 NS). At day 4 it was 4.6 in group A vs 6.5 in group B (P=0.03), at day in 7 it was 3.1 in group A vs 5.2 in group B (P=0.04). A complete recovery with restitutio ad integrum occurred after 9.1 mean days in group A vs 12.2 mean days in group B (P=0.04). The rate of therapeutical failures was significantly lower in group A (4.2% vs 30.6%; OR 0.235; P<0.01) than in group B. No adverse effects related to AT use were reported.
CONCLUSIONS:  AT in our experience proved to be safe and more effective than the commonly used skin ointments in the topical treatment of exulcerative skin lesions in NICU neonates.

Friday, February 03, 2012

Erosive Diaper Dermatitis

Here is a tough one:

Abstract:
Thirteen yo boy with 6 month history of erosive diaper dermatitis.
HPI:
The patient is a 13 yo boy with Down's Syndrome. As an infant he had Hirschprung's disease corrected by surgery. Subsequently, he has had problems with bowel movements and at this time is still incontinent of stool. He needs diapers to prevent soiling. Six months ago, he was diagnosed with Crohn's Disease. Since his colonoscopy, he has developed a painful and recalcitrant diaper dermatitis. See mother's note below*.

O/E: There is an erosive papular dermatitis of the perirectal area. Penis and scrotum not involved.

Clinical Photo:
(the artifact in the photo is a Maalox and Aquaphor mixture)

Diagnosis: Erosive papular dermatitis of perirectal area, most likely "Jacquet's Diaper Dermatitis."

Comment and Questions:
The patient was difficult to examine and was very disruptive. Frustrating as the office visit was, I marveled at the patience of his mother for whom he is a full-time job. My experience with erosive diaper dermatitis is limited and this boy's mother told me her son has been seen by three pediatricians and a gastroenterologist and his problem persists. I suppose the Hirschprung's has set up a situation where he is incontinent of stool and his Down's makes management of that even more difficult. Ted Rosen described a similar patient (see references) and the management was fairly simple. I will get Ted's opinion. Please let me know your thoughts.

* Mother's note: Hi Doctor, Thank-you for today's appointment. I'm grateful for your taking the time to research this. My partner and I were at our wits end watching J. suffer with this. I forgot to mention one other product that I use on him is Caldesene powder. This has worked well but only if it is timed just right. Meaning, if we were lucky after applying it, Jarod would stay dry /continent for a long period of time, like through the entire night, and the powder would dry it out and it would begin healing. He has an average of 4 to 5 bowel movements a day, sometimes more sometimes less and his stool is the consistency of toothpaste most of the time. Is there any other info. I could share with you that would be helpful in figuring a treatment plan ?
Thank-you again for your help. I really appreciate it. Sincerely, W.

References:

1. Van L, Harting M, Rosen T. Jacquet erosive diaper dermatitis: a complication of adult urinary incontinence. Cutis. 2008 Jul;82(1):72-4.

Abstract: Jacquet erosive diaper dermatitis is typically described as a severe irritant dermatitis of the perianal region. However, Jacquet erosive diaper dermatitis, perianal pseudoverrucous papules and nodules, and granuloma gluteale infantum/ adultorum have been regarded as discrete entities or all part of the same clinical spectrum, representing the result of chronic, severe, irritant contact dermatitis. We present a case of Jacquet erosive diaper dermatitis and a discussion of the clinical spectrum of diseases to which it belongs.


2. Clinical Presentation and Treatment of Diaper Dermatitis (Full Text)

Thursday, January 26, 2012

Atypical Diaper Dermatitis

Abstract: 9 week old infant with recalcitrant diaper dermatitis.

HPI: This child has had a dermatitis which began in the napkin area at ~ 1 month of age. He has been treated with topical Nystatin, clotrimazole cream, Aquaphor and Maalox. No response. New lesions have appeared around umbilicus and neck. His paternal grandfather may have psoriasis.

O/E: There is a sharply demarcated erythematous dermatitis in the pubic, perineal and perirectal area. The umbilicus is involved and there are a few patches in the neck folds. The child is otherwise healthy in appearance.

Clinical Photos:



Diagnosis: I am suspicious of psoriasis or a psoriasiform diaper dermatitis here. This is so well-demarcated and the umbilical lesion may be a clue. I have started him on triamcinalone 0.1% ointment after bath and will reevaluate in a week.

Questions: What alternative diagnoses would you suggest? What may I be missing? Would biopsy be helpful?

References:

Photo after 7 days of TAC 0.1% ointment: