Amoxicillin and diaper dermatitis

Assessment of diaper dermatitis using a novel electronic health record-embedded scale

OBJECTIVE

Quantify the evolution and severity of neonatal skin injury, specifically diaper skin compromise, by embedding a validated skin integrity evaluation into the electronic health record (EHR).

METHODS

Retrospective longitudinal cohort analysis of 747 patients stratified by gestation: 22-27, 28-31, 32-24, and 35-37 weeks, from birth to discharge. Primary outcomes were time to first perineal erythema, duration as percent days with erythema, and severity as maximum score. Data were analyzed using generalized linear models and multiple linear regression methods.

RESULTS

Seventy percent had erythema and, of these, 34% had at least one high score with bleeding. Days with erythema ranged from 34-44% (p < 0.05). Days to first erythema were inversely correlated with gestational age. Risks for severe injury included short time to first erythema, 5 or more stools/day, infection, and Caucasian race/ethnicity.

CONCLUSIONS

The EHR-based scale can be readily implemented to mitigate diaper skin compromise in premature infants.

An Adaptation of the Skin Safety Model to Guide Diaper Dermatitis Research in the NICU

Diaper dermatitis is an ever-present condition among infants. Little is known about the prevalence among infants in the NICU. This article presents an adaptation of the skin safety model (SSM) for the infant in the NICU. The concepts of the model were extracted, defined, and integrated into an adapted SSM model to provide a focus on the infant with diaper dermatitis in the intensive care setting. It is essential to include all factors of the infant's clinical characteristics and hospital experience in the modeling to accurately predict risk of skin vulnerability in this infant population.

Diaper (napkin) dermatitis: A fold (intertriginous) dermatosis

Diaper (napkin) dermatitis is an acutely presenting inflammatory irritant contact dermatitis of the diaper region. It is one of the most common dermatologic diseases in infants and children. In the past, the disease was thought to be caused by ammonia; however, a number of factors, such as friction, wetness, inappropriate skin care, microorganisms, antibiotics, and nutritional defects, are important. Diaper dermatitis commonly affects the lower parts of the abdomen, thighs, and diaper area. Involvement of skin fold regions is typical with diaper dermatitis. At the early stages of the disease, only dryness is observed in the affected area. At later stages, erythematous maceration and edema can be seen. Secondary candidal and bacterial infections can complicate the dermatitis. In the differential diagnosis of the disease, allergic contact dermatitis, intertrigo, psoriasis, atopic and seborrheic dermatitis, and the other diseases should be considered. Causes of the disease should be determined and eliminated primarily. Families need to be informed about the importance of a clean, dry diaper area and the frequency of diaper changes. The use of superabsorbent disposable diapers has decreased the incidence of the disease. Soap and alcohol-containing products should be avoided in cleaning the area. In some cases, corticosteroids and antifungal agents can be administered. If necessary, antibacterial agents and calcineurin inhibitors can also be beneficial.

Paediatric oropharyngeal and cutaneous candidiasis with special reference to Candida dubliniensis

Mucocutaneous and cutaneous candidiasis, though common in children, is often under-reported. The prevalence of Candida dubliniensis in causing these infections in this age group is also largely unknown. A prospective epidemiological cross-sectional study for candidiasis was performed in paediatric patients clinically suspected of candidiasis with oropharyngeal lesions (75 patients), cutaneous lesions (18 patients) and lesions at both sites (2 patients). Candida species were identified by conventional tests. For C. dubliniensis, chlamydospore production, growth on tobacco agar and growth at 45 °C were performed. Nine isolates were confirmed at a reference centre. The rates of candidiasis were 77.3 % (58 out of 75 patients clinically suspected of candidiasis) and 83.3 % (15/18) in oropharyngeal and cutaneous lesions respectively, and 1 of the 2 children with lesions at both sites was diagnosed as having chronic mucocutaneous candidiasis due to C. dubliniensis. The commonest species isolated was Candida albicans, in 41 (70.7 %) patients with oropharyngeal candidiasis and 11 (73.3 %) with cutaneous lesions; C. dubliniensis was isolated from 11 and 3 children respectively. In the paediatric population, C. albicans predominates in mucocutaneous and cutaneous candidiasis, with C. dubliniensis also contributing substantially.

Cow's Milk Allergy Is a Major Contributor in Recurrent Perianal Dermatitis of Infants

Background. Recurrent perianal inflammation has great etiologic diversity. A possible cause is cow's milk allergy (CMA). The aim was to assess the magnitude of this cause. Subjects and Methods. This follow up clinical study was carried out on 63 infants with perianal dermatitis of more than 3 weeks with history of recurrence. Definitive diagnosis was made for each infant through medical history taking, clinical examination and investigations including stool analysis and culture, stool pH and reducing substances, perianal swab for different cultures and staining for Candida albicans. Complete blood count and quantitative determination of cow's milk-specific serum IgE concentration were done for all patients. CMA was confirmed through an open withdrawal-rechallenge procedure. Serum immunoglobulins and CD markers as well as gastrointestinal endoscopies were done for some patients. Results. Causes of perianal dermatitis included CMA (47.6%), bacterial dermatitis (17.46%), moniliasis (15.87%), enterobiasis (9.52%) and lactose intolerance (9.5%). Predictors of CMA included presence of bloody and/or mucoid stool, other atopic manifestations, anal fissures, or recurrent vomiting. Conclusion. We can conclude that cow's milk allergy is a common cause of recurrent perianal dermatitis. Mucoid or bloody stool, anal fissures or ulcers, vomiting and atopic manifestations can predict this etiology.

Recent advances in diaper dermatitis: etiology and treatment

Diaper dermatitis is a highly prevalent condition that causes discomfort and stress for patients and frustration for healthcare staff. Diaper technology has evolved to substantially lessen the severity of diaper dermatitis, but additional improvements are needed. Premature infants and incontinent adults are particularly at risk for developing diaper dermatitis and its potential consequences. Contributing factors include overhydration, irritants, friction, increased skin pH, diet, gestational age, antibiotic use, diarrhea and medical condition. Treatments aim to reduce hydration, provide a semipermeable ‘layer’ to facilitate skin barrier repair, shield the skin from irritants, deactivate specific fecal components and maintain skin surface contact. The published research on the effects of diaper dermatitis treatments is especially sparse. Controlled clinical trials are needed to provide definitive evidence for selection of effective treatments. This article discusses the incidence and etiology of diaper dermatitis in infants and adults. It provides the scientific basis for repair of diaper skin barrier damage and describes recent developments that will be available in the future.

Prospective aetiological study of diaper dermatitis in the elderly

BACKGROUND

The different causes of diaper dermatitis (DD) in the elderly are not well known and the treatment is often empirical.

OBJECTIVES

To determine the causes of DD in the elderly and to evaluate the efficacy of antifungal treatments in this indication.

METHODS

Consecutive patients presenting with DD were included. Clinical evaluation, skin swabs for bacterial and mycological cultures, patch testing and skin biopsy were performed at inclusion. This was followed by 1 month of topical antifungal cream and, if needed, by oral fluconazole for the second month.

RESULTS

Forty-six patients were included (mean age 85 years). Causes of DD were established for 38 patients: 24 had candidiasis (63%), six irritant dermatitis (16%), four eczema (11%) and four psoriasis (11%). After 2 months of treatment, 27 of 37 (73%) patients were cured and five of 37 were improved.

CONCLUSIONS

Mycoses and irritant dermatitis are the main causes of DD in the elderly, and emollient skin care and topical antifungal treatment can be considered a first-line therapy for this indication.

Diaper dermatitis that does not quit

Diaper dermatitis is one of the most common skin disorders in infants. The humid, moist environment under the diaper makes the skin more susceptible to injury from exposure to irritants particularly related to urine and feces. A gentle cleansing routine, frequent diaper changes, and a thick barrier cream help control this condition. Irritant diaper dermatitis should be distinguished from other skin conditions that may develop in this sensitive area.

Disposable diapers: safe and effective

Nappy rash is a common problem in infants due to their thinner skin, wetness, heat and friction under cloth nappy, fecal enzymes and alkaline urine. The disposable diapers containing Super Absorbent Material (SAM) reduce the incidence of nappy rash. SAM quickly absorbs urine and keeps the skin dry. Also disposable diapers prevent fecal contamination by absorbing the urine and containing stools.

The aetiology and management of irritant diaper dermatitis

Irritant diaper dermatitis (IDD) is a common condition caused by the combination of wearing diapers, and incontinence of urine and faeces. The available evidence suggests that maceration of the stratum corneum by water increases susceptibility to frictional damage, and epidermal permeation of irritants. The most important irritants underlying IDD appear to be digestive enzymes persisting in faeces, particularly when these are activated by a high pH.

The effects of amoxicillin therapy on skin flora in infants

In order to determine the effect of amoxicillin therapy on the perineal skin microbial flora in infants, we took quantitative bacterial and fungal cultures of perineal and sternal areas from 25 infants treated with amoxicillin (40 mg/kg/day) for 10 days. Specimens were obtained prior to therapy, within 3 days of conclusion of therapy, and 14-16 days later. Immediately following therapy, a decline in the number of bacterial isolates occurred on both the perineum (89 to 47) and sternum (84 to 39). The greatest decline occurred in the number of anaerobic bacteria (mostly Peptostreptococcus spp. and Propionibacterium acnes). Other organisms that were less often isolated were aerobic streptococci and Staphylococcus epidermidis. The number of Candida albicans isolates increased from 3 to 11 (p < 0.05) on the perineum, and 1 to 7 (p < 0.025) on the sternum. Four of the infants developed diaper dermatitis. The density of C. albicans increased more than 14-fold following amoxicillin therapy. Cultures done 14-16 days after cessation of therapy revealed an increase in the number of bacterial isolates on the perineum (47 to 72) and on the sternum (39 to 61) and a decline in recovery of C. albicans. This study demonstrates the effects of amoxicillin on the ecology of skin microbial flora in infants-a decrease in the number of bacterial isolates and an increase in recovery of C. albicans.

Treatment of diaper dermatitis

Diaper rash therapy can be as simple as A, B, C, D, and E if you are able to identify generic diaper rash and exclude other causes. Components of diaper rash treatment include airing, barrier and other tropical product application, cleansing of the diaper area, diaper selection, and education of caregivers. Diaper rash therapy can be letter-perfect.

Cutaneous mycoses in children

This article describes common cutaneous mycoses in children: mucocutaneous candidiasis, pityriasis versicolor, tinea corporis, tinea pedis, onychomycosis and tinea capitis. Topical therapy is effective in tinea corporis and pedis, pityriasis versicolor and cutaneous candidiasis. It is ineffective in tinea capitis, in immunocompromised children and onychomycosis. Griseofulvin has been the main treatment until now in children, but it is only fungistatic, may cause interactions and has to be given for long periods. Ketoconazole has not been widely accepted for use in children because of hepatotoxicity and it is not an effective as griseofulvin. There are few data on paediatric use of fluconazole, although it is available in liquid form, has an excellent safety profile and may become important for treating paediatric mycoses. Similarly, there are only limited data on itraconazole in this area, with most experience in tinea capitis. There is only a 100-mg capsule available, which is not easy to administer in paediatric dosages. All azoles have the potential for drug interaction. Most experience in the treatment of children with the allylamine, terbinafine, has been in tinea capitis. A treatment time of 4 weeks with terbinafine and 8 weeks with griseofulvin has produced similar results at 12 weeks. There are also limited data on the use of terbinafine in paediatric onychomycosis. Terbinafine has the best safety profile, least risk of drug interactions and may be the most suitable alternative to griseofulvin in children. The lack of a liquid formulation may preclude its use. Itraconazole and fluconazole are also potential replacement drugs for griseofulvin.

Faecal enzymes: in vivo human skin irritation

Digestive enzymes in faeces have been reported to possess skin irritation potential. The present study was designed to investigate the in vivo irritant potentials of faecal concentrations of proteolytic and lipolytic digestive enzymes in bile salt mixtures. In a 21-day cumulative irritation assay, clinical evaluation and noninvasive bioengineering techniques were used. 5 days occlusive exposure to phosphate buffer (pH = 8) caused no visual skin damage but reflectance spectroscopy demonstrated significant vasodilation (p < 0.01) and increases in transepidermal water loss (TEWL) and skin pH were also observed (p < 0.01). These increases were still present at days 12 and 19. Occlusive exposure to physiologic concentrations of faecal enzymes resulted in significant visual and objective scores at day 5, 12, and 19, with increased readings as a function of exposure time (p < 0.01). The enzyme mixture containing lipase caused delayed onset of skin erythema and epidermal barrier disruption compared to elastase and chymotrypsin containing solutions. Prolonged occlusive exposure to digestive enzymes in faecal concentrations caused severe skin erythema and epidermal barrier disruption in a human model, suggesting a possible etiologic role of digestive enzymes in perianal, circumstomal or diaper dermatitis.

Neonatal skin disorders

Skin disorders are commonly seen in the neonatal period. A recent survey of neonates demonstrated that almost every neonate had some skin lesion. The most common skin findings are desquamation, Epstein's pearls, sebaceous hyperplasia, milia, toxic erythema, salmon patch, hypertrichosis, and Mongolian spot. In addition to these common cutaneous findings, other disorders may exist and are discussed in this article.