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Chiriac A, Wollina U. Diaper dermatitis-a narrative review of clinical presentation, subtypes, and treatment. Wien Med Wochenschr 2023:10.1007/s10354-023-01024-6. [PMID: 37861874 DOI: 10.1007/s10354-023-01024-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/26/2023] [Indexed: 10/21/2023]
Abstract
Diaper dermatitis (DD) is an umbrella term with different clinical presentations, pathophysiology, treatments, and outcomes. The major subtypes include irritant contact dermatitis and candida-associated DD. In case of atypical presentation or unresponsiveness to treatment, other differential diagnoses should be considered. Although DD can occur at any age, it peaks in newborns and infants < 2 years of age. We will focus on this age group in our narrative review.
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Affiliation(s)
- Anca Chiriac
- Department of Dermatology, Nicolina Medical Center, Iasi, Romania.
- Apollonia University, Iasi, Romania.
- P. Poni Institute of Macromolecular Chemistry, Romanian Academy, Iasi, Romania.
| | - Uwe Wollina
- Dermatology, Venereology and Allergology, Academic Teaching Hospital Dresden-Friedrichstadt, Dresden, Germany
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Yerramilli A, Bowen AC, Marcato AJ, McVernon J, Carapetis JR, Campbell PT, Tong SYC. Body distribution of impetigo and association with host and pathogen factors. PeerJ 2022. [DOI: 10.7717/peerj.14154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background
Impetigo or skin sores are estimated to affect >162 million people worldwide. Detailed descriptions of the anatomical location of skin sores are lacking.
Methods
We used prospectively collected data from a randomised control trial of treatments for impetigo in Aboriginal children in Australia. We generated heat-map distributions of skin sores on the human body from 56 predefined anatomical locations and stratified skin sore distribution by sex, age, causative pathogen and co-infection with scabies, tinea and head lice. We compared the distribution of sores between males and females, between sores with only Streptococcus pyogenes and sores with only Staphylococcus aureus; and across age groups with a Fisher’s exact test.
Results
There were 663 episodes of impetigo infections among 508 children enrolled in the trial. For all 663 episodes, the lower limbs were the most affected body sites followed by the distal upper limbs, face and scalp. On the anterior surface of the body, the pre-tibial region was the most affected while on the posterior surface, the dorsum of the hands and calves predominated. There was no observable difference between males and females in distribution of sores. Children up to 3 years of age were more likely to have sores on the upper posterior lower limbs and scalp than older age groups, with the distribution of sores differing across age groups (p = 3 × 10−5). Sores from which only Staphylococcus aureus was cultured differed in distribution to those with only Streptococcus pyogenes cultured (p = 3 × 10−4) and were more commonly found on the upper posterior lower limbs.
Conclusions
Skin sores were predominantly found on exposed regions of the lower leg and distal upper limbs. The distribution of sores varied by age group and pathogen. These results highlight key areas of the body for clinicians to pay attention to when examining children for skin sores.
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Affiliation(s)
- Arvind Yerramilli
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
| | - Asha C. Bowen
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, Western Australia, Australia
| | - Adrian J. Marcato
- Department of Infectious Diseases, The University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Jodie McVernon
- Department of Infectious Diseases, The University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Infection and Immunity, Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Reference Laboratory Epidemiology Unit, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, Melbourne, Victoria, Australia
| | - Jonathan R. Carapetis
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Department of Infectious Diseases, Perth Children’s Hospital, Perth, Western Australia, Australia
| | - Patricia T. Campbell
- Department of Infectious Diseases, The University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, Melbourne, Victoria, Australia
| | - Steven YC Tong
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- Department of Infectious Diseases, The University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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Clinical signs and symptoms of diaper dermatitis in newborns, infants, and young children: A scoping review. J Tissue Viability 2022; 31:404-415. [DOI: 10.1016/j.jtv.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 01/13/2022] [Accepted: 03/22/2022] [Indexed: 11/21/2022]
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Hertiš Petek T, Petek M, Petek T, Marčun Varda N. Emerging Links between Microbiome Composition and Skin Immunology in Diaper Dermatitis: A Narrative Review. CHILDREN 2022; 9:children9010112. [PMID: 35053737 PMCID: PMC8775025 DOI: 10.3390/children9010112] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/09/2022] [Accepted: 01/12/2022] [Indexed: 11/16/2022]
Abstract
Diaper dermatitis is a common type of irritant contact dermatitis occurring in infants and toddlers. Its occurrence is triggered by an unfavorable environment under the diaper, damage to skin integrity by fecal enzyme degradation, overhydration and disruption of the lipid bilayer structure facilitating the entry of irritants and microorganisms. In diaper dermatitis development, the central proinflammatory cytokines are IL-1α, IL-8 and TNF-α. The initial release of IL-1α and TNF-α starts a further cascade of pro-inflammatory chemo- and cytokines, resulting in inflammation and erythema of the skin. A recently recognized factor in diaper dermatitis is the composition of the skin microbiome; common pathogenic strains Candida albicans and Staphylococcus aureus are associated with skin irritation. The resulting impaired microbiome composition produces a local inflammatory response and may thus worsen the initial dermatitis clinical presentation and subsequent healing. Introduction of probiotics is an attractive treatment for microbiome modulation, which has shown success in other skin conditions in adults and children. Probiotics are thought to work as a protective shield against irritants, maintain low skin pH, secrete beneficial metabolites, and block pathogen invasion. There is preliminary evidence that certain probiotics given orally or topically could be used as a gentle intervention in diaper dermatitis.
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Affiliation(s)
- Tjaša Hertiš Petek
- Department of Pediatrics, University Medical Center Maribor, 2000 Maribor, Slovenia; (T.P.); (N.M.V.)
- Faculty of Medicine, University of Maribor, 2000 Maribor, Slovenia;
- Correspondence: ; Tel.: +386-(0)2-321-2110
| | - Maya Petek
- Faculty of Medicine, University of Maribor, 2000 Maribor, Slovenia;
| | - Tadej Petek
- Department of Pediatrics, University Medical Center Maribor, 2000 Maribor, Slovenia; (T.P.); (N.M.V.)
- Faculty of Medicine, University of Maribor, 2000 Maribor, Slovenia;
| | - Nataša Marčun Varda
- Department of Pediatrics, University Medical Center Maribor, 2000 Maribor, Slovenia; (T.P.); (N.M.V.)
- Faculty of Medicine, University of Maribor, 2000 Maribor, Slovenia;
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Conceptual Framework for Incontinence-Associated Dermatitis Based on Scoping Review and Expert Consensus Process. J Wound Ostomy Continence Nurs 2021; 48:239-250. [PMID: 33951713 DOI: 10.1097/won.0000000000000754] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Incontinence-associated dermatitis (IAD) has been studied over the last decades, but gaps in the knowledge related to its identification, etiological agents, and risk factors remain. We carried out a scoping review about IAD that included systematic reviews, experimental, and observational studies about IAD and its potential risk factors. We retrieved 24 articles that described 100 potential risk factors and which were synthesized by the authors and proposed to a panel of experts. Panelists used a structured process of consensus development to create a conceptual framework of factors associated with IAD. This framework proposes that liquid fecal material, when combined with exposure to urine and stool, and bacterial contaminated urine are etiological factors for development of IAD. The framework also proposes 2 pathophysiological mechanisms and 8 main risk factors for IAD development. The proposed model could improve the quality of care for patients with or at risk of IAD, assisting healthcare professionals to identify at-risk patients, diagnose the type of lesion, and establish adequate and effective prevention and treatment measures.
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An Integrative Review of Clinical Characteristics of Infants With Diaper Dermatitis. Adv Neonatal Care 2020; 20:276-285. [PMID: 31895136 DOI: 10.1097/anc.0000000000000682] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Diaper dermatitis (DD) severity is demonstrated by the degree of erythema and skin breakdown. Many studies describe diaper dermatitis, but lack a full description of clinical characteristic (CC) involvement. PURPOSE The purpose of this literature review is to explore the descriptions of CC of infants with DD provided within infant DD literature. SEARCH STRATEGY PubMed and Web of Science were searched using the keywords: diaper dermatitis, diaper rash, infant, and neonate. The inclusion criteria for this project are as follows: published after 1990, English language, include skin assessment or evaluation, and infant/children < two years of age. Review and opinion articles were excluded. RESULTS A total of 454 studies were retrieved, 27 remained after review for duplicates and relevance. The CC described most often were: type of feeds, stool frequency, history of DD, use of antibiotics, and delivery mode. SYNTHESIS OF EVIDENCE The studies reported inconsistent CC and a lack of correlation between these characteristics and the condition of diapered skin. Many studies focused solely on the efficacy of interventions lacking description of possible relationships between DD and CC. IMPLICATIONS FOR PRACTICE Skin condition outcome variables can be improved with the acknowledgment of the impact CC have on the development of DD. The combination of assessment measures and CC may ultimately demonstrate more merit or rigor for describing DD severity and skin condition. IMPLICATIONS FOR RESEARCH Future research should expand this exploration to include environmental or contributing factors to continue to identify additional risk factors for DD.
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Moskovicz V, Gross A, Mizrahi B. Extrinsic Factors Shaping the Skin Microbiome. Microorganisms 2020; 8:E1023. [PMID: 32664353 PMCID: PMC7409027 DOI: 10.3390/microorganisms8071023] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/07/2020] [Accepted: 07/07/2020] [Indexed: 12/13/2022] Open
Abstract
Human skin, our most environmentally exposed organ, is colonized by a vast array of microorganisms constituting its microbiome. These bacterial communities are crucial for the fulfillment of human physiological functions such as immune system modulation and epidermal development and differentiation. The structure of the human skin microbiome is established during the early life stages, starting even before birth, and continues to be modulated throughout the entire life cycle, by multiple host-related and environmental factors. This review focuses on extrinsic factors, ranging from cosmetics to the environment and antibacterial agents, as forces that impact the human skin microbiome and well-being. Assessing the impact of these factors on the skin microbiome will help elucidate the forces that shape the microbial populations we coexist with. Furthermore, we will gain additional insight into their tendency to stimulate a healthy environment or to increase the propensity for skin disorder development.
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Affiliation(s)
| | | | - Boaz Mizrahi
- Faculty of Biotechnology and Food Engineering, Technion, Haifa 3200003, Israel; (V.M.); (A.G.)
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Šikić Pogačar M, Maver U, Marčun Varda N, Mičetić-Turk D. Diagnosis and management of diaper dermatitis in infants with emphasis on skin microbiota in the diaper area. Int J Dermatol 2017; 57:265-275. [PMID: 28986935 DOI: 10.1111/ijd.13748] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 08/02/2017] [Accepted: 08/14/2017] [Indexed: 12/22/2022]
Abstract
Diaper dermatitis is the most common inflammatory skin eruption within the diaper area in infants and toddlers. Although it rarely causes problems for prolonged periods of time, it causes considerable distress for both infants and parents. Diapered skin is exposed to friction, excessive hydration, varying pH, and is in constant contact with urine and feces, both of which are highly irritant to the skin. The three most common types of diaper dermatitis include chaffing dermatitis, irritant contact dermatitis, and diaper candidiasis. However, a variety of other skin conditions may manifest in the diaper area. Candida albicans and Staphylococcus aureus are most frequently isolated from the affected area and are thought to have a predominant role in diaper dermatitis. The review includes an overview of the epidemiology, etiology, and common skin microbiota in the diaper area. State-of-the-art strategies for diagnosis, management, and prevention of diaper dermatitis are also included. Appropriate skin care can help in the prevention of diaper dermatitis and can aid the reparation of the skin. This review discusses common causes, skin microbiota within the diapered area, differential diagnosis, and finally possible prevention and treatment recommendations. Recent findings have proven that the key to efficient eradication of irritant diaper dermatitis lies in its prevention.
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Affiliation(s)
- Maja Šikić Pogačar
- Faculty of Medicine, Department of Pediatrics, University of Maribor, Maribor, Slovenia
| | - Uroš Maver
- Faculty of Medicine, Institute of Biomedical Sciences and Department of Pharmacology, University of Maribor, Maribor, Slovenia
| | | | - Dušanka Mičetić-Turk
- Faculty of Medicine, Department of Pediatrics, University of Maribor, Maribor, Slovenia
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Campbell JL, Coyer FM, Mudge AM, Robertson IM, Osborne SR. Candida albicans colonisation, continence status and incontinence-associated dermatitis in the acute care setting: a pilot study. Int Wound J 2016; 14:488-495. [PMID: 27478106 DOI: 10.1111/iwj.12630] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 06/10/2016] [Indexed: 12/31/2022] Open
Abstract
Candida albicans is the most prevalent human fungal commensal organism and is reported to be the most frequent aetiological organism responsible for infection associated with incontinence-associated dermatitis. However, it remains unclear whether incontinence predisposes a patient to increased Candida colonisation or whether incontinence acts as a trigger for Candida infection in those already colonised. The purpose of this observational cross-sectional study was to estimate colonisation rates of C. albicans in continent, compared to incontinent patients, and patients with incontinence-associated dermatitis. Data were collected on 81 inpatients of a major Australian hospital and included a pelvic skin inspection and microbiological specimens to detect C. Albicans at hospital admission. The mean age of the sample was 76 years (SD = 12.22) with 53% being male. Incontinent participants (n = 53) had a non-significant trend towards greater Candida colonisation rates at the perianal site (43% versus 28%) χ2 (1, N = 81) = 4·453, p = ·638 and the inguinal site (24% versus 14%) χ2 (1, N = 81) = 6·868, p = ·258 compared to continent patients (n = 28). The incontinent subgroup with incontinence-associated dermatitis (n = 22) showed no difference in colonisation rates compared to those without incontinence-associated dermatitis. Understanding the epidemiology of colonisation may have implications for the prevention of Candida infection in these patients.
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Affiliation(s)
- Jill L Campbell
- Skin Integrity Service, Royal Brisbane and Women's Hospital, Metro North Hospital Health Service, Herston, Queensland,, Australia.,School of Nursing, Queensland University of Technology, Kelvin Grove, Queensland,, Australia
| | - Fiona M Coyer
- School of Nursing, Queensland University of Technology, Kelvin Grove, Queensland,, Australia.,Joint Appointment Intensive Care Services, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Herston, Queensland,, Australia.,University of Huddersfield, UK
| | - Alison M Mudge
- Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Metro North Hospital Health Service, Herston, Queensland,, Australia
| | - Ivan M Robertson
- Department of Dermatology, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Services, Herston, Queensland,, Australia
| | - Sonya R Osborne
- School of Nursing, Queensland University of Technology, Kelvin Grove, Queensland,, Australia.,Australian Centre for Health Services Innovation (AusHSI), School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland,, Australia.,Visiting Research Fellow, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Herston, Queensland,, Australia
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Bonifaz A, Rojas R, Tirado-Sánchez A, Chávez-López D, Mena C, Calderón L, María POR. Superficial Mycoses Associated with Diaper Dermatitis. Mycopathologia 2016; 181:671-9. [PMID: 27193417 PMCID: PMC5014885 DOI: 10.1007/s11046-016-0020-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 05/11/2016] [Indexed: 11/24/2022]
Abstract
Diapers create particular conditions of moisture and friction, and with urine and feces come increased pH and irritating enzymes (lipases and proteases). Fungi can take advantage of all these factors. Candida yeasts, especially C. albicans, are responsible for the most frequent secondary infections and are isolated in more than 80 % of cases. Correct diagnosis is important for ensuring the correct prescription of topical antimycotics. Nystatin, imidazoles and ciclopirox are effective. It is important to realize there are resistant strains. Dermatophytes can infect the diaper area, with the most common agent being Epidermophyton floccosum. The clinical characteristics of dermatophytosis are different from those of candidiasis, and it can be diagnosed and treated simply. Malassezia yeasts can aggravate conditions affecting the diaper area, such as seborrheic dermatitis, atopic dermatitis, and inverse psoriasis. Additional treatment is recommended in this case, because they usually involve complement activation and increased specific IgE levels. Erythrasma is a pseudomycosis that is indistinguishable from candidiasis and may also occur in large skin folds. It is treated with topical antibacterial products and some antimycotics.
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Affiliation(s)
- Alexandro Bonifaz
- Department of Mycology and Dermatology Service, Hospital General de México, "Dr. Eduardo Liceaga", Dr. Balmis 148, Col Doctores, CP 06720, Mexico, DF, Mexico.
| | - Rubí Rojas
- Dermatology Service, Hospital Infantil de México, "Dr. Federico Gómez", Mexico, Mexico
| | - Andrés Tirado-Sánchez
- Department of Mycology and Dermatology Service, Hospital General de México, "Dr. Eduardo Liceaga", Dr. Balmis 148, Col Doctores, CP 06720, Mexico, DF, Mexico
| | - Dinora Chávez-López
- Dermatology Service, Hospital Infantil de México, "Dr. Federico Gómez", Mexico, Mexico
| | - Carlos Mena
- Dermatology Service, Hospital Infantil de México, "Dr. Federico Gómez", Mexico, Mexico
| | - Luz Calderón
- Department of Mycology and Dermatology Service, Hospital General de México, "Dr. Eduardo Liceaga", Dr. Balmis 148, Col Doctores, CP 06720, Mexico, DF, Mexico
| | - Ponce-Olivera Rosa María
- Department of Mycology and Dermatology Service, Hospital General de México, "Dr. Eduardo Liceaga", Dr. Balmis 148, Col Doctores, CP 06720, Mexico, DF, Mexico
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Abstract
BACKGROUND/OBJECTIVE Diaper dermatitis (DD) is a common infantile dermatosis with a highly variable prevalence and incidence. This study aimed to present the demographic and clinical features of babies with DD. METHODS Data, including demographic and clinical features, obtained from DD patient forms were retrospectively analyzed. RESULTS The study included 63 babies with DD (female: n = 35 [55.6%]; male: n = 28 [44.4%]; mean age 11.6 mos). Most of the patients (43.5%) were 0 to 6 months of age. In all, 76.3% were breastfed, of whom 31.7% were exclusively breastfed. The number of previous episodes of DD was significantly lower in breastfed babies. The most common diaper area cleansing method was wet wipes (54.1%). Diaper creams were used in 86.2% of patients. DD was severe in 22.2% of patients, moderate in 57.4%, and mild in 20.4%. Candida infection was noted in 77.4% of patients. The median number of previous episodes of DD was significantly higher in patients with Candida infection than in those without (p = 0.02). Treatment yielded greater than 50% improvement (complete and moderate response) in 59.4% of patients at the first follow-up visit (3-5 days) and 82.6% at the second follow-up visit (10 days). CONCLUSION Most babies with DD were 0 to 6 months of age. Breastfed babies had fewer previous episodes of DD, so mothers should be encouraged to breastfeed their babies to reduce the incidence of DD. Candida infection was common; clinicians should be aware of its association with DD.
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Affiliation(s)
- Sibel Ersoy-Evans
- Department of Dermatology, Hacettepe University, School of Medicine, Ankara, Turkey
| | - Hande Akıncı
- Department of Dermatology, Hacettepe University, School of Medicine, Ankara, Turkey
| | - Sibel Doğan
- Department of Dermatology, Hacettepe University, School of Medicine, Ankara, Turkey
| | - Nilgün Atakan
- Department of Dermatology, Hacettepe University, School of Medicine, Ankara, Turkey
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Lagier L, Mazereeuw-Hautier J, Raffin D, Beneton N, Lorette G, Maruani A. Les dermites du siège du nourrisson. Ann Dermatol Venereol 2015; 142:54-61; quiz 53, 62. [DOI: 10.1016/j.annder.2014.09.611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 09/18/2014] [Accepted: 09/25/2014] [Indexed: 01/05/2023]
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Pontes AC, Amaral RL, Giraldo PC, Beghini J, Giraldo HP, Cordeiro ES. A systematic review of the effect of daily panty liner use on the vulvovaginal environment. Int J Gynaecol Obstet 2014; 127:1-5. [DOI: 10.1016/j.ijgo.2014.06.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 06/11/2014] [Accepted: 07/23/2014] [Indexed: 10/25/2022]
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Abstract
This article presents an overview of diaper dermatitis for the pediatric community. The pathogenesis, differential diagnosis, and management of this common condition in infancy are reviewed. This information will assist in making the appropriate diagnosis and managing this irritant contact dermatitis of the diaper area. With conservative management, most cases of irritant diaper dermatitis are self-limited. When the condition persists, one must consider other diagnoses.
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Stamatas GN, Tierney NK. Diaper dermatitis: etiology, manifestations, prevention, and management. Pediatr Dermatol 2014; 31:1-7. [PMID: 24224482 DOI: 10.1111/pde.12245] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Pediatricians and parents report diaper dermatitis (DD) to be one of the most common skin diseases that affects almost every child at some point during the early months and years of life. Diapered skin is exposed to friction and excessive hydration, has a higher pH than nondiapered skin, and is repeatedly soiled with feces that contains enzymes with high irritation potential for the skin. The combination of these factors frequently results in skin damage, leading to visible erythematous lesions that can be irritating and painful to the child. Behavioral changes such as increased crying and agitation and changes in eating and sleeping patterns indicate emotional distress. Appropriate skin care can help to prevent the occurrence of DD and to speed up the healing of affected skin. This includes frequent diaper changes and aeration, gentle cleansing, and the use of a barrier cream. Mild to moderate cases usually resolve after a few days of following this routine, but the use of harsh cleaning products can exacerbate DD.
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Li CH, Zhu ZH, Dai YH. Diaper dermatitis: a survey of risk factors for children aged 1-24 months in China. J Int Med Res 2013. [PMID: 23206457 DOI: 10.1177/030006051204000514] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To measure the prevalence of diaper dermatitis and identify risk factors relating to diaper dermatitis in Chinese children aged 1-24 months. METHODS This was a cross-sectional study that used structured questionnaires during face-to-face interviews with parents to determine the risk factors associated with diaper dermatitis. Univariate and multivariate logistic regression analyses were used to test the association between diaper dermatitis and 15 potential risk factors. RESULTS A total of 43.8% (454/1036) of infants in the study had experienced diaper dermatitis in the 6 weeks prior to enrolment. Multivariate logistic regression analyses showed that the risk of diaper dermatitis was significantly decreased by solid foods (eggs), home location (urban) and frequency of diaper changing (≥ 6 changes/day), whereas the risk was increased by diarrhoea. CONCLUSIONS Diarrhoea was a major risk factor for diaper dermatitis. Confirmation of the risk factors could lead to better understanding of the aetiology of diaper dermatitis and to new prevention strategies in Chinese infants.
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Affiliation(s)
- C H Li
- Graduate School, Peking Union Medical College, Beijing, China
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Bonifaz A, Tirado-Sánchez A, Graniel MJ, Mena C, Valencia A, Ponce-Olivera RM. The efficacy and safety of sertaconazole cream (2 %) in diaper dermatitis candidiasis. Mycopathologia 2013; 175:249-54. [PMID: 23546772 PMCID: PMC3622746 DOI: 10.1007/s11046-013-9642-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 03/20/2013] [Indexed: 11/29/2022]
Abstract
Aim Diaper dermatitis (DD) is an inflammatory irritating condition that is common in infants. Most cases are associated with the yeast colonization of Candida or diaper dermatitis candidiasis (DDC), and therefore, the signs and symptoms improve with antimycotic treatment. Sertaconazole is a broad-spectrum third-generation imidazole derivative that is effective and safe for the treatment for superficial mycoses, such as tineas, candidiasis, and pityriasis versicolor. Our goal was to assess the efficacy and safety of sertaconazole cream (2 %) in DDC. Materials and methods Twenty-seven patients with clinical and mycological diagnosis of DDC were enrolled and treated with 2 daily applications for 14 days and were followed-up for 2 further weeks. Results Three etiologic agents were isolated: Candida albicans in 88.8 %, Candida parapsilosis in 7.3 %, and Candida glabrata in 3.2 %. There was an average symptom reduction from 7.1 to 3.2 in the middle of treatment and to 1.2 and 0.4 units at the end of treatment and follow-up, respectively. The treatment evaluation at the end of the follow-up period showed a total clinical and mycological cure in 88.8 %, improvement in 3.7 %, and failure in 7.4 %. There was side effect (3.7 %) of skin irritation, but the drug was not discontinued. Conclusions Based on its safety and effectiveness, sertaconazole cream may be considered a new alternative for DDC treatment.
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Affiliation(s)
- Alexandro Bonifaz
- Department of Mycology, Hospital General de México OD, Mexico, DF, Mexico.
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Gunes T, Akin MA, Sarici D, Hallac K, Kurtoglu S, Hashimoto T. Guaiazulene: a new treatment option for recalcitrant diaper dermatitis in NICU patients. J Matern Fetal Neonatal Med 2012; 26:197-200. [PMID: 22928495 DOI: 10.3109/14767058.2012.722711] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIM Based on a maternal observation, we aimed to evaluate the treatment effectiveness of guaiazulene (GA) containing local pomade in the high-risk neonates with recalcitrant diaper dermatitis (RDD). METHODS We included 30 NICU patients of RDD, with level II-III aged between 22 and 67 days. Study group patients (n = 20) were treated with GA containing local pomade (0.05 g/100 g). Control group consisted of patients who had extended antifungal treatment. A visual scale was used to assess the response to treatment at the end of a week. Scoring was done at the beginning of the treatment, on the first, third and seventh days. RESULTS Statistically significant differences in visual scores were determined between the two groups at the initial and following days of the treatment. In study group, improvements at the first and third days of the treatment were better than those of control group. Additionally, complete recovery rate in study group was better than that in controls. CONCLUSION Having beneficial but no adverse effects, GA containing local pomade provided rapid recovery in risky neonates with RDD, who required rapid improvement.
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Affiliation(s)
- Tamer Gunes
- Faculty of Medicine, Department of Pediatrics, Division of Neonatology, Erciyes University, Kayseri, Turkey
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El-Hodhod MAA, Hamdy AM, El-Deeb MT, Elmaraghy MO. Cow's Milk Allergy Is a Major Contributor in Recurrent Perianal Dermatitis of Infants. ISRN PEDIATRICS 2012; 2012:408769. [PMID: 22988522 PMCID: PMC3439954 DOI: 10.5402/2012/408769] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/12/2012] [Accepted: 08/01/2012] [Indexed: 11/23/2022]
Abstract
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.
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Panahi Y, Sharif MR, Sharif A, Beiraghdar F, Zahiri Z, Amirchoopani G, Marzony ET, Sahebkar A. A randomized comparative trial on the therapeutic efficacy of topical aloe vera and Calendula officinalis on diaper dermatitis in children. ScientificWorldJournal 2012; 2012:810234. [PMID: 22606064 PMCID: PMC3346674 DOI: 10.1100/2012/810234] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 11/21/2011] [Indexed: 11/17/2022] Open
Abstract
Introduction. Diaper dermatitis (DD) is a common inflammatory disorder among children and infants. The objective of the present randomized and double-blind trial was to compare the therapeutic efficacies of Aloe vera cream and Calendula officinalis ointment on the frequency and severity of DD in children. Methods. Sixty-six infants with DD (aged < 3 years) were randomized to receive either Aloe cream (n = 32) or Calendula ointment (n = 34). Infants were treated with these drugs 3 times a day for 10 days. The severity of dermatitis was graded at baseline as well as at the end of trial using a 5-point scale. The adverse effects of study medications were assessed during the trial. Results. Although improvement in the severity of DD was observed in both treatment groups (P < 0.001), patients receiving Calendula ointment had significantly fewer rash sites compared to Aloe group (P = 0.001). No adverse effect was reported from either of the medications. Discussion. The evidence from this study suggests that topical Aloe and in particular Calendula could serve as safe and effective treatment for the treatment of diaper dermatitis in infants.
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Affiliation(s)
- Yunes Panahi
- Chemical Injuries Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.
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Hoeger PH, Stark S, Jost G. Efficacy and safety of two different antifungal pastes in infants with diaper dermatitis: a randomized, controlled study. J Eur Acad Dermatol Venereol 2010; 24:1094-8. [PMID: 20553355 DOI: 10.1111/j.1468-3083.2010.03735.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Diaper dermatitis (DD) is the most common type of irritative dermatitis in infancy. It is frequently complicated by Candida superinfection. OBJECTIVE Comparison of efficacy and safety of two antifungal pastes (Imazol = 1% clotrimazole; Multilind = 100,000 IU nystatin/g + 20% zinc oxide) in infants with DD. METHODS A total of 96 infants were included in this multi-centre, controlled, randomized, evaluator-blinded phase IV trial and treated with pastes containing either clotrimazole (n = 45) or nystatin (n = 46) twice daily for 14 days. In all, 91 children (age 12.1 +/- 5.3 months; 48 females) with DD were evaluable. Total symptom score after 7 days (TSS7) was assessed as primary parameter. Secondary efficacy parameters were TSS at 14 days (TSS14), clinical and microbiological cure rates and global assessment (GA) of clinical response. RESULTS TSS improved markedly with both pastes. Decreases in symptom score were 4.5 +/- 2.1 (day 7) and 6.1 +/- 1.9 (day 14) with clotrimazole compared with 4.2 +/- 2.3 and 5.4 +/- 2.4 with nystatin (P < 0.0001). With respect to TSS14, clotrimazole was superior to nystatin (P = 0.0434). Clinical cure rate was higher with clotrimazole [36.2% (day 7) and 68.1% (day 14)] compared with 28.6% and 46.9% (nystatin). GA was very good in 26 (55.3%) clotrimazole-treated children (nystatin: 16 [32.7%], P = 0.0257). Frequency of adverse events was comparable in both treatment groups. CONCLUSION Clotrimazole was superior to nystatin with respect to reduction in symptom score and GA. Microbiological cure rate was 100% for both agents. Both treatments were safe and well-tolerated.
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Affiliation(s)
- P H Hoeger
- Department of Paediatric Dermatology, Catholic Children's Hospital Wilhelmstift, Hamburg, Germany.
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Heath C, Desai N, Silverberg NB. Recent microbiological shifts in perianal bacterial dermatitis: Staphylococcus aureus predominance. Pediatr Dermatol 2009; 26:696-700. [PMID: 20199443 DOI: 10.1111/j.1525-1470.2009.01015.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Traditionally, bacterial infections of the anal skin have been found to be caused by Streptococcus. The aim of this study was to determine the breakdown of bacterial isolates and the current presentation of bacterial diseases involving the perineum. From the chart review of children who had bacterial cultures of the anus from 2005 to 2008 in a pediatric dermatology practice population in New York City, 26 pediatric patients (ages 5 months to 12 yrs) who had the indications of anal erythema or recurrent buttocks dermatitis were identified. Bacterial cultures of 17 patients grew pathogens, that of 14 (82% of identifiably infected patients) grew Staphylococcus aureus, in 11 as a solo pathogen (6 MSSA and 5 MRSA in 2 family clusters). Streptococcus was identified in three patients, two on culture and one on latex agglutination test; and two patients were identified as having both group A beta hemolytic Streptococcus and Staphylococcus aureus (2 MSSA and 1 MRSA). In patients with S. aureus perianally, concurrent small papules and pustules of the buttocks or extension of the erythema to adjacent buttock skin was the primary clinical feature distinguishing this condition from isolated streptococcal disease. Whereas Streptococcal infections of the anus and buttocks occur commonly, Staphylococcus aureus has become the leading cause of anal bacterial infection in the setting of skin involvement; therefore, antibacterial therapy for anal and buttock bacterial infections should be tailored accordingly.
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Affiliation(s)
- Candrice Heath
- Department of Dermatology, St. Luke's-Roosevelt Hospital Center, New York, NY 10025, USA
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25
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Abstract
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.
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Affiliation(s)
- Marty O Visscher
- The Skin Sciences Institute, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
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Abstract
Though most dermatoses are not life-threatening, skin diseases play an important role in intensive care medicine. Skin findings in intensive care patients may reflect the underlying disease or be complications of intensive medical care. Most important are drug reactions, infections, bacterial toxin reactions, erythroderma, ANCA-positive vasculitides (such as Wegener granulomatosis) and bleeding disorders.
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Affiliation(s)
- Matthias Fischer
- Department of Dermatology and Venereology, HELIOS-Clinic Aue, Gartenstrasse 6, Aue, Germany.
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Abstract
Honey has been shown to have antibacterial activity against a variety of species of bacteria in vitro. Although the evidence regarding the use of honey for wound treatment in neonates and infants is interesting, it is not strong. The sample sizes in the cited clinical studies are small; there were no comparison groups and no randomization. It appears that honey may be safe and useful in treating difficult-to-heal infected wounds, but double-blinded randomized controlled clinical trials with sufficient power are needed to determine the efficacy of honey in both initial wound management and secondary treatment of infected and poorly healing wounds. A comparison of different types of honey would be an important component of these trials. Currently, there is not enough evidence to recommend one type of honey over another type; however, honey and wound care experts do recommend honey for wound care, not for consumption.
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Affiliation(s)
- Linda S Nield
- West Virginia University School of Medicine, Morgantown, West Virginia, USA
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Abstract
Skin, as the outermost organ in the human body, continuously confronts the external environment and serves as a primary defense system. The protective functions of skin include UV-protection, anti-oxidant and antimicrobial functions. In addition to these protections, skin also acts as a sensory organ and the primary regulator of body temperature. Within these important functions, the epidermal permeability barrier, which controls the transcutaneous movement of water and other electrolytes, is probably the most important. This permeability barrier resides in the stratum corneum, a resilient layer composed of corneocytes and stratum corneum intercellular lipids. Since the first realization of the structural and biochemical diversities involved in the stratum corneum, a tremendous amount of work has been performed to elucidate its roles and functions in the skin, and in humans in general. The perturbation of the epidermal permeability barrier, previously speculated to be just a symptom involved in skin diseases, is currently considered to be a primary pathophysiologic factor for many skin diseases. In addition, much of the evidence provides support for the idea that various protective functions in the skin are closely related or even co-regulated. In this review, the recent achievements of skin researchers focusing on the functions of the epidermal permeability barrier and their importance in skin disease, such as atopic dermatitis and psoriasis, are introduced.
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Affiliation(s)
- Seung Hun Lee
- Department of Dermatology, Yonsei University College of Medicine, Kangnam-gu, Seoul 135-720, Korea.
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Abstract
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.
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Affiliation(s)
- Helen T Shin
- Pediatric Dermatology, The Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, Hackensack, NJ, USA.
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Al-Waili NS. Clinical and mycological benefits of topical application of honey, olive oil and beeswax in diaper dermatitis. Clin Microbiol Infect 2005; 11:160-3. [PMID: 15679495 DOI: 10.1111/j.1469-0691.2004.01013.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Twelve infants suffering from diaper dermatitis were treated four times daily for 7 days with a mixture containing honey, olive oil and beeswax. The severity of erythema was evaluated on a five-point scale. Three infants had severe erythema and ulceration, four had moderate erythema, and five had moderate erythema with maceration. The initial mean lesion score of 2.91 +/- 0.79 declined significantly (p < 0.05) to 2.0 +/- 0.98 (day 3), 1.25 +/- 0.96 (day 5) and 0.66 +/- 0.98 (day 7). Candida albicans was isolated initially from four patients, but from only two patients after treatment. This topical treatment was safe and well-tolerated, and demonstrated clinical and mycological benefits in the treatment of diaper dermatitis.
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Affiliation(s)
- N S Al-Waili
- Dubai Specialized Medical Center, Islamic Establishment for Education, Dubai, United Arab Emirates.
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Abstract
Eruptions in the diaper area are the most common dermatologic problem in infancy. Such eruptions can be subdivided into primary diaper dermatitis, an acute inflammation of the skin in the diaper area with an ill-defined and multifactorial etiology, and secondary diaper dermatitis, a term which encompasses eruptions in the diaper area with defined etiologies. The most important factors in the development of primary diaper dermatitis are: (i) water/moisture, (ii) friction, (iii) urine, (iv) feces, and (v) microorganisms (sometimes). Possible treatments include minimizing diaper use and using disposable diapers, barrier creams, mild topical cortisones, and antifungal agents. A variety of other inflammatory and infectious processes can occur in the diaper area and an awareness of these secondary types of diaper dermatitis aids in the accurate diagnosis and treatment of patients.
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Affiliation(s)
- Noah Scheinfeld
- Department of Dermatology, St Lukes Roosevelt Hospital Center, New York 10025, USA.
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Nguyen MH, Cheng S, Clancy CJ. Assessment of Candida albicans genes expressed during infections as a tool to understand pathogenesis. Med Mycol 2004; 42:293-304. [PMID: 15473353 DOI: 10.1080/13693780410001722485] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Candida albicans is the most common fungal opportunistic pathogen of humans and causes mucocutaneous, bloodstream and deep organ infections. Screening for C. albicans genes that are preferentially expressed within infected hosts represents a strategy to identify novel virulence factors and define global expression patterns relevant to pathogenesis. Until recently, C. albicans has not been amenable to screening using existing technologies. This has begun to change with the development of new molecular genetic tools and the sequencing of the C. albicans genome. In this paper, we review studies using recently developed techniques to identify genes expressed by C. albicans during infections, as well as work from our laboratory using a human antibody-based strategy. Along with others, we have shown that selected in vivo expressed genes encode known and previously unrecognized candidal virulence factors. Future studies in this area will identify additional novel virulence factors, as well as advance our understanding of pathogenesis.
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Affiliation(s)
- M Hong Nguyen
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL 32610, USA
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, Sunnybrook and Women's College Health Sciences Center Sunnybrook site, London, Ontario, Canada.
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Fluhr JW, Mao-Qiang M, Brown BE, Hachem JP, Moskowitz DG, Demerjian M, Haftek M, Serre G, Crumrine D, Mauro TM, Elias PM, Feingold KR. Functional Consequences of a Neutral pH in Neonatal Rat Stratum Corneum. J Invest Dermatol 2004; 123:140-51. [PMID: 15191554 DOI: 10.1111/j.0022-202x.2004.22726.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
At birth, neonatal stratum corneum (SC) pH is close to neutral but acidifies with maturation, which can be ascribed, in part, to secretory phospholipase A(2) and sodium/hydrogen antiporter 1 (NHE1) activities. Here we assessed the functional consequences of a neutral SC pH in a newborn rat model. While basal transepidermal water loss rates are near normal, barrier recovery (BR) rates after acute barrier disruption were delayed in newborn animals. The abnormality in barrier homeostasis could be improved by topical applications of an acidic buffer, indicating that barrier abnormality is primarily due to high SC pH. The delay in BR correlated with incompletely processed lamellar membranes and decreased activity of beta-glucocerebrosidase. Inhibition of NHE1 delayed BR after acute barrier perturbation. SC integrity was abnormal in newborn animals. Electron microscopy demonstrated decreased corneodesmosomes (CD) in newborn animals with decreased expression of desmoglein 1 and corneodesmosin. Serine protease activation appears to be responsible for CD degradation in newborn animals, because serine protease activity is increased in the SC and it can be reduced by acidification of the SC. The delay in acidification of neonatal SC results in abnormalities in permeability barrier homeostasis and SC integrity and are likely due to pH-induced modulations in enzyme activity.
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Affiliation(s)
- Joachim W Fluhr
- Dermatology and Medical Service, Veterans Affairs Medical Center, San Francisco, California 94121, USA.
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ZINC-BASED BARRIER CREAM FOR TREATMENT OF DIAPER DERMATITIS IN HOSPITALIZED INFANTS. J Wound Ostomy Continence Nurs 2004. [DOI: 10.1097/00152192-200405001-00065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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