Recent advances in diaper dermatitis: etiology and treatment

Emerging Links between Microbiome Composition and Skin Immunology in Diaper Dermatitis: A Narrative Review

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.

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.

Prevention Strategies for Neonatal Skin Injury in the NICU

PURPOSE

The purpose of this article was to determine specific skin injury prevention interventions for neonates in the NICU.

DESIGN

The design was a systematic review.

SAMPLE

PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase, and Scopus were systematically searched to identify quantitative studies identifying skin injury preventions for neonates in the NICU.

OUTCOMES

The outcomes included skin integrity or skin condition.

RESULTS

Nineteen studies were included in the review. Twelve studies included a randomized design. Barriers were the main interventions for the prevention of pressure injury, medical adhesive skin injury, diaper dermatitis, and general skin condition. The types of barriers included hydrocolloids, polyurethane-based dressings, film-forming skin protectant, or emollients. Nonbarrier interventions included rotation between a mask and nasal continuous positive airway pressure (NCPAP) interfaces, utilization of prescribed guidelines to decrease pressure injuries, and use of a lower concentration of chlorhexidine gluconate as a disinfectant.

An Integrative Review of Clinical Characteristics of Infants With Diaper Dermatitis

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.

Neonatal Opioid Withdrawal Syndrome: A Developmental Care Approach

Tens of thousands of infants are impacted yearly by prenatal opioid exposure. The term neonatal opioid withdrawal syndrome (NOWS) is now replacing the more familiar term neonatal abstinence syndrome (NAS). Ongoing debate continues related to standard regimens for treatment of this oftentimes perplexing condition. Historically, treatment has focused on pharmacologic interventions. However, there is limited research that points to nonpharmacologic methods of treatment as viable options, whether alone or in addition to pharmacologic interventions. This article, utilizing a review of pertinent literature, outlines the physical aspects of NOWS, including its pathophysiology and the resulting physical clinical signs. In addition, we present an overview of how age-appropriate, nonpharmacologic interventions, centered on developmental care, may be a valuable approach to organize and prioritize routine care for these infants, their families, and the health care team facing the challenges of NOWS. Finally, the need for further research to better define evidence-based standards of care for these infants and their families is discussed.

Prevention and Management of Incontinence-Associated Dermatitis in the Pediatric Population: An Integrative Review

An integrative review was conducted to synthesize evidence on prevention and management of incontinence-associated dermatitis (IAD) in the pediatric population. A 5-step integrative process was used to guide the review. Articles published from January 2000 to April 6, 2017, were identified and retrieved from CINAHL, PubMed, ProQuest (MEDLINE), and Scopus; key terms were associated with IAD, pediatric, prevention, and management. Supplemental and manual searches were carried out to identify other relevant studies. The studies' findings were extracted and summarized in a table of evidence, with their quality evaluated using the Joanna Briggs Institute's Critical Appraisal Checklist. Sixteen articles were included in the review. Articles explored prevention and management strategies including skin cleansing technique, diaper selection, and the application of topical skin care products. Inconsistent and limited evidence was found regarding the benefits of using disposable wipes in preference to water-moistened washcloths in the cleansing process and on the use of superabsorbent polymer diapers with breathable outer lining in IAD prevention. Findings were inconclusive with regard to the best topical skin care product for IAD care. However, the application of skin protectants was encouraged by the authors, as well as promoted in various clinical guidelines. The development of a structured skin care regimen supplemented by a comprehensive patient education program was advised to enhance the prevention and management of IAD.

Benefits of Using an Appropriately Formulated Wipe to Clean Diapered Skin of Preterm Infants

The skin of premature infants is underdeveloped rendering it more prone to break down and irritation. Therefore, special care is needed to protect premature skin and ensure it is not adversely affected. Many health care professionals advise using just water and cloth to clean diapered skin after a bowel movement despite evidence that shows improved infant skin health with the use of modern appropriately formulated baby wipes. This article describes the unique physiology of premature infant skin, reviews clinical evidence comparing use of baby wipes to water and cloth, and describes attributes of appropriately formulated baby wipes.

Applying Developmentally Supportive Principles to Diapering in the NICU: What We Know

Developmental care measures are integrated in the NICU, but these measures are largely overlooked when it comes to standard care activities such as diapering. This general review of developmental care in the NICU discusses how caregivers can apply appropriate, individualized developmental care measures to diapering regimens. Numerous opportunities to expand developmental care measures into diapering care are identified; these opportunities can protect and promote sleep for hospitalized infants, enhance the diapering environment, minimize stress that infants may experience with diapering, improve infant skin health outcomes through use of evidence-based skin care practices, and foster family involvement during diapering care in the NICU. A developmental approach to diapering offers hospitalized infants regular opportunities to reach their neurodevelopmental potential.

Diaper Dermatitis: What Do We Do Next?

Diaper dermatitis is a major issue among hospitalized infants, leading to increased medical costs, pain, risk for infection, and distress among patients and caregivers. An evidence-based algorithm for prevention and treatment of diaper dermatitis was developed and introduced in a level IV neonatal intensive care unit (NICU). Two cases are discussed as examples of severe diaper dermatitis. The first case demonstrates the final case of severe diaper dermatitis since the introduction of the algorithm. The second case demonstrates a less severe, but equally frustrating, case of diaper dermatitis that occurred after the practice of using the algorithm was established. The need for consistency in the prevention and treatment of diaper dermatitis is paramount to providing quality care. There are a number of points within the bedside care regimen where breakdown in consistency occurs. The adherence to consistent and evidence-based treatment regimens has the potential to decrease the incidence and severity of diaper dermatitis in high-risk hospitalized infants. Initiation of an evidence-based algorithm to assist in the prevention and treatment of diaper dermatitis can be supported by data of the number of cases of diaper dermatitis collected before and after implementing the algorithm. The information can further assist in continued education and pursuance of investigation of other major skin injuries in NICU patients. The importance surrounding infant skin care and building awareness surrounding all of the facets of skin care in this vulnerable population demonstrate the benefits to quality outcomes and care.

Infant Skin Care Products: What Are the Issues?

BACKGROUND

Infant skin is susceptible to dryness and irritation from external factors, including topical skin care products not formulated for the infant's skin. This may increase the risk of contact dermatitis. Parents frequently express concern regarding potential harm from ingredients in skin care products and seek information. This is complicated by several skin care myths.

PURPOSE

The purpose of this literature review was to provide evidence-based information to educate parents on the use of products for preterm and term infants.

SEARCH STRATEGY

Multiple searches using PubMed were conducted including the search terms "infant skin care," "infant products," "infant bath," "emollients," "diaper skin care," and "diaper wipes." Reference lists of comprehensive reviews were also scanned. Google searches were used to assess consumer information, product information, and regulatory guidelines.

FINDINGS

There is little scientific evidence to support safety of natural/organic products on infant skin. Raw materials originate from different sources, complicating testing and comparisons of ingredients. Research shows that cleansers formulated for infant skin do not weaken the skin barrier the way harsher soaps and detergents can. Oils with the lowest oleic acid content provide a lower risk of irritant contact dermatitis.

IMPLICATIONS FOR PRACTICE

Nurses must be informed about natural and organic products, preservatives, and fragrances and know the definition of commonly used marketing terms.

IMPLICATIONS FOR RESEARCH

Decisions regarding the use of infant products in preterm and term infants should be evidence based. More research is needed to support claims regarding the safety of products used on infant skin.

Mathematical analysis of dermal absorption rate of heavy metals

Presently 90 - 95% of children in the US wear disposable diapers before completing their toilet training at average age of 30 months. The diaper absorbs urine and liquid component from feces contaminated with excreted toxicants. In this initial study, we posit that the long contact between the diaper and the skin leads to increased dermal reabsorption of excreted body toxicants, mainly heavy metals, which are statistically associated with autism and neurodevelopmental disorder. We developed a mathematical model to analyse the increase of the level of toxicants due to dermal reabsorption after excretion. This simple kinetic model gives us the average reabsorbtion factor in the range of 1.6 to 5. The limitation of this work is that only mathematical model has been considered and it has not been verified experimentally.

Newborn infant skin: physiology, development, and care

Infant skin is critical to the newborn child's transition from the womb environment to the journey to self-sufficiency. This review provides an integrative perspective on the skin development in full term and premature infants. There is a particular focus on the role of vernix caseosa and on the implications of skin development for epidermal penetration of exogenous compounds. Healthy full-term newborn skin is well-developed and functional at birth, with a thick epidermis and well-formed stratum corneum (SC) layers. Transepidermal water loss is very low at birth, equal to, or lower than adults, indicating a highly effective skin barrier. Vernix facilitates SC development in full-term infants through a variety of mechanisms including physical protection from amniotic fluid and enzymes, antimicrobial effects, skin surface pH lowering, provision of lipids, and hydration. Premature infants, particularly those of very low birth weight, have a poor skin barrier with few cornified layers and deficient dermal proteins. They are at increased risk for skin damage, increased permeability to exogenous agents and infection. The SC barrier develops rapidly after birth but complete maturation requires weeks to months. The best methods for caring for infant skin, particularly in the diaper region, are described and related to these developmental changes.

Prevention of diaper dermatitis in infants--a literature review

Diaper dermatitis (DD) is one of the most common skin conditions in neonates and infants, with a peak between the ages of 9 and 12 months. Appropriate skin care practices that support skin barrier function and protect the buttocks skin from urine and feces are supposed to be effective in the prevention of DD. Despite many recommendations for parents and caregivers on proper diaper skin care, there is no up-to-date synthesis of the available evidence to develop recommendations for DD prevention practice. Therefore we performed a systematic literature review on the efficacy of nonmedical skin care practices on the diapered area of healthy, full-term infants ages 0 to 24 months. We identified 13 studies covering skin care practices such as cleansing, bathing, and application of topical products. DD prevalence and incidence and physiologic skin parameters were used as efficacy parameters. The results of this review indicate that cleansing of the diaper area using baby wipes or water and a washcloth have comparable effects on diapered skin. Bathing with a liquid baby cleanser twice weekly seems comparable with water alone. The application of ointments containing zinc oxide or petrolatum with or without vitamin A seems to have comparable effects on DD severity. There seems to be no information on whether single skin care practices such as cleansing, bathing, and application of topical preparations can prevent DD. High-quality randomized clinical trials are needed to show the effectiveness of skin care practices for controlling and preventing DD.

Diaper dermatitis: a survey of risk factors for children aged 1-24 months in China

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.