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Neonatal Nursing Education Briefs

Evidence-Based Care of Diaper Dermatitis

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Purpose and Goal: CEARP# 1087

  • Describe an evidence-based approach to treating diaper dermatitis.
  • Identify specific strategies for specific causes of diaper dermatitis.

None of the planners, faculty or content specialists has any conflict of interest or will be presenting any off-label product use. This presentation has no commercial support or sponsorship, nor is it co-sponsored. 

Requirements for Successful Completion

  • Successfully complete the post-test.
  • Complete the evaluation form.

Date

  • June 2014–June 2016

Learning Objectives

  • Describe the etiology of diaper dermatitis.
  • Describe the signs and symptoms of diaper dermatitis.
  • Identify at least three approaches for the prevention and treatment of diaper dermatitis.

Introduction

  • Diaper dermatitis is an acute inflammatory reaction.
  • It is extremely common in infants.
    • Occurs in diapered infants of any age
    • Neonates are at greatest risk.
      • Preterm infants at highest risk
    • Also common in infants 9–12 months of age.
  • The etiology is multifactorial.

Etiology

  • The etiology includes:
    • Moisture
    • Warmth
    • Friction
    • Urine
    • Feces
  • Skin contact with urine and feces
    • Plays an integral role
    • Traps moisture against skin
    • Increases skin pH
    • Increases skin permeability
    • Activates fecal enzymes
    • Leads to loss of barrier protection
      • Increases skin breakdown
      • Encourages secondary skin infections

Signs and Symptoms

  • Generalized erythema
    • Irritated skin
    • Inflamed skin
  • Candida infection
    • Beefy red skin
    • Oval lesions scattered at edges
  • Skin breakdown
    • Excoriated skin
    • Denuded skin
  • Denuded skin
    • Moist skin
    • Open, oozing areas

Prevention Strategies

  • Intact skin without erythema
    • Prevent skin breakdown.
    • Use Vaseline or other petrolatum product .
      • Apply thick layer over entire area.
  • Intact skin of high-risk infants with or without erythema
    • Infants with increased stool output
    • Prevent skin breakdown.
    • Provide barrier protection.
    • Use Triple paste or Ilex then Vaseline.
      • Apply thick layer over entire area.

Treatment Strategies

  • Intact skin with erythema and no signs of candida
    • Prevent skin breakdown.
    • Provide barrier protection.
    • Use Desitin ointment.
      • Apply thick layer over entire area.
  • Intact skin with erythema and signs of candida
    • Prevent skin breakdown.
    • Treat candida infection.
    • Provide barrier protection.
    • Use an antifungal product then Desitin.
      • Apply thick layer of antifungal product.
      • Apply thick layer of Desitin over entire area.
  • Denuded skin without signs of candida
    • Prevent further skin breakdown. 
    • Provide barrier protection.
    • Use Stomadhesive powder then Triple paste.
      • Apply thin layer of Stomadhesive powder.
      • Brush off excess powder.
      • Apply thick layer of Triple paste.
    •  Use Stomadhesive powder then Ilex then Vaseline.
      • Apply thin layer of Stomadhesive powder.
      • Brush off excess powder.
      • Apply thick layer of llex then Vaseline.
    • Use one of the above plus crusting technique
  • Denuded skin with signs of candida
    • Prevent further skin breakdown.
    • Treat candida infection.
    • Provide barrier protection.
    • Use antifungal powder then Triple paste.
      • Apply thin layer of antifungal powder
      • Brush off excess powder.
      • Apply thick layer of Triple paste.
    • Use antifungal powder then Ilex then Vaseline.
      • Apply thin layer of antifungal powder.
      • Brush off excess powder.
      • Apply thick layer of Ilex then Vaseline.
    • Use one of the above plus crusting technique.

Ilex Paste

  • Press Ilex paste into place.
  • Do not spread onto skin.
  • Apply a thick layer of Vaseline on top of Ilex.
    • Prevents Ilex from sticking to diaper
    • Prevents further skin damage
  • With each diaper change:
    • Remove only stool.
    • Try to leave Ilex/Vaseline in place.
    • Replace only the product that comes off.
  • With each diaper change:
    • If skin is showing →  replace Ilex then Vaseline.
    • If Ilex is showing → replace Vaseline.

Crusting Technique

  • Cleanse denuded skin.
    • Use a gentle skin cleanser.
    • Use normal saline.
    • Use a blotting motion.
  • Allow skin to air dry.
  • Sprinkle thin layer of powder on denuded skin. 
    • Allow moisture from denuded skin to form a crust.
    • The crust will seal and protect denuded areas.
  • Repeat this process two to three times if skin is weeping.
  • Allow to dry for maximum skin protection.
  • After the powder is crusted → blot with NoSting barrier film.
    • NoSting barrier film may only be used in infants >28 days.
  • Cover entire area with thick layer of Triple paste or Ilex then Vaseline.

Summary

  • Diaper dermatitis is common.
    • It causes infant discomfort.
    • It causes caregiver stress.
  • Prevention is often possible.
  • Mixing of products has not been shown to be effective.
  • Thick layering provides an evidence-based approach.

References

  1. The Children’s Hospital of Philadelphia
  2. Heimall, L.M., Storey, B., Stellar, J.J. & Finn Davis, K. 2012. Beginning at the Bottom: Evidence-Based Care of Diaper Dermatitis. The Journal of Maternal/Child Health, 37 (1), p. 10-16.
  3. Association of Women’s Health, Obstetric and Neonatal Nurses. 2013. Neonatal Skin Care: Evidence-Based Clinical Practice Guideline.
  4. Neid, L.S. & Karnat, D. 2007. Prevention, diagnosis, and management of diaper dermatitis. Clinical Pediatrics, 46 (6), p. 480-486.

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