Is it diaper rash or is it atopic dermatitis?

Irritated skin in the diaper area may make parents first think of diaper rash, but atopic dermatitis is another possible condition. Knowing the triggers can help determine the correct diagnosis.

When it comes to irritation in an infant’s diaper area, it’s common for parents to jump to a diagnosis of diaper rash, but what if it’s not?

Atopic dermatitis, or eczema, affects more than 25% of infants.1 Sixty percent of people who have the condition in adulthood developed it during their first year of life.1 Eczema usually develops because of allergens, irritants, and other triggers. Although there is no cure, triggers can be avoided. Knowing these triggers, though, and how eczema presents is key to making the right diagnosis.

Bernard A. Cohen, MD, professor of dermatology and pediatrics at Johns Hopkins School of Medicine and director of the Johns Hopkins University Pediatric Dermatology and Cutaneous Laser Center as well as section editor of Dermcase in Contemporary Pediatrics, said eczema and diaper rash are often confused with one another, but the presentation and causes of these 2 skin conditions set them apart.

“Atopic dermatitis doesn’t usually affect the diaper area until after a child is toilet trained,” Cohen said, explaining that irritation and dryness are common triggers for eczema whereas diaper rash results from skin that stays wet with things like urine and feces.

“In younger children, these areas are protected and they don’t get dry and irritated,” he said.

Diaper rash develops from contact irritants and usually doesn’t appear in the creases of the skin but focuses instead on more prominent areas, he added.

Clinicians can help parents make the right call when it comes to identifying and treating diaper rash versus eczema by providing them with examples of how different skin irritations look and how they appear. A 2018 paper published in Pediatric Dermatology offers a good start to making a differential diagnosis.2

Questions to ask parents and caregivers include:

  • How long has the irritation lasted?
  • Which areas are involved?
  • Are there other signs of inflammation or irritation on other areas of the body, or is there a family history of conditions like eczema or psoriasis?
  • What types of wipes or cleansers are used during diapering?
  • What types of diapers or creams are used?
  • Have there been any medication or diet changes?
  • Does the irritation appear to cause pain or itching?

The paper also outlines common features of diaper rash versus atopic dermatitis and other common skin conditions in infants.

  1. Contact or allergic dermatitis: Erythema or papules on prominent surfaces
  2. Seborrheic dermatitis: Yellowish scales or redness in skin folds
  3. Atopic dermatitis: Eczematous lesions on the scalp, cheek, or extremities that sometimes spare the diaper area
  4. Psoriasis: Red or scaly plaques on prominent areas or in skin folds

Redness with papules that drain or widespread redness can also indicate infection or even autoimmune skin conditions like Lichen sclerosus or Kawasaki disease, according to the paper.

References

1. American Academy of Dermatology Association. How to Treat Eczema in Babies. Accessed October 5, 2021. https://www.aad.org/public/diseases/eczema/childhood/treating/treat-babies

2.Fölster-Holst R. Differential diagnosis of diaper dermatitis.Pediatric Dermatology. 2018;35(S1):s10-s18. doi: 10.1111/pde.13484