What to consider with severe or persistent diaper rash


Most diaper rash requires strict hygiene and over-the-counter barrier creams. When dealing with more severe cases, there are a number of diagnoses and treatments to consider.

Moderate to severe diaper dermatitis affects nearly 9% of infants in the first year of their life.1 Commonly known as diaper rash, these reactions are typically caused by some type of contact irritant, but there are a number of differential diagnoses that could also increase the severity of these rashes.2

Bernard A. Cohen, MD, a professor of pediatric dermatology at the Johns Hopkins School of Medicine and director of the Johns Hopkins University Pediatric Dermatology and Cutaneous Laser Center, in Baltimore, Maryland, said contact dermatitis is the most common cause of diaper rash. Infants spend almost every minute of their day in diapers, and near-constant exposure to urine, stool, and general moisture can irritate the delicate skin in the perianal and genital areas.

Although many cases of diaper rash can be treated simply with strict hygiene and over-the-counter barrier creams, there are some red flags that pediatricians should consider that may signal a more severe problem.

What’s the cause?

First, pediatricians need to determine the type of diaper rash. Contact dermatitis tends to appear mostly on skin prominences, whereas irritations caused by bacteria or yeasts tend to settle into the folds of the groin, Cohen said. The development of blisters or pustules are a sign that you probably aren’t seeing a simple case of contact dermatitis. These symptoms usually point to infections like herpes simplex or enterovirus.

Pediatricians must also consider whether other dermatological conditions are playing a role. Psoriasis and lichen sclerosus are 2 conditions that can affect the skin of infants in the diaper area. Psoriasis in particular may be considered if there a child is experiencing diaper dermatitis that just doesn’t seem to clear with the usual remedies.

When weeping or blistering papules appear, a culture may be helpful, Cohen added. Skin biopsies are also a good diagnostic tool when it comes to conditions like psoriasis and lichen sclerosus, according to Cohen.

When fever develops alongside dermatitis in the diaper area, treatment may have to be stepped up.

“If a child presents with fever, especially under 2 months of age and it looks like the source is in the diaper area, we’re looking at sepsis,” Cohen warned.

Cultures should be taken, and intravenous antibiotics are usually started to help keep the infection from getting out of control. Severe infections and irritations can lead to the formation of abscesses and other problems that could require surgical intervention like debridement or other therapies. However, early recognition is key because these treatments usually can’t begin until sepsis is resolved or the infection is brought under some sort of control, he said.

Fever is a key symptom when it comes to uncovering the cause of severe diaper rash, Cohen continued. Infants whose severe irritation develops from an underlying dermatological condition wouldn’t usually have a fever. Fever is more common in viral infections, and Cohen warned that pediatricians need to keep viral diseases like herpes simplex in mind when looking at infectious causes.

“Herpes simplex is important to recognize and treat early to prevent more severe ill ness,” Cohen added.

Other considerations for atypical rash causes may include nutritional deficiencies like cystic fibrosis. Diseases that result in malabsorption or malnutrition—especially of nutrients like zinc—can cause erosions in the skin creases of the diaper area, Cohen said. Other diseases that could lead to skin blistering include rare immunobullous diseases like epidermolysis bullosa. Clinicians should also rule out structural malformations in the genitourinary tract that could cause chronic urine leakage, Cohen said.

Treatment options

Although antibiotics are the treatment of choice for infectious causes of severe diaper rash, treatments for skin conditions that can lead to severe diaper rash vary, especially when it comes to broader dermatologic issues like psoriasis, Cohen explained. Topical steroids may be used to help treat a rash caused by psoriasis, but many typical psoriasis treatments are limited for use in children. Examples include calcipotriol and tacrolimus. Calcipotriol is a synthetic form of vitamin D that can help regulate skin growth. Although it has been approved by the US Food and Drug Administration to treat psoriasis in adults, it’s usually used off-label—if at all–in children and infants. Tacrolimus is another possible off-label choice, he said. This immunosuppressive medication is used to treat skin conditions like eczema, and has been approved for use in children, but not very young infants. Tacrolimus may also be an off-label option as a non-steroidal agent to help control psoriasis in the diaper area, Cohen added. Other new topical agents, like Janus kinase inhibitors, are on the horizon and offer additional options but, again, these would have be used off-label in infants for the most part.3


1. Carr A, DeWitt T, Cork M, et al. Diaper dermatitis prevalence and severity: Global perspective on the impact of caregiver behavior. Pediatr Dermatol. 2019;37(1):130-136. doi:10.1111/pde.14047

2. Cohen B. Differential diagnosis of diaper dermatitis. Clin Pediatr (Phila). 2017;56(5_suppl):16S-22S. doi:10.1177/0009922817706982

3. Damsky W, King B. JAK inhibitors in dermatology: the promise of a new drug class. J Am Acad Dermatol. 2017;76(4):736-744. doi:10.1016/j.jaad.2016.12.005

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