Nappy dermatitis is one of the common dermatoses of infancy and early childhood. It is characterised by skin lesions and general symptoms, which in the vast majority of cases allow the diagnosis to be established. The general symptoms observed and reported by parents include the child's restlessness, irritability and excessive crying, which increase especially during nappy changes, washing or wiping of the nappy area. Nappy dermatitis is rarely accompanied by pruritus. In cases complicated by local and generalised bacterial or fungal infection, fever and deterioration of the general condition may occur [5,10,14,15].
Diagnosis of nappy rash is based on the finding of skin lesions that appear in the child's nappy area. In most cases, the clinical picture is characteristic of this disease. Sometimes, however, the diagnosis is difficult and requires differentiation with such conditions as: atopic dermatitis, juvenile seborrhoeic dermatitis, candidiasis, mycosis fungoides, psoriasis, allergic contact dermatitis or diaper rash [3,5,7,10,11,17]. The first symptoms of nappy rash are erythema and scaling of the skin in areas covered by the nappy (buttocks, groin, genital area, lower abdomen, sometimes the inner surface of the thighs and sacral area). If irritants are prolonged, papules, vesicles, erosions and signs of secondary infection appear on the skin. Lesions in nappy rash can be sparse, limited to a small area, or severe, covering an extensive area. They usually respond well to treatment consisting of the removal of the skin irritant and the application of good hygiene of the nappy area.
In addition to the typical localisation of the skin lesions, anamnesis regarding the peri-occurrence of the lesions, the child's care regime, characteristics of the child's cosmetics and washing products, frequency of nappy changes, the child's diet, quantity and quality of stools, use of antibiotics both in the child and in the breastfeeding mother is helpful in making the diagnosis [2,3,6,7,10,13,14,16,17].
Atopic dermatitis is also a common condition among children, occurring with a similar frequency to nappy rash, but lesions in infancy rarely appear before 3 months of age and mainly occupy the central cheeks, hairy scalp, upright surfaces of the limbs and trunk. Exudative papules are the characteristic lesion, the lesions do not occupy the axillae and the skin of the nappy area usually remains lesion-free. Atopic dermatitis is characterised by severe pruritus, which increases the child's discomfort and is a cause of great distress [3,7,10,11].
Eczema pilaris is most common in children with atopy and in most cases the diagnosis is clear. Difficulties may arise when the characteristic small papular and vesicular coin-shaped lesions form clustered foci. The lesions usually occur on the arms, lower limbs and trunk and are accompanied by pruritus [3].
Seborrhoeic dermatitis is the most common chronic dermatosis in infants and may appear in the first days or weeks of a child's life. The skin lesions are located on the scalp, face, neck, preauricular and retroauricular areas, skin folds, around the umbilicus and in the nappy area. In addition to erythematous lesions, thick, oily, strongly adherent yellowish scales are characteristic [3,4,5,7,10,11,17].
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photo: Sudocrem
Allergic contact dermatitis rarely affects the nappy area and more often affects children with a positive personal or family history of allergy. Skin lesions appear one week after the first contact with the allergen and within one hour after the next exposure [5]. The most common agents are cosmetics, detergents, dyed clothes, powders and fabric softeners. Erythematous lesions and papular eruptions occur in areas exposed to a particular allergen or over the whole skin in the case of a secondary reaction caused by generalised hypersensitivity. In the differential diagnosis, epidermal patch tests are performed to confirm contact allergy [5].
