Welcome to the Don't Be Rash Pediatric Dermatology
Podcast, the owner's manual for your kid's skin.
I'm your host, Dr. K, board -certified pediatric
dermatologist and father of two boys. I'm here
to chat with you to promote dermatological education
and improve skin health in our children everywhere.
Let's get started. Welcome to Don't Be Rash,
the pediatric dermatology show coming to you
from beautiful, historic Bethlehem, Pennsylvania.
I'm your host and board -certified pediatric
dermatologist, Dr. Andrew Krakowski. On today's
show, we're going to get "down in the dumps.". That's
right, we're going to be discussing diaper rashes,
or as we call them in pediatric dermatology, more
generally,, "diaper dermatitis." Here's the clinical
scenario: You have a six -month-old baby with
a bright red rash and satellite pustules. Don't
worry, if you don't know what that is, you soon
will. Is this caused by irritation from the poop
and pee? Or is this yeast? Or is it a combination
of both? Helping me "get to the bottom" - so to
speak - is our guest pediatric dermatologist co
-host, Dr. Caroline Piggott. In addition to being
one of my best personal friends and colleagues,
Dr. Piggott is a pediatric dermatologist at Scripps
Clinic, in San Diego. Welcome, Dr. Piggott. Thanks
for joining me today to talk about a topic not
everyone would be so willing to try to tackle.
Thank you so much for having me. This is something
we encounter really often in clinic, a major
concern for families. So I think this is a great
topic to discuss. Yeah, it really is one of the
most common things that I see in my pediatric
dermatology clinic, which means if it got to
me, I can only imagine how many cases of diaper
rash our pediatrician and family medicine colleagues
are seeing before they refer those kids to us.
Is that fair? Oh, totally. And just as a mom
in general, it's a concern you have with any
baby and probably a lot of them don't even go
to the doctor. Yeah. And it's and it's such you
know, it's such an opportunity, I feel, for education...
You...you have a baby. No one. I mean, I've
had two of them. Right. So I've never had someone
come into the room before we were discharged
from the hospital to tell us. There's a right
way or a wrong way to take care of poop and pee
in the diaper area. And if you just got that
little bit of education, I think you'd be 100%
better off. Absolutely. And there's a lot of
misinformation online too. Even if you haven't
been taught about it, when you read about it
online, there's just so many different opinions.
It's hard to know where to begin. Yeah, it's
actually kind of scary because some of the stuff
is just wrong, so we'll get to that. Let's talk
a little bit about what makes the diaper area
such a unique environment. I mean, it's normal
skin, right? But there's some things that happen
in that specific environment under an occlusive
diaper that changes some things for us. Absolutely.
And we're the only species that uses a diaper,
really. The problem, there's a couple issues.
First, there's occlusion. You have moist environment
due to urine or stool. And then you have something
pressed right up against it that's rubbing against
it all day. Added on to that, there's sweat,
especially in kids who live in warm climates.
There's also all those things mixed together
make a perfect environment for a rash or irritation
to occur. Yeah. And on top of that, you're talking
about a newborn baby. So, you know, we know the
skin barrier on children is a little thinner
compared to our adults. In that particular area,
you're probably talking a higher pH, so not what
the normal skin is used to seeing. And everything
is a little leakier as well because of that thinner
skin barrier. And then you've got, you know,
obvious change or the obvious big difference
is you're pooping into. basically a bucket that's
held right up against the skin for at least a
couple of minutes right and you know to me when
I talk about it with my families they always
are amazed at why the skin can get so irritated
just from that and it's like well I don't know
how you approach that but I use the analogy or
not analogy it's really kind of a story like,..
Imagine you're a bite of food that gets taken
into the mouth goes down the esophagus in your
stomach. Now it's going through the intestinal
tract and finally it comes out the other end.
It had to have been digested. And what is it
getting digested by? Enzymes, chemicals that
are breaking down that food into something that
your body can then absorb into it for sustenance
and energy, right? Well, those enzymes are also
coming out the bottom end and landing right in
that diaper. And when you put that on the skin,
you can get into some real trouble. Yeah. And,
you know, we all have normal skin flora on our
skin, but stool also can carry with it certain
pathogens that like to live in that environment
that are then sitting against the skin for, you
know, minutes to hours. There's also, you know,
depending, especially when babies are a little
bit older or depending on what the mother is
eating in her diet, if the baby's breastfed,
different foods process differently and have
different pHs when they come out the other end.
Is it a spicier diet? Is it more bland of a diet?
Things like that even play a role. Yeah. And
then you get into even more specific clinical
scenarios where let's say you never had a problem
with diaper dermatitis, but now your baby or
young infant is suffering through like a gastroenteritis
where, hey, everything else is probably going
to be okay, but you're pooping 14 times in 24
hours. No matter what, that's going to cause
some sort of irritation. Exactly. Or a kid on
antibiotics. The antibiotics themselves can change
the pH of the poop or, you know, what's in the
poop and make it looser, more irritated. Or another
thing that can affect it is even if kids have
allergies, it changes their poop and then that
poop is then rubbing against the skin. Yeah.
So let's take more of a 50,000 -foot view look
at this, although I don't know if you want to
look at it any more than I do. But let's say
we're considering diaper rash in general. There's
a lot of specific causes for why a kid could
have diaper rash, right? Oh, absolutely. There's
about a dozen different things that are on our
what we call "differential diagnosis" - or things
that can potentially cause them. And one of the
key things to know about is some of the clues
to look for to figure out. which one it is. So
the one that kind of already put our foot in,
so to speak, is this idea that poop and pee itself
can irritate the skin. And we call that "Irritant
Diaper Dermatitis." That doesn't sound very specific,
but if you mention that to a pediatric dermatologist,
we know that what you're basically saying is
that the urine and feces itself is irritating
the skin. And I think we already alluded to the
fact that that's the most common cause, right?
Like, way more than anything else. Yeah. Yeah.
When in doubt, statistically speaking, that's
what is the most common cause. And what we typically
do when a baby presents is we look for first
some of the key visual clues to figure out what's
going on. And with this particular type of dermatitis
or irritant diaper dermatitis, It typically presents
as sort of a beefy red-colored rash or plaque.
Sometimes it might look a little shiny, not always
though. And one of the things, because if you
think about the anatomy and where the skin is
rubbing with the diaper, it typically is located,
you know, sort of in the pubic area, maybe on
the inner thigh, but because of where the diaper
rubs more and rubs less, it often spares the
actual very edge of the folds and the groin so in other
words there's a skip area where the rash often
you know it disappears and then then reforms
on the other edge passing sort of jumping from
the inner thigh skipping the fold and and then
moving over onto the pubic area. Basically the
"area under the chunk" is sort of protected is
that fair? Yes, it spares the folds. Spares the
folds, yeah. And that's a mechanical thing, right?
So, if the chunk wasn't there and that poop and
pee could get into that area, it would also cause
the same rash that you can see everywhere else.
But it's a clue that it's something that's right
up against the diaper, right up in contact, hence
the name "Irritant Contact Dermatitis." And is
this one like, this is one where I would say,
geez, when your history of recent antibiotic
use or upset. stomach causing diarrhea that's
where you really start to think about this one
as well. Exactly but you know it's not always
the case where there's a history of that some
babies you know one of the most common things
that pediatrician sees is parents you know calling
in with questions: Why did my baby's poop change?
You don't always have a reason. Sometimes it's
looser. Sometimes it's more foreign. Depends
on what the baby or mother is eating. And so
it's not always history of an infection or things
like that. Sometimes just the stool changes on
its own periodically. Now, within this category,
I also include something that's really much more
severe in my mind, something called Jacquet's
or Jacquet's erosive diaper dermatitis. Is that
fair? Yes, it's almost like it's basically a
fancy name for an extreme form of this. We see
it a lot in like premature babies who have really
thin skin or just cases where the stool is loose
just for longer periods of time just consistently.
The irritation becomes so bad that it actually
tears a little layer superficially of the skin
and the baby has these very painful ulcers. I
mean, imagine whether it's in your diaper or
not, if you have a little sore on your skin and
you rub a piece of material against it over and
over all day, anybody is going to have a sore
area. And the poor baby unfortunately suffers
from this. Yeah, it's very painful. It has to
be differentiated from something called "herpes
simplex virus," especially in a younger kid, two
weeks old. You have to make sure it's not herpes
before you think about anything, in fact. But
I don't know about you, but some clues that I
have is it tends to be worse. closer to the actual
anus. And then as you get farther and farther
away, it seems to kind of get a little better.
That sometimes can be a clue that it's this Jaquet's.
But yeah, it can be tremendously painful and
horrific looking. It would scare anybody, right?
Yeah. And I agree completely. One of the things
on your differential for those would be infection.
But usually these ulcers are very dry looking,
like they might be open and sore, but there's
no pus - or we call it purulence - coming out or
fluid. They're often just very just dry and raw.
So probably in my mind, at least the next most
common diaper dermatitis cause, specific cause,
would be yeast. And we call that... "Candidal,
Diaper Dermatitis." Candida is the species
name of the yeast in this particular case that's
driving the problem. Talk a little bit about
what you're looking for when you're considering
is yeast possibly the culprit. When you have
just the regular irritant diaper dermatitis,
yeast can eventually infect it. So this is always
something you want to look for on your differential.
And sort of the classic clue is we call them
"satellite pustules." So you'll have the rash,
but then there might be individual discrete bumps
or papules that have a little pus or fluid in
the center, almost white or off-white. And there
will be often a couple of them, that's why we
call them "satellites," often around the periphery.
And that's one of the clues. Often the color
is even more red than the typical rash. And oftentimes
you even smell a little bit of an odor. I'm not
getting that close because I don't want to smell
any odor. The mom will tell you it smells weird.
Okay, sure. And now this one, the satellite port,
do you attribute that to sort of the yeast organism
itself kind of getting on the skin and spreading
on its own, right? It can go outside of the normal
diaper spot. Yes. And the thing with this is
it does, we mentioned that the sort of conventional
diaper dermatitis will spare sometimes the folds.
Well, this one, this one does not spare anything.
It just keeps going and it'll continue even within
that fold of the skin. And I don't know, you
and I were trained at the same place, but I remember
Dr. Friedlander, one of our mentors, always telling
you, you got to check the mouth, right? Because
yeah, many times, like a lot. more than half
you're going to find oral thrush that white tongue
which is yeast on the tongue on that baby too.
And it makes sense you're swallowing that and
pooping it out into the diaper which again is
just really kind of a bucket now you've got that
yeast organism held in the bucket up against
the skin it's no surprise that it's taken off.
I agree. And then if you're not sure, we dermatologists
do a test called a KOH, which is we take a little
sample of the skin and look at it under the microscope.
But if you don't have access to that, it's okay.
There's another way to test it. The swab that
we use for a lot of our bacterial cultures can
also be used to take what's called a fungal culture.
And you just take a gentle Q-tip, swab it against
the skin, and you can actually have your lab
plate it on a Petri dish and look for yeast or
fungus or things. things like that. Within three
to five days, you got an answer. Yes. Yes. Although
I do, we typically leave it for yeast. We do
have to sometimes leave it a little bit longer.
But yes, so even if you don't have a microscope,
Worry not, That's another way to do it. And I
think your point that no matter what rash you're
talking about, within a certain amount of time,
you almost always get colonization where the
yeast is living on the skin. So you kind of have
to build that into any treatment plan for a rash
that's there more than a couple of days. Is that
fair? Correct. And not just yeast, but also you
have other organisms like Strep or Staph that
also can infect the area too. Talk a little bit
about sort of "cradle cap" in the diaper area.
So our term for that is "Seborrheic Dermatitis"
or "seborrhea." And so on the scalp, it'll present
with flaking, sort of like a greasy, scaly plaque
that often extends sort of onto the facial area
as well. But kids with this can also have the
same condition. in the diaper area. We like to
say a "salmon-colored" red as opposed to the beefy
red of the previous one. And this one will tend
to be a lot more scaly, a little bit greasier
in color. And the clue is often that you do have
rashes elsewhere on the body in these cases.
And it can look just like eczema or atopic dermatitis.
Correct. Correct. And so what, what, what's also
always helpful in a baby is not to just examine
their diaper area, but do an exam elsewhere on
the skin. Even sometimes parents don't even realize
it's elsewhere, but you can look in the, in the
folds of the armpit neck, look at the scalp behind
the ears, et cetera. And, you know, correct me
if I'm wrong, but in my mind, what I'm trying
to figure out is this seborrheic dermatitis versus
something else or eczema versus seborrheic dermatitis.
I'm thinking - relative to seborrheic dermatitis -
atopic dermatitis or eczema tends to spare, not
involve the diaper area as much. Is that fair
to say? I'm much more likely, if it looks like
eczema and it's in the diaper area, I'm leaning
towards seborrheic dermatitis. At the same time,
you can often have both. Yeah, right. They run
together. It can be really tricky. Let's talk
a little bit about "eczema/atopic dermatitis"
in the diaper area. What are some clues there?
Usually these are very, very dry patches. You
don't have as many pustules or greasy look. It's
just a dry. scaly, often scratched area. Sometimes
there's thickening of the skin from frequent
scratching. And the key with that is, you know,
you very rarely have isolated to the diaper as
well with eczema. You'll have clues elsewhere,
sort of in the antecubital popliteal fossa, there
will be rashes. The child might have a sibling
with eczema or atopic dermatitis. Or even the
child or siblings might have other conditions
in the atopic family. And when I say atopic family,
I mean things like asthma, hay fever, things
like that. Yeah, and classically, you are taught
that eczema does tend to spare the diaper area
because it's that occlusive, humid environment.
But to your point, if it's bad enough, it can
be in the diaper as well. One of the things that
I think I see... in the diaper area when it's
eczema more than other rashes is this sort of
thickening of the skin or lichenification, which
can be a clue that this is long-standing chronic
inflammation that's caused the skin to almost
thicken up in response to getting rubbed and
scratched as much as it has been. But that can
be pretty tricky, I think. And to make it even
trickier, they can also have a thick condition
in their diaper area called "psoriasis," which
can also manifest there. That's one of the, that
I stand by the fact that it took me longer to
be able to pull the trigger and make the diagnosis
of psoriasis in a kid. But now you're talking
baby. It's even more because in my head, I've
told, I've talked about this. I've had that in
my brain as an adult problem. And even in pediatric
dermatology fellowship, it was just hard for
me to say, "Geez, this is probably psoriasis."
Now I make the diagnosis a couple of times a
week and I'm comfortable with it, but it really
took me a long time to get comfortable saying
this is, this is probably psoriasis. What clues
are you looking for for something to be labeled
psoriasis? One of the first things I've noticed
is with the psoriasis kids is a lot of it extends
up onto the pubic area a lot more, a lot higher.
It typically has very sharp or we call it well
demarcated borders.. So with eczema, so basically
imagine you took a pen. With psoriasis, you
can literally take a perfect outline of the edge
of the lesion, usually, and tell where the skin
of psoriasis ends and the normal skin begins.
Whereas in eczema, we call it ill-defined. You
know, it's hard to, it almost melts into the
surrounding skin. Whereas, you know, really with
psoriasis, you can see a sharp outline. Yeah,
and psoriasis is unique, at least compared
to atopic dermatitis and seborrheic dermatitis
and irritant contact dermatitis, because it often
can do something called "koebnerize," which is wherever
there is friction or trauma to the skin. In this
case, it's the friction of the diaper rubbing
on the kid. You can actually see a totally perfect
match of rash to diaper. And it takes it right
up to the waistband, all the way down to the
waistbands, or I guess what you call them, leg
bands. And you can say, geez, that looks exactly
like where the diaper would be. Yeah, that's
exactly right. Absolutely. And two of my other
favorite clues for baby psoriasis especially
is looking in two other folds, armpit and groin.
So if there's another well demarcated plaque
elsewhere, that's really helpful. And then the
third most favorite area. uh sort of on the torso
is actually in the umbilical - the "bebo" - yep yep
on and then with psoriasis too that often not
always but often runs in families so does grandma
does mom dad have any history of psoriasis and
then the last thing that's always important to
check is Sometimes you can get ridging or little
dots we call pits in the fingernails or toenails.
But again, not all of these things are always
present. So that's why it's so hard to diagnose.
And to treat, right? I mean, they can all be
hard to treat, even irritant contact if the
poop and pee just keep coming, you're really
kind of behind the eight ball. But psoriasis,
I feel like that definitely requires longer treatment,
longer direct treatment than some of these other
conditions. Probably in part because of that
koebnerization phenomenon where if the rubbing
is still there, so is the skin condition. That's
just my take. I don't know. Absolutely. And often
prescription strength medicine is needed, whereas
many of these other things, especially if we're
talking steroids and things like that, stronger
medicine is needed for psoriasis, certainly.
Now, one thing that I don't feel is as common
as these other things that we just have been
talking about is a true allergy to the diaper,
right? For whatever reason, it seems the most
common question I get when I see patients with
diaper rashes from families, and I understand
why. "Is my child allergic to something we're
using?" Is it an allergy to the diaper? Is it
an allergy to the butt paste? Is it an allergy
to the wipes? Certainly these are possible, but
actually quite rare. Yeah, yeah. I mean, it makes
sense. You're putting a plastic sheet on your
kids - on your newborn baby's most sensitive skin
area. As a new mom or dad, I would certainly
understand why someone could think, geez, they
must be allergic to the plastic. But where it's
very common for older kids and adults to develop
allergies to the chemicals in their sneakers
or their gloves that they wear for their occupation,
it's pretty rare to have a kid with true allergy
to their diaper. thankfully. Yeah especially if
it's not the whole way around towards the back
on the bottom um and but but if it is going to
be an allergy some of the things that can do
it are is it a wipe that has a lot of fragrance?
Fragrances are never a good idea when you're
talking about baby wipes um. Does your diaper
rash cream have lavender in it or something extra
that you don't need? Those are some of the culprits
if there is going to be something. That's a great
point. And thankfully, we have the ability, even
in babies, to do what's called patch testing.
Do you have an age limit that you go down to
for patch testing? You know, we'll do it on babies,
but it's not my favorite thing to do. Just there's
not much room on the back to do testing. Right.
I mean, at may be a year or two. I would probably,
you know, I'm not doing it much younger than
that because the risk is you might sensitize
them also, right, with some of the testing products
that you're using. But I don't have a problem
if it's a one and a half year old and mom or
dad thinks that they're allergic to their diaper.
I mean, you can always just test for. the diaper
as a use test as well. Right. So you don't have
to do it. Correct. I'd rather do something like
that or, or, or do a trial and error of elimination.
Right. Right. Exactly. Does it get any better
when you don't wear this diaper or, or a different,
different kind? You have to be, if you're going
to switch out the diaper, then you have to make
sure you're completely switching it out so that
it's, if it was a plastic diaper before, maybe
you're going to an all cotton diaper instead,
or a, or even one of those washable cotton cloth.
napkins that they call, right? So try that for
a couple of weeks. Yeah, which unfortunately
rarely solves the problem, but can. One infection
that we see, not infrequently, I don't know about
you guys out in San Diego, but beefy red, right
around the sort of perirectal area, Strep. Strep
bacteria. Correct. And in these kids, it's often
persistent despite, you know, multiple different
creams that they've tried, switching diaper paste,
etc. It's quite a bright rash. Sometimes you
have little fissures around the area. And it's
typically just in the perianal area, not elsewhere.
What I usually do is take a little swab and culture.
And it usually responds pretty well to oral antibiotics
in the penicillin/amoxicillin family, barring
allergies. Sometimes in these kids, throat cultures
can be positive. I've been fooled and it's not
Strep and it's actually Staph. For point of clarification,
when you say that they are walking around with
strep in their throat, you would do a culture
and it's positive. Doesn't necessarily mean they
have to show symptoms of strep throat. Yes, there's
no sore throat. They're not otherwise ill. They
just sometimes are even carriers. Yeah, another
place I've seen. Strep also kind of land is in
the neck crease and sometimes the armpits. I
mean, it's rare, but sometimes usually it's just,
it's just in that diaper area. And when it's,
when it's just there and nothing else is involved,
it's, I think that's the strongest clue that
you're probably dealing with something infectious,
like, like perianal strep. And the good news
is it gets very better, very quickly with, as
you said, I usually just use Keflex. I don't
know about you, but. Yeah, Keflex. Because that
way it covers for Staph if it happens to be Staph
as well, in most cases. Well, the next one I'll
throw at you is not a common diagnosis, but quite
severe if you're suffering from it. And that's
a "zinc deficiency," of which there can be a lot
of different versions of how you can end up being
zinc deficient. But tell us how you might expect
someone to come into your clinic as a child with
zinc deficiency. So first of all, this is super
rare. I maybe see it once every year or two.
So it's not something that, you know, most families
need to worry about, but they'll come in with
the, you know, sort of a diaper rash, but they'll
also have. basically a similar looking rash on
the perioral area. So it's not just in the diaper
area. It can be on the perioral area or also
even on the hands or feet or other areas. They
are very scaly, very red, resistant to sort of
the typical treatments that you might give. So
it's not the first thing that I think of. I wouldn't
go jump right to that diagnosis, but I'll ask
mom's history. Is the baby breast? fed or not?
Did it start after you stopped breastfeeding?
um Was the baby born early any other issues medically
like you know syndromes of malabsorption things
like that and the reason you're asking about
if the baby was breastfed because sometimes mom's
breast milk just simply doesn't have enough zinc
in it To get the baby's zinc levels up, right?
Right. Or sometimes the mom's breast milk has
enough and you don't notice it until the mom
stops breastfeeding. Stops breastfeeding. And
then premature, they just can't stack the amount
of zinc that they need. Correct. To not get deficient.
Correct. If this is on my differential, which
again, it is not the first thing I think of in
most cases, but if it is, oftentimes a way to
figure it out is to do labs and blood work, which
what we look for is low alkaline phosphatase
levels. We check zinc levels, which would be
low. There's good treatment available. This is
totally fixable, but the labs are really helpful
in this case. Well, that's the miracle of zinc
deficiency. I mean, the couple of kids that I've
had, actually have zinc deficiency when you supplement
them with zinc what, what looks like the most
horrific diaper rash in three, five, seven days
it's gone i mean it just gets better it's amazing!
So it's important to make that diagnosis and
i don't know about you but i always kind of think
of the rash on the face that you mentioned as
being an important part of this it's sort of
got this distinct "U-shape" to it. And it's, I
don't know, it's always looked pinkish yellow
to me whenever I've seen it in real life. Now,
how many have I seen? Not that many, but you
know. Right, right. And again, in most of these
cases, it's not that. It's probably just eczema
on the face as well, but definitely something
to have in your differential and not to be forgotten.
So now I'm going to get your pulse up because
I know you and I know you always think of what
the worst case scenario could be. When you have
a kid that comes in with a diaper rash that's
not responsive to treatment, the zinc's normal,
everything that we've talked about up to this
point is just not making sense. What are you
concerned about? So there's this really rare
condition called "Langerhans Cell Histiocytosis."
We call it LCH. And most of these children, something
doesn't... look right on their rash. So the first
thing you'll notice on kids with this condition,
which basically what it is, it's this inflammatory
myeloid condition that the reason it's significant
is it not only affects the skin, but it can affect
the child's bones, blood cell counts, livers,
etc. What you'll do on your exam, you'll see...
just the usual scale redness plaques but there's
sometimes these little bumps called "purpura" which
like the name it looks almost like a little darker
red or purple in color, or something called "petechiae",
which is these little dark red, purple, flat
lesions that do not blanch when you touch them,
which means when you push on them, the color
doesn't go away at all. And then some of the
lesions will be very open sores that scab or
crust, whereas most typical rashes don't have
that presentation. And so if a baby comes in
with this type of rash, doesn't respond to the
usual treatment, I usually recommend to the family.
to consider taking a small biopsy of the skin.
And the reason this is very important is these
babies can get very sick, not really from the
skin lesions, but from what can be happening
inside their body. Yeah, and we don't... We don't
just biopsy kids willy-nilly. I mean, if you're,
you know, if you're talking about doing a biopsy
in the diaper area where again, poop and pee
can get into an open wound. Now you're putting
that kid at risk for infection. So, you know,
or you should know if you're a parent and a pediatric
dermatologist is suggesting a biopsy in the diaper
area to make sure it's not that we've already
considered the worst case scenario, and that's
what we're trying to make sure it's not. Right,
right. And there's usually some other clues with
this too. Often they have skin lesions on the
palms or soles as well. So sometimes we actually
can get away with not biopsying the diaper area.
I've had a couple diagnosed elsewhere. Oh, that's
interesting, yeah. Yeah, and I've had a couple
with also scalp lesions. And for me, one of the
worst things to see is to open up a baby's diaper.
When you're looking at the rash and you're trying
to figure out if it's this Langerhans Cell Histiocytosis,
LCH, and what do you see in those folds are huge
hulking lymph nodes. You can actually see their
swollen glands in the creases, and that's not
a good thing. Yeah. Often these children also
have systemic symptoms. Sometimes they'll have
weight loss. Sometimes if you palpate their tummy,
they'll have elevated or enlarged, excuse me,
liver, things like that too. So often there's
other clues as well. Yeah, I'm not, and I've
really never been great at feeling a liver or
a spleen for what we call hepatosplenomegaly.
When in doubt. I'll get an ultrasound and find
out if the liver and the spleen are within normal
size for that kid. And that's reassuring. It
doesn't mean it's not LCH, but you certainly
don't want to see something being bigger than
normal in those kids that you're concerned with.
And sometimes, let's say I'm really suspicious
and I order blood work to look for anomalies
there. If it does end up being, you know, just
to go down this rabbit hole, if it does end up
being LCH. It's a condition that you involve
other specialists with, like oncologists, to
look inside the body as well. Yeah. This is managed
by cancer doctors. I mean, let's, right, this
is, we're outside of the realm of a skin doctor
at this point. This is a systemic illness that
has to be managed as if it was a cancerous process.
Right. The good news is a lot of them actually
have really good prognosis. So when I hear the
word cancer, it's almost not the right word or
there almost needs to be an adjacent word for
it. but we treat it very seriously nonetheless.
Yeah. Now the good news is that again, you know,
upwards of 50-70 % of your diaper rash cases
are really just, again, the basic irritant contact
dermatitis from the feces and urine in that area.
Knowing that just with some basic routine diaper
area skincare, most of the time you can knock
out. 90% of the problem, even before they become
larger ones. So, give me your sort of gold standard
routine for how you approach diaper area skincare.
What are you recommending to your families? So
the first thing is to talk about is how are they
cleaning the area? So a lot of the times parents
are actually cleaning too aggressively, using
too much soap. So, while gentle soap and water
are good, you don't want to use anything with
fragrance. And sometimes you can do soap not
every day, maybe every other day or every third
day. You want to make sure they're using wipes
that are gentle and fragrance-free. Um, and
that they're not wiping too hard. Sometimes I'll
watch parents change diapers in front of me and
the - how, how much friction and rubbing is going
on is just far too much. So, you know, especially
if there's open areas, you want to almost dab
instead of rub. The other thing I will do if
soap is the issue, sometimes I'll have them do
a bath with no soap, you know, multiple times
a week. Um, the, the, the next thing to make
sure is that this child is not sitting in the
diaper too long. I have some kids who go to daycare
and they're not changed as frequently and they
come home rashy and then overnight things get
better just because families are able to uh change
the diaper more often so whenever possible frequent
diaper changes um do the trick. I have some parents
who i'm not saying you need to do it every hour
but at least if you can when they're having acute
flares to do it as often as you can especially
after bowel movements. You know urine you don't
have to do it quite as frequently but if possible
the minute you notice a child has a bowel movement
you want to do a clean and diaper change. Yeah,
that's, you know, this is a case where technology
maybe is not our best friend. They have this
super ultra-potent absorbing gel technology in
the diapers now that it can suck up anything
and hold it there for hours. And, you know, not
saying it's a matter of being lazy, but when
you have that convenience, you do tend to let
the kids sit in the diaper and have that. urine
and poop sort of stew in the diaper area because
it's not dripping out. So you don't need to feel
like you have to change the diaper as much. But
to your point, yeah, once an hour, take a peek.
I get it. Diapers are expensive. You're talking
up to 50 cents a diaper now, I think, last time
I looked. So I don't want you to just have to
feel like you have to change a diaper no matter
what. taking a quick peek and making sure that
your baby's not, you know, carrying a huge load
in there that you didn't know about and it's
up against their skin can make a huge difference.
Absolutely. And then if possible, every now and,
you know, when at home, if you can give a little
bit of time for some air drying or naked time,
that always helps after a diaper change, if possible.
And I get it, can't always be done. But if you
have a chance when they're at home, let them
run around for a little bit. Yeah, I do. I do
try to encourage that as well. Letting them just
take the diaper off and air it out. You know,
that's but invariably you hear the story. It's
like it was off for 30 seconds and kid went to
the bathroom on the floor. Yeah, I'm sorry. Sorry
about it. Sorry. We meant well. The other thing
I did with my son, probably PTSD from seeing
so many diaper rashes in clinic, is I made sure
I had a barrier ointment at each change. So instead
of just applying the diaper alone, I alternated
every change. It was either a petroleum-based
product or a zinc oxide-based barrier product.
And if there was no diaper rash, I actually...
would alternate them because the benefit of the
petroleum-based ones is they're more hydrating,
not as good of a barrier. And then the benefit
of the zinc oxide-based ones, better barrier,
not as moisturizing. So I found if I alternated,
I got a little bit of both. Yeah. Out of those
two products, I like triple paste, something
like that with the zinc oxide is there. The issue
there is, my goodness, it gets everywhere. I
mean, once you get that on your hands, It's going
to be on whatever furniture is closest to you.
Then you got to change the diaper for that kid.
I mean, I know what I'm putting the parent through
when I suggest using zinc oxide. But to your
point, to me, at least, it works the best. And
the nice thing is some of those brands even have
ones with, like, if there is a little yeast component,
you can buy ones that have a little antifungal
property to them, like triple paste AF. Yeah.
What do you not do for your normal diaper care?
Fragrance. I actually didn't do any of those
super absorbent disposal type, or excuse me,
I didn't do any of those cloth type diapers.
Like if the diaper itself has a fragrance, is
that something you're? Oh, absolutely not. Yeah.
I've seen that for whatever reason. I've been
seeing that a lot in clinical of late - diapers
coming in with actually a fragrance to them.
Yeah. I just stuck with sort of the fragrance
free, you know. pretty commonly available brand.
Did not do the cloth diapers. Not that they're
bad. It's just, I didn't find honestly that there
was much of an added benefit to them for the
effort and expense. Well, let's take a deeper
dive into the topic of Candida or the yeast that
we mentioned earlier, because that does require
some special consideration. And again, you know,
that's living everywhere. You can throw a softball.
right now in any part of your room and you could
hit some yeast, it's there. It normally doesn't
cause any problems because it's not getting sort
of into the skin or even, you know, really there
at any given time for an extended period of time.
But once you start talking about a diaper that's
occluding it, You've got, again, what I loved
is you mentioned the antibiotics, more frequent
pooping, diarrhea. Now all of a sudden you got
a chance for that Candida to really take a
hold and cause some problems. So what are you
doing to treat yeast in the diaper area? The
first thing that I usually will try is a topical.
There's a couple ointments available that treat
yeast like Nystatin. There's also an oral medication
that you can prescribe - Diflucan being one of
the more common ones that's pretty safe and requires
a pretty short treatment. A lot of the diaper
paste versions of them that have an antifungal
property. So some of the zinc oxide ones you
can buy that way. But I try to avoid putting
things like cornstarch or things like that on
top because sometimes those actually make it
worse. Yeah. And do you have a particular order
that you'd be applying these things in? Like
what would you put to the skin directly? Let's
say I was doing Nysatin. I might put that
first and then I would put my diaper paste on
top and then apply the diaper. And then maybe
the next diaper change, I would do my Nystatin
with a little petrolatum based product. Yeah,
that's exactly what I would do as well. That's
good. It makes me feel good when I hear smart
people are doing what I'm doing. That's great.
Yeah. So, okay. So let's talk a little bit about
some of those other conditions. So psoriasis,
seborrheic dermatitis, atopic derm. What's the
extra step there that you're adding to try to
treat that? So in many cases, we actually use
very, very low potency steroids against the skin.
And these are not like anabolic steroids that,
you know you hear about it on social media.
These are very low strength topical steroids.
So even over-the-counter, you can buy them. Widely
available is 1% over the counter hydrocortisone
ointment, for example. When you buy those, it's
better to always do the thicker ointment than
the cream versions. And you don't want to buy
one that has extra things added. Like if you
look at the pharmacy aisle where hydrocortisone
is located, you'll see some that have aloe, some
that have fragrance, some that have Neosporin.
None of that. You want to buy the plain 1% hydrocortisone.
I would always recommend getting your doctor's
advice first. But if that's the way they want
to go, I do that and I do it for a very short
time, very thin layer underneath your, underneath
whatever your selected barrier cream is. I might
do it twice a day for maybe seven days max. And
then it, you know, every now and then we have
to do even stronger versions of that, but that
would be under the guidance of your doctor. I
love what you said about avoiding the additives
to the 1% hydrocortisone. When you're a parent
going into the pharmacy looking for exactly that
product, do you have a particular vehicle that
you're like, it comes as a lotion, it comes as
a cream, it comes as an ointment? I love the
ointments. The thicker, the better. You want
to think of it like the old school Vaseline version
of hydrocortisone. That's great. So what would
you do for a condition like psoriasis, where
we said earlier, it's even a little harder to
treat? So psoriasis, we actually treat very similar
to eczema or atopic dermatitis, but sometimes
we have to use more potent medications, sometimes
prescriptions, drinks, steroids. There's also
for actually both... and psoriasis, some prescription
non -steroidal anti-inflammatories available
that can decrease the inflammation without having
to worry about the risk of thinning of the skin,
which is the main concern with steroids. One
of the oldest treatments on the market for psoriasis,
for example, is a topical vitamin D-based ointment
called calcipotriene. But even modern day, there's
even more effective a non-steroidal on steroid
alternatives out there as well as systemic options.
One that I like in the diaper area, if I know
it's going to require a long-term use is a topical
calcineurin inhibitor called Protopic or tacrolimus.
In this age range, you're kind of stuck using
0 .03% unless you have some trick that I don't
know about to get approved for the 0 .1%. You
have to be - I do have a trick. You have a trick?
What's your trick? I have some specialty pharmacies
available that you can get them for about $30
cash. The tacrolimus 0 .1.%. 0 .1%, yeah. Technically,
only for 16 years of age or older, we commonly
would, as dermatologists, we commonly would love
to use that stronger product on younger kids.
But as soon as the insurance company sees that
the child's younger than 16, they can say, sorry,
the FDA did not give approval for this medicine,
so we don't have to pay for it. So I have specialty
pharmacies where I can get the generic version
and you can also get them if needed through compounding
pharmacies. Yeah, that's great. That's a good
trick. Awesome. So when as a pediatric dermatologist,
would you want a pediatrician or family medicine
physician to absolutely refer these kids into
you? When is it appropriate for you to be taking
a look and doing something extra? So my favorite
referral would be someone who's been cultured,
Someone who's had a trial of you know, if you're
not sure, maybe a topical antifungal or a topical
over -the -counter strength steroid that just
hasn't worked, that I'm happy to see a patient.
I have pediatricians who sort of know my typical
technique. We'll do sort of the intro-level
treatments, and if they don't work, I'm happy
to see the baby. Yeah, for me as well, I would
add to that, you know, anytime you've got blisters
in the area or, again, if you can see those lymph
nodes, That's something that we want to take
a look at. And that's not like a, hey, I'm just
going to refer and whatever happens, happens.
because it might be nine months before you get in to
see me. I don't want to wait nine months. You
pick up the phone and either call my personal
cell, which I give out to everybody, or use whatever
your health system or clinic's messaging system
is and get a message to that person directly
and say, hey, you need to see this person because
they've got something really concerning sounding.
Is that fair? Agreed. Well, I want to thank Scripps
Clinic's own Dr. Caroline Piggott for joining
me today. I cannot have handled this "messy load,"
so to speak, without her expert existence. And
just always a pleasure speaking with you, Dr.
Piggott. I look forward to doing many, many more
of these things with you and getting smarter
as a result. Thank you for having me, Dr. K.
It's good to see you and it's a pleasure doing
this anytime. Thanks for tuning in to this episode
of the Don't Be Rash Pediatric Dermatology Podcast.
I'm your host, Dr. Andrew Krakowski. Don't forget
to subscribe to our show on your favorite podcast
platform and check out don'tberash .org for more
information. A special thank you to our nonprofit
sponsor, the St. Luke's University Health Network,
for making this episode possible. Until next
time, remember, keep calm and don't be rash.