Diaper Area, Buttocks, and Gluteal Cleft

OVERVIEW

The unique environment of the diaper area is predisposed to the friction of repeated movement, chafing, local heat, and maceration from retained moisture, all of which serve to provide an excellent environment for potential irritant, fungal, as well as bacterial complications.

Being sun-protected, most eruptions that arise on the buttocks are inflammatory rather than neoplastic in nature. The relatively rare, but increasing incidence, of cutaneous T-cell lymphoma (mycosis fungoides) is an exception.

Dermatoses that occur in the perineal region, the buttocks, and the gluteal cleft are often associated with lesions on other parts of the body. Examples include folliculitis, furunculosis, psoriasis, eczema, and tinea corporis. There are also disorders that are characteristically seen perianally such as anogenital warts, condyloma lata of secondary syphilis, and external hemorrhoids. Perianal bacterial dermatitis and anogenital warts are problems that may appear in the pediatric age group.

DIAPER AREA AND BUTTOCKS

Infants and Toddlers

Diaper Rash

Diaper rash, referred to as napkin dermatitis in the United Kingdom, is the result of overhydration of the skin due to urine and sweat produced by the occlusive diaper (“nappy”) that leads to increased permeability of the skin to irritants. Diaper rash is by far the most common rash in infancy, and it can also affect persons of any age group who wear diapers, such as incontinent patients. It can first present as early as the first few weeks of life with a peak incidence at 9 to 12 months.

Irritant triggers include friction or rubbing of skin on skin, soaps, antibacterial and cleansing substances found in baby wipes and topical diaper ointments, urine, and proteolytic enzymes in stool. Diaper rash may also be exacerbated by the presence of atopic dermatitis, seborrheic dermatitis, or a secondary infection by Candida albicans.

Distinguishing Features

The dermatitis presents as erythematous, shiny, moist patches on the convex surfaces of the buttocks, the vulva, perineal area, proximal thighs, and lower abdomen (Fig. 17-1)

In contrast to infantile atopic dermatitis (see below), lesions typically spare the genitocrural folds because such areas do not come into direct contact with the diaper

Figure 17-1 Diaper rash.

Shiny, glazed, wrinkly eczematous plaques on convex surfaces of skin.

Figure 17-2 Diaper rash.

Note how the erythematous eruption conforms to the shape of this infant’s diaper, demonstrating the sharp margination where the diaper ends.

Figure 17-3 Candidal diaper dermatitis.

Beefy red erythema and satellite papules and pustules characteristic of a yeast-induced diaper rash. The shiny, glazed appearance of buttocks and satellite papules and pustules are characteristic.

(Reprinted with permission from Edwards L. Genital Dermatology Atlas. 2nd ed. Wolters Kluwer; 2011.)

The eruption may conform to, and be limited to, the diaper area (Fig. 17-2), or it may be more widespread
When Candida albicans complicates diaper rash, the infection preferentially affects the skin folds, with bright red erythema and satellite papules and pustules (Fig. 17-3)
With neglect, painful erosions or ulcerations can develop

Diagnosis

Clinical

Management

Prevention

Keep the skin of the diaper area clean and dry
Change diapers promptly after voiding or soiling
Minimize friction—dry the skin by patting, not rubbing, keeping in mind that friction is one of the causes
Absorb moisture—use disposable diapers with super absorbent gelling materials
Use gentle, soap-free cleansers such as Cetaphil nonsoap gentle cleanser
Apply a skin protectant/barrier cream to the skin at each diaper change
Recommended barrier creams or ointments: Aquaphor, Triple paste, or Desitin. Apply these with every diaper change
Avoid the use of high-potency topical steroids in the diaper area

Treatment

If the eruption is mild, use a low-potency steroid such as hydrocortisone 1% cream or ointment twice daily to affected areas and apply a generous coating of a petrolatum (Aquaphor or Vaseline) or a zinc oxide-based ointment (Balmex, Triple paste, or A&D ointment) over the topical steroid
Stronger topical steroids such as desonide 0.05% (class 6), hydrocortisone valerate 0.02% cream (class 5), or ointment (class 4) may be used for brief periods when necessary
Crisaborole 2% ointment (Eucrisa), a phosphodiesterase-4 inhibitor, is a nonsteroidal agent approved primarily for the treatment of eczema in children >3 months of age
If there is no improvement after several days and the presence of C. albicans is suspected, a topical antifungal preparation such as miconazole 2% cream, ketoconazole 2% cream, nystatin cream or powder, Triple Paste AF or Vusion ointment (0.25% miconazole, 15% zinc oxide and white petrolatum) may be used. For resistant cases, oral therapy with nystatin or fluconazole may be required

Infantile Atopic Dermatitis

Infantile atopic dermatitis, irritant contact dermatitis, seborrheic dermatitis, and psoriasis in infants may be indistinguishable from one another; however, each may be distinguished based upon the family history and the location and appearance of the rash. Infantile atopic dermatitis occurs in association with a personal or family history of atopy.

Those infants who have atopic dermatitis are more likely to develop irritant contact dermatitis (diaper rash) as a result of their inherent skin sensitivity and defective barrier function.

Distinguishing Features

Lesions typically appear in the inguinal creases; the diaper area is remarkably spared (Fig. 17-4)
“Cradle cap” is often present (see also Figs. 2-1 and 2-2)
There may be evidence of atopic dermatitis elsewhere on the body
Lesions are often pruritic

Bullous Impetigo (See Cheeks)

Distinguishing Features

Starts with small vesicles that enlarge to 1-2 cm superficial bullae
Later bullae collapse leaving a “collarette of scale” (Fig. 17-5)

Diagnosis

Usually made clinically
Bacterial culture and sensitivity testing are recommended if standard topical or oral treatments do not result in improvement

Figure 17-5 Bullous impetigo.

Shiny erosions with peripheral scale that represents remnants of the blister roof.

(Reprinted with permission from Edwards L. Genital Dermatology Atlas. 2nd ed. Wolters Kluwer; 2011.)

Adults

Tinea Corporis

Figure 17-6 Tinea corporis.

Note asymmetric distribution of this scaly plaque that extended from tinea cruris in this immunocompromised patient.

Distinguishing Features

Distribution of lesions is usually asymmetrical
Lesions of tinea corporis are generally annular, with peripheral enlargement and central clearing; however, lesions on the buttocks have a propensity to be more blended into one or more confluent scaly patches, and, therefore, the entire lesion tends to be scaly (Fig. 17-6)
Often asymptomatic