That Poor Little Bum! The Trials and Tribulations of Diaper Dermatitis.

That Poor Little Bum!
The Trials and Tribulations
of Diaper Dermatitis
Disclosure

I have nothing to disclose
Objectives
Identify evidence-based solutions
to improve prevention and
treatment of diaper dermatitis.
Recognize the importance of
consistency and identification of
risk factors to prevent and treat
diaper dermatitis.
Causes of Diaper Dermatitis
(DD)
Over hydration of
skin = increased
pH
Redness and
breakdown
occurs
Friction from
diapers and
wiping
Unable to protect
from invasion
Elevated pH
affects flora of
skin
Stool and urine
cause pH to
become alkaline
Acidic barrier of
skin
compromised
Signs of Diaper
Dermatitis
Erythema
Edema
Blistering
Erosion
Weeping
Taken from: http://dermalsystems.com/science/skin/
Supporting Evidence
Review Articles
Few Randomized Controlled Studies
Poster Presentations
1/2 of all
infant’s
that visit
ped’s
office
will have
DD
Friction
major
factor
Microbes
DO NOT
play a
role
Breast
fed
infants
have
less DD
Less DD
with
more
diaper
changes
Shin, H. T. (2005). Diaper dermatitis that does not quit. Dermatologic
Therapy, 18(2), 124-135.
Cleansing
can be
useful
Shin Article Cont.
Most baby
wipes not
recommended
when skin is
broken
Barriers are
useful in
protecting
the skin
Powders
have been
seen as
helpful in
reducing
friction (No
talc, boric
acid, or
baking
soda)
No
prescription
medications
have been
proven to
treat DD
(except
Nystatin)
Shin, H. T. (2005). Diaper dermatitis that does not quit. Dermatologic Therapy,
18(2), 124-135.
Concern over increased product
related costs related to
inconsistent treatment practices
Tested the use
of a single skin
protectant on 5
neonates
Noted a
reduction of
erythema within
24 hours
Continued
product
prophylactically
until DC
Catherine Ratliff, M. D. (2007). Treatment of incontinence-associated dermatitis (diaper
rash) in a neonatal unit. Journal of Wound, Ostomy, Continence Nursing, 34(2), 158.
DD most common
dermatoses in infants
Prevention is Key!
(skin hygiene, preserve
barrier, prevent friction)
Identification of
predisposing factors
important
Resistance to treatment or
chronic DD should be
further investigated
De Raeve, L. (2008). Diaper dermatitis: Differential diagnosis
and treatment. Expert Review of Dermatology, 3(6), 701-709.
Bottom Line!
Preserving the Skin
Barrier Protection
Zinc Oxide
White
powder
suspended
in cream or
ointment
Repels fluid
Not
absorbed
into skin
Antibacterial,
antiseptic,
and
astringent
properties
Petrolatum
Protects the skin by
traveling through the
interstitial spaces of the SC
to aid in barrier recovery
Watch Out!
Preservatives
Fragrances
Additives
Barrier Ingredients
St. Elizabeth Hospital Study
32 day old
with NAS
3 day old on
abx therapy
60 day old
with caustic
stool possibly
r/t formula
65 day old
with reflux
and increased
gastric
enzymes
Bauer, J. (2012). Management of incontinent associated dermatitis (IAD)
in the neonatal population. Poster session presented at the meeting of
WOCN.
DD Treatment/Algorithm
St. Elizabeth Hospital
Mild
DD:
• sensitive wipes and 5% dimethicone cream
Moderate
DD:
Severe
DD:
Candida:
Improvement in 3 days
• rinse with water (no wipes), ostomy
powder once daily and 15% dimethicone
cream (contact MD and Ostomy RN)
• rinse with water (no wipes), ostomy
powder daily, 15% dimethicone
cream (contact MD and Ostomy RN)
• treatment with Nystatin
powder or ointment
• transition to 5%
dimethicone treatment
Children’s Hospital of
Philadelphia
Hospital’s prevalence rate of DD in
2007 was 2.5% when national
average was at 16-42% at the time
Promote prevention with diaper
wipes, Aloe Vesta, Aquaphor or 3M
No sting (infants over 30 days)
DD Treatment/Algorithm CHOP
• Cleanser and zinc based barrier
Mild DD:
Moderate
DD:
Severe
DD:
Other:
• Cleanser and extra protective cream (notify skin
nurse)
• Cleanse and soak BID, stomahesive powder, 3M
No sting, extra protective cream (notify WOCN)
• Discusses yeast(Nystatin), pull-through (Ilex),
and short gut (cholestyramine paste)
Consistency in practice
and Development of DD
Algorithm
Initial
prevalence rate
24%
Promotes
prevention with
Vaseline, triple
paste, or desitin
After
implementation
on high risk
units rate
decreased to
11% over a 2
year period
Heimall, L., Storey, B., Stellar, J., & Davis, K. (2012). Beginning at the bottom: Evidence-based
care of diaper dermatitis. MCN, 37(1), 10-16.
DD Treatment/Algorithm
Erythema (intact skin):
• Desitin
Denuded skin: stomahesive powder then triple paste
or Ilex (with Vaseline over) or crusting technique
• Stomahesive powder then seal with No sting, repeat, then layer with
triple paste or Ilex (Vaseline over)
Candida:
• Treatment with Antifungal
Heimall, L., Storey, B., Stellar, J., & Davis, K. (2012). Beginning at the
bottom: Evidence-based care of diaper dermatitis. MCN, 37(1), 10-16.
DD Treatment/Algorithm
CHW NICU
Prevention
“butt baths”
Barrier wipes
Redness noted
Vaseline or petrolatum 100%
Breakdown noted
Sensicare
Excoriation
Ilex with the need for Ilex coating to protect from sticking to diaper
Candida
Nystatin Ointment
M. Esser
Algorithm
Sensicare
Ilex
Petrolatum base
Petrolatum base
15% zinc oxide
Has undisclosed
amount of zinc
Sticks to skin well
Adheres to
denuded skin
Can be used
alone or in
combination with
other treatments
Requires
Vaseline over as
protectant from
sticking to diaper
Case Studies
Audience
participation
encouraged
Scenario #1
36 week infant admitted from repeat Csection 3 days ago, weaned to NC
2Lpm, starting to PO feed more.
Beginning to pass looser stools.
What do you see?
What do you put on this diaper area?
Scenario #2
2 week old IDM infant now 38 weeks.
Blood sugars were borderline high
now stable, continues to have higher
urine output with frequent stools.
What do you see?
What do you put on this diaper area?
Scenario #3
3 month old ex 26 weeker now
term. History of several abdominal
surgeries. On full feeds of 24cal
formula, stooling frequently.
What do you see?
What do you put on this?
One nurse’s process for ilex
application with Nystatin.
-Coats the diaper in vaseline
-Applies Nystain liberally
-Applies ilex thickly
-Then places the diaper
Key Points
Prevention
“butt bath”
Do not rub
or wipe
barrier
cream off
Consistency
Lack of
knowledge
of products
Insufficient
access to
products
There are a number of
points within the bedside
care regimen where
breakdown occurs.
Loss of
followup
Lack of
adherence to
treatment
regimens.
Promote
adherence
to treatment
regimens
Enhancing
awareness.
Overcome
with
education,
tools, hospitalwide skin care
team.
Reduce
rates of
skin care
issues
Increase
proactive
prevention
strategies
References
Bauer, J. (2012). Management of incontinent associated dermatitis (IAD) in the
neonatal population.
De Raeve, L. (2008). Diaper dermatitis: Differential diagnosis and treatment. Expert
Review of Dermatology, 3(6), 701-709.
doi:http://dx.doi.org.ezproxy.apollolibrary.com/10.1586/17469872.3.6.701
Heimall, L., Storey, B., Stellar, J., & Davis, K. (2012). Beginning at the bottom:
Evidence-based care of diaper dermatitis. MCN, 37(1), 10-16.
Pasek, et al. (2008). Skin care team in the pediatric intensive care unit: A model for
excellence. Critical Care Nurse, 28(2), 125-135.
Catherine Ratliff, M. D. (2007). Treatment of incontinence-associated dermatitis
(diaper rash) in a neonatal unit. Journal of Wound, Ostomy, Continence Nursing,
34(2), 158.
Shin, H. T. (2005). Diaper dermatitis that does not quit. Dermatologic Therapy, 18(2),
124-135. Retrieved from
http://search.ebscohost.com.ezproxy.apollolibrary.com/login.aspx?direct=true&db=m
dc&AN=15953142&site=ehost-live
Visscher, M. O. (2009). Recent advances in diaper dermatitis: Etiology and
treatment. Pediatric Health, 3(1), 81-98.
doi:http://dx.doi.org.ezproxy.apollolibrary.com/10.2217/17455111.3.1.81
Thank You
Please email me with any questions:
Media Esser NNP-BC, APNP
[email protected]