Patient Presentation
A 13-month-old female came to clinic for a diaper rash of a few days that was not improving with usual treatments. The physical examination showed pink papular lesions that were slightly vesicular in the labial area with general erythema in the intertrigenous areas and satellite lesions. The patient was diagnosed with candidal diaper dermatitis and treated with nystatin. A second pediatrician saw her 3 weeks later the rash had not completely improved with the nystatin. The general erythema and satellite lesions had improved but she had flesh-colored papules that had central ulcerations. There was no umbilication and they were 4-5 mm in size mainly scattered around the labia major but with some that were more linear. There were some excoriations from the patient picking at them. The patient was diagnosed with impetigenous diaper dermatitis and given mupirocin as instructed to return to the clinic if not improving in the next few days. The pediatrician also considered that these were an underlying molluscum contagiosum or flat wart that had now been irritated and impetigenized. If not improving then a dermatology appointment would be made. Over the next month, the lesions had gone away with the mupirocin but then returned. The second doctor again saw the patient and the physical examination showed 4-5 mm flesh-colored papules that were flat on top with some central ulceration and no umbilication. They were scattered again. The physician was not sure what these lesions were and sent the patient to dermatology and restarted the mupirocin in the interim as it had appeared to help before.

The diagnosis of severe Jacquet’s erosive diaper dermatitis or granuloma glutate infantum was made by the dermatologist. As the patient had been using reusable diapers exclusively, it was recommended to use disposable diapers that were changed frequently. Additionally heavy use of zinc-based barrier cream was also recommended. Both pediatricians were surprised by the diagnosis and went to MEDLINE to learn more about it.

Discussion
The differential diagnosis of diaper dermatitis is usually fairly easy with irritant, fungal and bacterial causes being the most common. These are usually easily treated with resolution. When it is not improving then the differential must be expanded and other disease processes must be considered. These again usually include problems that are relatively easily treated such as scabies, lice or tinea. Other much less likely conditions in this age group would be syphilis or granuloma inguinale. Other signs or symptoms need to also be considered as Crohn’s disease, histocytosis or acrodermatitis enteropathica can present as a diaper rash also.

A review of rashes by distribution and pattern can be seen here.

Learning Point
Jacquet erosive diaper dermatitis (JED) is a severe irritant dermatitis that affects the genital area caused by prolonged moisture contact and fecal enzymes which alter the skin permeability and change the skin pH. These changes cause severe but non-specific inflammatory patterns. There are several patterns that have different names that are similar and some people believe they are all one disease process.

• JED are 2-5 mm umbilicated or eroded papules and nodules which may be red-purple to begin with and have a heterogenerous pattern.
• Perianal pseudoverrucous papules and nodules are papules and nodes that appear verrucous mainly in the perianal area but other areas as well..
• Granuloma glutaela infantum is red-purpose nodules mainly the gluteal and groin areas that may have an eroded appearance.

Obviously it can be quite difficult to distinguish these entities. Additionally there are other names for these diseases in the literature including Sevestre and Jacquet erosive diaperdermatitis and dermatitis syphiloides posterosiva. Some believe that these entities are relatively rare because of the use of more absorbent disposable diapers but are reemerging because of a resurgence of using reusable diapers. These entities are also seen in the adult population with incontinence problems for a variety of reasons. Main treatment is changing to disposable diapers with frequent diapers changes. Additionally, other treatments including zinc-based creams, aqueous solution of eosin, anti-fungals, steroids, non-steroidal antiinflammatory drugs, and sucralfate have been used with varying success.

Questions for Further Discussion
1. What is your favorite diaper barrier cream and why?
2. What other treatments besides frequent diaper changes and barrier creams can be used to help diaper dermatitis?

Related Cases

Disease: Jacquet’s Erosive Diaper Dermatitis | Rash | Infant and Newborn Care

Symptom/Presentation: Rash

Specialty: Dermatology

Age: Toddler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Rashes and Common Infant and Newborn Problems.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Paradisi A, Capizzi R, Ghitti F, Lanza-Silveri S, Rendeli C, Guerriero C. Jacquet erosive diaper dermatitis: a therapeutic challenge.
Clin Exp Dermatol. 2009 Oct;34(7):e385-6.

Maruani A, Lorette G, Barbarot S, Potier A, Bessis D, Hasselmann C, Mazereeuw-Hautier J; Groupe de Recherche de la Societe Francaise de Dermatologie Pediatrique. Re-emergence of papulonodular napkin dermatitis with use of reusable diapers: report of 5 cases.
Eur J Dermatol. 2013 Apr 1;23(2):246-9.

Ricci F, Paradisi A, Perino F, Capizzi R, Paolucci V, Rendeli C, Guerriero C. Jacquet erosive diaper dermatitis: a not-so-rare syndrome. Eur J Dermatol. 2014 Mar-Apr;24(2):252-3.

Author

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital