Diaper Rash: The Bottom Line

Irritant contact dermatitis
Irritant contact dermatitis is by far the most common cause of diaper rashes in infants. Irritation can be caused by exposure of the skin to urine and feces, as well as by friction from the diaper itself. This type of diaper rash usually affects the genitals and inner thighs, but spares the actual creases, since the creases (where skin touches skin) are not exposed to the irritating chemicals. The main treatment of irritant diaper dermatitis is barrier creams (Aquaphor, Vaseline, and zinc-oxide-containing diaper creams). My favorite is Triple Paste  (http://www.triplepaste.com/). The barrier cream should be applied with every diaper change to protect the skin from urine, feces, etc. More severe cases may require application of a mild strength topical steroid for a few days.

Contact allergy
Actual allergy is less common than irritant contact dermatitis, but kids can become allergic to actual components to the diaper, such as dyes (diaper manufacturers use blue dyes to make diapers appear bright white) and the rubber contained in th elastic.  Like irritant diaper dermatitis, this rash tends to spare the creases of the groin where skin is not touching the diaper.  The rash may also affect the inner thighs and lower abdomen where the elastic of the diaper touches the skin. The first step in management is removing the allergen. There are a couple of brands that make dye-free diapers: Tushies (http://www.tushies.com/) and Seventh Generation (www.seventhgeneration.com/Diapers) and Earth’s Best (http://www.earthsbest.com/).  Barrier creams are also helpful, although more severe cases may require application of a mild strength topical steroid for a few days.

Yeast infection
Candida albicans is the most common infection to cause a diaper rash. Candida is a yeast, and yeast loves warm, moist, environments. Because of that, diaper rashes caused by yeast tend to involve the skin in the creases of the groin, unlike rashes caused by irritation or allergy. The rash is likely to be a brighter, “beefy” red, and there may be “satellite lesions” (red bumps a slight distance from the main rash). A yeast diaper rash is less likely to clear up with traditional diaper creams. It needs to be treated with a topical antifungal or anti-yeast cream, such as nystatin or clotrimazole. Some are available at the drugstore without a prescription.

Psoriasis, zinc deficiency, perianal strep infection, etc.
There are several medical conditions, some common & others rare, which can present with a rash in the diaper area. If your child’s diaper rash does not follow the pattern of one of the common causes listed above, or if the rash does not clear up with over-the-counter treatments, it is important that the rash be evaluated by your child’s pediatrician or a pediatric dermatologist.


In summary, to prevent diaper rashes, you should change your child’s wet or soiled diaper as soon as possible, clean his or her bottom thoroughly after a bowel movement and allow it to dry before putting on a new diaper. Diaper creams such as Triple Paste are a good first-line treatment for most diaper rashes. Occasionally diaper rashes may require a change in diapers or prescription treatment, so if a rash doesn’t clear in a few days be sure to bring it to the attention of your child’s physician.



What's Biting You?



Bugs… those little critters sure can cause big problems! Bug bites are often the culprit for itchy rashes in kids, especially in the summer time. Dermatologists have a fancy term for it… papular urticaria. Papular urticaria is a common (and annoying) disorder which shows up as little red, itchy bumps on the skin, caused by an allergic reaction to the bites of mosquitoes, fleas, bedbugs, and other insects. This happens primarily in children, usually between the ages of 2 to10. Often only one family member is affected, which makes the diagnosis a little bit challenging. Kids eventually outgrow this tendency, probably because they eventually develop a tolerance after multiple exposures.

Fleas can jump over 100 times their height, but that still is only about a foot high. For this reason, flea bites tend to be located mostly on the lower legs. While bites from different insects may cause similar lesions, flea bites are the most likely to cause blisters.

Mosquitoes aren’t much of a problem in California, but where I grew up in the Midwest they were a huge problem! If you are "allergic" to them, when a mosquito bites you, the area swells up as a response to the saliva which remains in your skin. (Gross, huh?) Eventually, the swelling goes away, but the itch remains until your immune cells break down the saliva proteins.

Bedbugs have been all over the news lately, and just the mention of the word makes my skin crawl! These little bugs, about the size of a small apple seed, hide in the crevices of beds, box springs and mattresses. When they bite humans, they tend to bite a few times in a row, causing red bumps in groups of 3 (termed “breakfast, lunch and dinner”).

What can you do to prevent the pesky pests from biting you or your children?
1) Wear protective clothing & insect repellents while outside. Insect repellants whould be applied to a child’s clothing, not directly on their skin.
2) Treat pets for fleas if they have them and use preventative treatments for fleas regularly.
3) Have your home professionally treated. If the source of bugs eludes you, consider having someone evaluate for the presence of bedbugs, bird nests (which can harbor bird mites), etcetera.
4) You can treat the itchiness of the bites with hydrocortisone cream, and you nay be able to suppress the rash and itching with an over-the-counter antihistamine such as Zyrtec or Benadryl.

The problem tends to recur in sensitive individals, so even if your child's bug bites have disappeared from this summer, don't be surprised if it happens again next summer.  My best advice is to prevent as much as possible, treat the symptoms when they occur, and get some reassurance from the fact that your child will EVENTUALLY outgrow this.

What Is Molluscum?

Molluscum contagiosum… I see at least 5 cases a day. It’s so common that I describe it to parents as a "right of passage" of childhood. They don’t spread from kids to adults, probably because we were all exposed at some point and are immune. Yet most people have never heard of it. What ARE these little bumps?


Mollusca (I think that’s the plural of molluscum) are tiny little bumps on the skin caused by a virus called molluscum contagiosum virus. Because it’s a virus, the bumps spread very easily. They eventually disappear on their own, but that can take a year or two. Not many moms are content to wait this long for something on their child’s skin to disappear, especially if it is on the face. In children who have skin conditions such as eczema, these buggers spread even more easily. And there is a stigma that goes along with having them (since they are contagious). For these reasons, many parents wish to have them treated. That’s where I come in.

Treatment of molluscum does NOT have to be painful. The most commonly used treatment in the United States, and in my clinic, is a medication called cantharidin. Kids love to hear that it is made from the extract of a blister beetle. This “beetlejuice” is a liquid that is applied to each bump in the doctor’s office which dries as a clear film. It is then washed off with soap & water 3 to 4 hours later. Within a day or so, a blister forms & the bump peels off. The best part is that this treatment doesn’t hurt. In published studies, it takes an average of 2-3 treatments to be rid of the pesky bumps. Although this is the most common treatment, other treatments may be considered if your child has a lot of lesions, or if the bumps are on the face or private area.

It is hypothesized that the virus that causes molluscum may be spread by swimming pools and in bath water. So do I recommend avoiding swimming pools altogether? Nah, I’m a big proponent of letting kids lead normal lives and doing things that are fun. I do, however, tell parents to avoid bathing their kids together when one of them has molluscum. And kids can’t be kept out of school for this very common problem.

You’re on the internet right now… the first thing you probably do when you get home from the doctor’s office is google the diagnosis that your little one has been given, right? I always try to figure out the worst thing you could find so I can do a little damage control. Adults DO get molluscum, but in the setting of sexual contact. Molluscum is NOT a sexually transmitted disease in children, EVEN when they are located in the genital area.

Don’t let the little guys drive you crazy. In fact, many pediatricians don’t even recommend treating them if a child only has a couple. However, if your child has lots of them, if they are in visible areas, if your child has eczema, if they are spreading, or if you are an OCD parent like me, you can see a pediatric dermatologist for easy, painless treatment.

A Healthy Tan?

I read an article the other day which chronicled the decline in celebrity tanning. It mentioned celebrities such as Nicole Kidman, Cate Blanchett, Julianne Moore and Gwyneth Paltrow, whose porcelain skin is proof that you can be beautiful with pale skin. The trend for paleness is also about women wanting to protect their skin from the damaging effects of the sun.

It’s a great concept, but I’m not sure it’s totally caught on yet.

For many years, people have associated a deep bronze tan with health and beauty, but this was not always the case. In the early 1800s, pale skin was in fashion. Tan skin was a stigma associated with the lower classes, who were mostly farmers. The wealthy took great measures to protect their skin from the sun by using parasols.

The Industrial Revolution brought a dramatic shift in the economy and social classes. The lower classes began spending their days indoors laboring in factories, and sunbathing became an indulgence of the wealthy. Tan skin became a mark of affluence, a hallmark of having time and money to vacation. A shift in clothing styles and the introduction of the bikini in 1946 further encouraged the tanning obsession.

The relationship between sun exposure and skin cancer has been recognized for some time. In fact, the term “sunlight cancer” was coined in 1933. The first tanning salon opened in Orange, California in the late 1970s. Despite the knowledge that sun exposure is harmful, causing skin cancer (including melanoma, the deadliest type) and (*gasp*) wrinkles, people continue to risk their health for bronzed skin.

Just as smoking has become unfashionable due to knowledge of its association with cancer and heart disease, we hope to discourage behaviors which lead to harmful UV exposure. The advent of self-tanning lotions and spray tans has likely delayed the shift in attitude, because now a glow can be achieved without the UV exposure.
However, in a survey this year by the Skin Cancer Foundation 53% believed they don’t look better with a tan, and 63% said they aren’t more attracted to someone with a tan. Is the appeal of tan skin finally waning?

Acne – Have You Heard of It?

The American Acne & Rosacea Society (AARS) has declared June “National Acne Awareness Month.” This struck me as kind of funny. It’s not like melanoma, where you need to publicize it so people know to look for it. I’m pretty sure that anyone who has had acne is aware of it. Why does it need a month?  Here's why...

A study was conducted last year by the AARS in which pictures of teens (some clear-skinned and others digitally altered to look like they had acne) were shown to 1000 adults and 1000 teens. It probably comes as no surprise that both adults and teens viewed the acne-free kids more favorably than the ones with acne. Teens and adults alike reported that, when viewing an image of a person with acne, the acne was the first thing they noticed.

The survey also asked questions of teens who themselves had acne in an attempt to determine how big a problem their skin condition is to them. Adults also were asked to say how much they figured kids' acne bothered them. While the adults tended to minimize acne's impact, acne-plagued teens reported that their zits made them feel pretty bad. Get this: 59 percent said they'd be willing to forego Facebook for a year in exchange for being acne-free forever. And 13 percent of the kids with acne were so truly desperate they said they'd ask their mom or dad to be their date for the prom if they could get rid of their pimples!

I think we're all pretty aware of acne already. The purpose of National Acne Awareness Month is to impress upon parents and physicians what a big deal acne really can be to teenagers who have it. It needs to be seen as a disease, not just as a cosmetic problem.  Maybe what we really need is a National Shallow-People-Who-Judge-Based-on-Appearance Awareness Month.

A Spoonful of Sugar

A recent report in the March/April 2010 edition of the journal Pediatric Dermatology reported the use of an oral sucrose solution for pain relief in infants who were undergoing steroid injections into vascular birthmarks called hemangiomas.


As a pediatric dermatologist, minimizing pain is extremely important to me. I choose painless treatment modalities whenever possible, and when a painful procedure is necessary I take whatever measures I can to make it as pleasant as possible for the patient. It has been suggested that this is especially important for infants, because pain control for early procedures affects how kids respond to pain when they are older. Oral sucrose solution is currently commonly used in neonatal intensive care units and for circumcisions, and is used by some pediatricians for immunizations.


This 24% solution of sucrose is administered 2 minutes prior to the procedure, either by placing it on the anterior tip of the tongue or by dipping a pacifier into the solution. How does sugar numb pain? Well, we aren’t exactly sure, but it may activate sites in the brain that decrease pain perception, or it may cause the release of chemicals which cause babies to have less feeling of pain.


In addition to hemangioma steroid injections, oral sucrose solution could be used by pediatric dermatologists for biopsies and laser treatments. One caveat: it is only useful for infants less than one year of age. For older children, I use topical anesthetics and distraction techniques such as a portable DVD player. For infants less than a year of age, however, oral sucrose solution may help an infant tolerate many dermatologic procedures… in a most delightful way!

Be a Savvy Sunscreen Shopper

Parents ask me every day, “Which sunscreen should I use for my child?” The short answer is, “Whichever one they will actually use!” Most sunscreens, as long as they provide UVA/UVB coverage and are applied appropriately, will provide reasonable protection from the sun. The five following scenarios can help you choose which sunscreen might be best for your kiddos.

1) For daily use:

It is never too early to start applying a facial moisturizer with sunscreen on a daily basis. Kids don’t tend to mind them either, because they are non-greasy and don’t have the smell of traditional sunscreens.

My picks: Eucerin Everyday Protection Face Lotion, Oil of Olay Complete Defense, Neutrogena Healthy Defense

2) For infants:

Until 1996, the American Academy of Pediatrics didn’t recommend that any sunscreens be applied to infants under 6 months of age. Physicians agree that the best strategy for infants is sun avoidance and sun-protective clothing, but it is now recommended that sunscreen be applied where an infant’s skin is not protected adequately by clothing. For infants I recommend choosing one without chemical sunscreen ingredients. Look for a sunscreen with ONLY zinc oxide and titanium dioxide. This used to be really hard to find until Neutrogena introduced a new one last year.

My pick: Neutrogena Pure & Free Baby SPF 65+

3) For kids with sensitive skin:

Chemical sunscreens can cause irritation in children with sensitive skin or skin conditions such as atopic dermatitis.  Look for a sunscreen with ONLY zinc oxide and titanium dioxide.

My picks: Neutrogena Pure & Free Baby, Blue Lizard

4) For kids with REALLY sensitive skin or “allergy” to a previously used sunscreen

Not only can the chemical sunscreens be irritating, but some people can be allergic to fragrance or preservatives in the cream itself. Choose a brand with ONLY zinc oxide and titanium dioxide PLUS no added dyes, fragrance, lanolin, parabens, and other preservatives.

My pick: Vanicream Sensitive Skin Sunscreen

5) None of the above apply to you or your kids? Have fun with it!

Sunscreen comes in all kinds of formulations, including sprays (good for wiggly kids), sticks (great to carry in a pocket, purse, or diaper bag), and wipes.  Coppertone even makes a spray which goes on purple then disappears. (Coppertone Kids Colorblock SPF 40)

Disclaimer: I have absolutely no financial interest in any of these companies, by the way (just a sincere interest in getting kids to use sunscreen early & always).  Happy summer!