A 6-month-old girl is brought to the clinic by her mother due to a rash in her diaper area for the past 2 days. The patient has been fussy with diaper changes but otherwise well with no fever, vomiting, or diarrhea. There have been no changes in the type of diapers, soap, or wipes. The patient had thrush twice in the first month of life and acute otitis media a month ago that resolved with a course of antibiotics. Vital signs are normal. Physical examination shows a well-appearing infant. Mucous membranes are moist and have no lesions. Examination of the labial area is shown in the exhibit. The remainder of the examination is normal. Which of the following is the best next step in the management of this patient?

Question

A 6-month-old girl is brought to the clinic by her mother due to a rash in her diaper area for the past 2 days.  The patient has been fussy with diaper changes but otherwise well with no fever, vomiting, or diarrhea.  There have been no changes in the type of diapers, soap, or wipes.  The patient had thrush twice in the first month of life and acute otitis media a month ago that resolved with a course of antibiotics.  Vital signs are normal.  Physical examination shows a well-appearing infant.  Mucous membranes are moist and have no lesions.  Examination of the labial area is shown in the exhibit.  The remainder of the examination is normal.  Which of the following is the best next step in the management of this patient?

Quizplus · Accepted Answer

11ec25c8_d643_b16c_bc81_b5467cf83c1d_MD0003_00 This patient has characteristic findings of irritant contact diaper dermatitis, the most common diaper dermatitis in infants. The rash is due to skin breakdown caused by moisture (ie, urine, stool) and friction from the diaper. Irritant contact diaper dermatitis is a clinical diagnosis based on the classic appearance of erythema in the genital region that is confined to the area in contact with the diaper. Mild dermatitis may cause scattered, painless papules, and more severe cases can present with areas of confluent erythema, maceration, or erosions. As seen in this patient, the absence of both skinfold involvement and satellite lesions (ie, discrete papules outside the borders of the rash) is classic. Irritant contact diaper dermatitis Conservative measures to prevent irritant contact diaper dermatitis include frequent diaper changes, diaper-free periods, and gentle cleansing with soap and water (or fragrance-/alcohol-free wipes). Application of a barrier ointment (eg, petrolatum) or paste (eg, zinc oxide) is first-line treatment and protects the skin from contact with local irritants. Low-potency topical corticosteroid ointment (eg, hydrocortisone) can be considered for refractory cases. (Choice A) Irritant contact dermatitis that is unresponsive to standard therapy warrants consideration of candidal diaper dermatitis, but characteristic findings include skinfold involvement and satellite lesions (not seen in this patient). Moreover, initial treatment of candidal superinfection is topical (not oral) antifungal therapy. Oral antifungal therapy is typically prescribed for oral candidiasis; this patient has a remote history of thrush, which is common in newborns due to immature immune systems, but no oral lesions on examination. candidal diaper dermatitis (Choice B) Topical permethrin is the treatment for scabies, a mite that causes discrete, erythematous papules with linear burrows. Although the lesions can involve the genitalia, they typically are also scattered elsewhere on the body (eg, hands, feet, axillae). This patient's rash confined to the diaper area makes scabies unlikely. (Choice D) Bacterial culture can be performed for suspicion of bacterial superinfection (ie, impetigo). Classic lesions include honey-crusted papules and pustules, not seen in this patient. (Choice E) Viral culture can be used to diagnose herpes simplex virus, which causes clusters of fluid-filled vesicles on an erythematous base, not scattered papules as seen in this patient. Educational objective: Irritant contact diaper dermatitis is common in infants and characterized by erythema that is confined to the area in contact with the diaper and spares skinfolds. Diagnosis is clinical, and treatment is with a barrier ointment or paste. References: Differential diagnoses of diaper dermatitis. (http://www.ncbi.nlm.nih.gov/pubmed/29596730)

A 6-Month-Old Girl Is Brought to the Clinic by Her