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The etiology of a DR is multifocal and the rash is not a single entity, but a reaction of the skin to several factors, both local and systemic (Liptak, 2001). There are several causative theories, ranging from food allergies to damage of the stratum corneum or the skin's top layer such as maceration, friction, and... show more The etiology of a DR is multifocal and the rash is not a single entity, but a reaction of the skin to several factors, both local and systemic (Liptak, 2001). There are several causative theories, ranging from food allergies to damage of the stratum corneum or the skin's top layer such as maceration, friction, and chapping (Liptak, 2001; Spraker, 2000). Wetness, dry skin, cleansing agents such as soap, elevated pH levels, fecal enzymes, fecal incontinence, and diarrhea due to infection or antibiotic use will alter skin integrity making the skin more susceptible to diaper dermatitis (Liptak, 2001; Spraker, 2000). Urinary incontinence may be associated with pediatric anomalies, neurological disorders, genetic syndromes, and trauma. Conditions associated with fecal incontinence may include: an ostomy takedown, anorectal malformations, perineal fistula, spina bifida, Hirshsprungs Disease, fecal impaction, and diarrhea.
Soaps strip away lipids, making the skin more permeable and vulnerable to diaper dermatitis. The normal pH of the skin is between 4.5-5.5. When urea from the urine and stool mix, urease breaks down the urine, increasing the hydrogen ion concentration (pH). Elevated pH levels increase the hydration of the skin and make the skin more permeable.
It was previously believed that ammonia was the primary cause of diaper dermatitis. Recent studies have disproved this, showing that when ammonia or urine is placed on the skin for 24 to 48 hours, no apparent skin damage occurs (Farrington, 1992; Berg et al., 1986). urine ammonia levels are the same in infants with or without diaper dermatitis (Farrington, 1992). Ammonia may be a secondary irritant on damaged skin, but it is probably not a primary cause of diaper dermatitis on intact skin.
Prevention
The goal in the management of a diaper rash is prevention. This is achieved through maintenance of skin integrity to prevent damage to the stratum corneum, the skin's barrier. Keeping the baby dry, which entails frequent diaper changes is the ideal way to both treat and prevent irritant diaper dermatitis. The frequency of diaper dermatitis decreases in relation to the increased number of diaper changes (Jorden et al., 1986).
Soiled diapers should be changed as soon as possible. If diaper dermatitis is present, diapers should be changed at least every 2 hours during the day and once at night. If possible, the infant should go without a diaper.
Cloth diapers, diaper services, and disposable diapers are debatable and a matter of preference, convenience, time, and cost. Home washed cloth diapers and commercial laundered diapers have significant differences (Farrington, 1992). Home laundering of cloth diapers will vary. Soaking soiled diapers in washing soda (sodium carbonate), such as Arm and Hammer in cold water, will act as a laundry booster, assist in removing stains, and neutralize odors. Wash all diapers in detergent and bleach in hot water. The detergent is the cleansing agent and bleach will disinfect and whiten. Adding a laundry booster or vinegar to the wash cycle will eliminate odors, counteract ammonia, and rinse out residue. Rinse and double rinse in cold water to remove chemicals and residual detergent. Fabric softener may be added to keep the diapers soft and to prevent friction. If irritation persists, products will need to be changed. Plastic pants are occlusive and should be avoided. Diaper services will use very hot water to effectively destroy microorganisms, along with detergents, multiple rinses, and sterilization techniques (Farrington, 1992; Spraker, 2000). When selecting a disposable diaper, consider type, size, and cost. There are many varieties and sizes available. Super absorbent disposable diapers contain an absorbent gelling material (AGM) that wicks away moisture. Studies suggest that these diapers are associated with less-severe diaper rashes (Farrington, 1992; Wong et.al., 1992). Trial and error techniques may be required, and several types or different diaper brands may need to be tested before the appropriate one is found best for the child.
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