Don’t Be Rash: The Pediatric Dermatology Podcast

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Welcome to the Don’t Be Rash Pediatric Dermatology

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Podcast, the owner’s manual for your kid’s skin.

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I’m your host, Dr. K, board -certified pediatric

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dermatologist and father of two boys. I’m here

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to chat with you to promote dermatological education

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and improve skin health in our children everywhere.

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Let’s get started. Welcome to Don’t Be Rash,

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the pediatric dermatology show coming to you

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from beautiful, historic Bethlehem, Pennsylvania.

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I’m your host and board -certified pediatric

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dermatologist, Dr. Andrew Krakowski. On today’s

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show, we’re going to get “down in the dumps.”. That’s

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right, we’re going to be discussing diaper rashes,

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or as we call them in pediatric dermatology, more

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generally,, “diaper dermatitis.” Here’s the clinical

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scenario: You have a six -month-old baby with

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a bright red rash and satellite pustules. Don’t

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worry, if you don’t know what that is, you soon

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will. Is this caused by irritation from the poop

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and pee? Or is this yeast? Or is it a combination

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of both? Helping me “get to the bottom” – so to

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speak – is our guest pediatric dermatologist co

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-host, Dr. Caroline Piggott. In addition to being

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one of my best personal friends and colleagues,

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Dr. Piggott is a pediatric dermatologist at Scripps

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Clinic, in San Diego. Welcome, Dr. Piggott. Thanks

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for joining me today to talk about a topic not

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everyone would be so willing to try to tackle.

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Thank you so much for having me. This is something

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we encounter really often in clinic, a major

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concern for families. So I think this is a great

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topic to discuss. Yeah, it really is one of the

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most common things that I see in my pediatric

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dermatology clinic, which means if it got to

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me, I can only imagine how many cases of diaper

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rash our pediatrician and family medicine colleagues

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are seeing before they refer those kids to us.

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Is that fair? Oh, totally. And just as a mom

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in general, it’s a concern you have with any

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baby and probably a lot of them don’t even go

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to the doctor. Yeah. And it’s and it’s such you

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know, it’s such an opportunity, I feel, for education…

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You…you have a baby. No one. I mean, I’ve

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had two of them. Right. So I’ve never had someone

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come into the room before we were discharged

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from the hospital to tell us. There’s a right

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way or a wrong way to take care of poop and pee

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in the diaper area. And if you just got that

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little bit of education, I think you’d be 100%

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better off. Absolutely. And there’s a lot of

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misinformation online too. Even if you haven’t

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been taught about it, when you read about it

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online, there’s just so many different opinions.

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It’s hard to know where to begin. Yeah, it’s

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actually kind of scary because some of the stuff

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is just wrong, so we’ll get to that. Let’s talk

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a little bit about what makes the diaper area

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such a unique environment. I mean, it’s normal

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skin, right? But there’s some things that happen

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in that specific environment under an occlusive

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diaper that changes some things for us. Absolutely.

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And we’re the only species that uses a diaper,

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really. The problem, there’s a couple issues.

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First, there’s occlusion. You have moist environment

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due to urine or stool. And then you have something

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pressed right up against it that’s rubbing against

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it all day. Added on to that, there’s sweat,

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especially in kids who live in warm climates.

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There’s also all those things mixed together

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make a perfect environment for a rash or irritation

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to occur. Yeah. And on top of that, you’re talking

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about a newborn baby. So, you know, we know the

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skin barrier on children is a little thinner

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compared to our adults. In that particular area,

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you’re probably talking a higher pH, so not what

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the normal skin is used to seeing. And everything

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is a little leakier as well because of that thinner

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skin barrier. And then you’ve got, you know,

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obvious change or the obvious big difference

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is you’re pooping into. basically a bucket that’s

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held right up against the skin for at least a

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couple of minutes right and you know to me when

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I talk about it with my families they always

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are amazed at why the skin can get so irritated

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just from that and it’s like well I don’t know

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how you approach that but I use the analogy or

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not analogy it’s really kind of a story like,..

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Imagine you’re a bite of food that gets taken

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into the mouth goes down the esophagus in your

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stomach. Now it’s going through the intestinal

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tract and finally it comes out the other end.

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It had to have been digested. And what is it

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getting digested by? Enzymes, chemicals that

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are breaking down that food into something that

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your body can then absorb into it for sustenance

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and energy, right? Well, those enzymes are also

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coming out the bottom end and landing right in

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that diaper. And when you put that on the skin,

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you can get into some real trouble. Yeah. And,

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you know, we all have normal skin flora on our

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skin, but stool also can carry with it certain

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pathogens that like to live in that environment

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that are then sitting against the skin for, you

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know, minutes to hours. There’s also, you know,

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depending, especially when babies are a little

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bit older or depending on what the mother is

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eating in her diet, if the baby’s breastfed,

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different foods process differently and have

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different pHs when they come out the other end.

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Is it a spicier diet? Is it more bland of a diet?

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Things like that even play a role. Yeah. And

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then you get into even more specific clinical

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scenarios where let’s say you never had a problem

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with diaper dermatitis, but now your baby or

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young infant is suffering through like a gastroenteritis

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where, hey, everything else is probably going

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to be okay, but you’re pooping 14 times in 24

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hours. No matter what, that’s going to cause

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some sort of irritation. Exactly. Or a kid on

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antibiotics. The antibiotics themselves can change

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the pH of the poop or, you know, what’s in the

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poop and make it looser, more irritated. Or another

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thing that can affect it is even if kids have

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allergies, it changes their poop and then that

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poop is then rubbing against the skin. Yeah.

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So let’s take more of a 50,000 -foot view look

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at this, although I don’t know if you want to

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look at it any more than I do. But let’s say

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we’re considering diaper rash in general. There’s

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a lot of specific causes for why a kid could

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have diaper rash, right? Oh, absolutely. There’s

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about a dozen different things that are on our

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what we call “differential diagnosis” – or things

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that can potentially cause them. And one of the

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key things to know about is some of the clues

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to look for to figure out. which one it is. So

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the one that kind of already put our foot in,

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so to speak, is this idea that poop and pee itself

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can irritate the skin. And we call that “Irritant

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Diaper Dermatitis.” That doesn’t sound very specific,

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but if you mention that to a pediatric dermatologist,

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we know that what you’re basically saying is

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that the urine and feces itself is irritating

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the skin. And I think we already alluded to the

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fact that that’s the most common cause, right?

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Like, way more than anything else. Yeah. Yeah.

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When in doubt, statistically speaking, that’s

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what is the most common cause. And what we typically

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do when a baby presents is we look for first

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some of the key visual clues to figure out what’s

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going on. And with this particular type of dermatitis

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or irritant diaper dermatitis, It typically presents

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as sort of a beefy red-colored rash or plaque.

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Sometimes it might look a little shiny, not always

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though. And one of the things, because if you

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think about the anatomy and where the skin is

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rubbing with the diaper, it typically is located,

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you know, sort of in the pubic area, maybe on

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the inner thigh, but because of where the diaper

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rubs more and rubs less, it often spares the

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actual very edge of the folds and the groin so in other

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words there’s a skip area where the rash often

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you know it disappears and then then reforms

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on the other edge passing sort of jumping from

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the inner thigh skipping the fold and and then

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moving over onto the pubic area. Basically the

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“area under the chunk” is sort of protected is

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that fair? Yes, it spares the folds. Spares the

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folds, yeah. And that’s a mechanical thing, right?

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So, if the chunk wasn’t there and that poop and

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pee could get into that area, it would also cause

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the same rash that you can see everywhere else.

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But it’s a clue that it’s something that’s right

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up against the diaper, right up in contact, hence

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the name “Irritant Contact Dermatitis.” And is

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this one like, this is one where I would say,

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geez, when your history of recent antibiotic

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use or upset. stomach causing diarrhea that’s

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where you really start to think about this one

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as well. Exactly but you know it’s not always

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the case where there’s a history of that some

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babies you know one of the most common things

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that pediatrician sees is parents you know calling

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in with questions: Why did my baby’s poop change?

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You don’t always have a reason. Sometimes it’s

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looser. Sometimes it’s more foreign. Depends

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on what the baby or mother is eating. And so

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it’s not always history of an infection or things

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like that. Sometimes just the stool changes on

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its own periodically. Now, within this category,

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I also include something that’s really much more

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severe in my mind, something called Jacquet’s

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or Jacquet’s erosive diaper dermatitis. Is that

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fair? Yes, it’s almost like it’s basically a

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fancy name for an extreme form of this. We see

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it a lot in like premature babies who have really

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thin skin or just cases where the stool is loose

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just for longer periods of time just consistently.

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The irritation becomes so bad that it actually

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tears a little layer superficially of the skin

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and the baby has these very painful ulcers. I

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mean, imagine whether it’s in your diaper or

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not, if you have a little sore on your skin and

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you rub a piece of material against it over and

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over all day, anybody is going to have a sore

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area. And the poor baby unfortunately suffers

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from this. Yeah, it’s very painful. It has to

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be differentiated from something called “herpes

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simplex virus,” especially in a younger kid, two

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weeks old. You have to make sure it’s not herpes

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before you think about anything, in fact. But

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I don’t know about you, but some clues that I

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have is it tends to be worse. closer to the actual

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anus. And then as you get farther and farther

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away, it seems to kind of get a little better.

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That sometimes can be a clue that it’s this Jaquet’s.

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But yeah, it can be tremendously painful and

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horrific looking. It would scare anybody, right?

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Yeah. And I agree completely. One of the things

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on your differential for those would be infection.

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But usually these ulcers are very dry looking,

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like they might be open and sore, but there’s

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no pus – or we call it purulence – coming out or

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fluid. They’re often just very just dry and raw.

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So probably in my mind, at least the next most

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common diaper dermatitis cause, specific cause,

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would be yeast. And we call that… “Candidal,

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Diaper Dermatitis.” Candida is the species

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name of the yeast in this particular case that’s

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driving the problem. Talk a little bit about

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what you’re looking for when you’re considering

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is yeast possibly the culprit. When you have

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just the regular irritant diaper dermatitis,

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yeast can eventually infect it. So this is always

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something you want to look for on your differential.

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And sort of the classic clue is we call them

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“satellite pustules.” So you’ll have the rash,

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but then there might be individual discrete bumps

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or papules that have a little pus or fluid in

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the center, almost white or off-white. And there

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will be often a couple of them, that’s why we

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call them “satellites,” often around the periphery.

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And that’s one of the clues. Often the color

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is even more red than the typical rash. And oftentimes

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you even smell a little bit of an odor. I’m not

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getting that close because I don’t want to smell

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any odor. The mom will tell you it smells weird.

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Okay, sure. And now this one, the satellite port,

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do you attribute that to sort of the yeast organism

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itself kind of getting on the skin and spreading

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on its own, right? It can go outside of the normal

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diaper spot. Yes. And the thing with this is

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it does, we mentioned that the sort of conventional

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diaper dermatitis will spare sometimes the folds.

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Well, this one, this one does not spare anything.

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It just keeps going and it’ll continue even within

00:12:32.779 –> 00:12:35.980
that fold of the skin. And I don’t know, you

00:12:35.980 –> 00:12:37.840
and I were trained at the same place, but I remember

00:12:37.840 –> 00:12:40.500
Dr. Friedlander, one of our mentors, always telling

00:12:40.500 –> 00:12:43.080
you, you got to check the mouth, right? Because

00:12:43.080 –> 00:12:47.480
yeah, many times, like a lot. more than half

00:12:47.480 –> 00:12:50.460
you’re going to find oral thrush that white tongue

00:12:50.460 –> 00:12:53.419
which is yeast on the tongue on that baby too.

00:12:53.419 –> 00:12:55.440
And it makes sense you’re swallowing that and

00:12:55.440 –> 00:12:57.779
pooping it out into the diaper which again is

00:12:57.779 –> 00:13:00.080
just really kind of a bucket now you’ve got that

00:13:00.080 –> 00:13:03.039
yeast organism held in the bucket up against

00:13:03.039 –> 00:13:05.000
the skin it’s no surprise that it’s taken off.

00:13:05.470 –> 00:13:10.470
I agree. And then if you’re not sure, we dermatologists

00:13:10.470 –> 00:13:14.809
do a test called a KOH, which is we take a little

00:13:14.809 –> 00:13:16.830
sample of the skin and look at it under the microscope.

00:13:16.870 –> 00:13:18.909
But if you don’t have access to that, it’s okay.

00:13:19.309 –> 00:13:22.149
There’s another way to test it. The swab that

00:13:22.149 –> 00:13:24.490
we use for a lot of our bacterial cultures can

00:13:24.490 –> 00:13:26.590
also be used to take what’s called a fungal culture.

00:13:26.750 –> 00:13:29.570
And you just take a gentle Q-tip, swab it against

00:13:29.570 –> 00:13:31.649
the skin, and you can actually have your lab

00:13:31.649 –> 00:13:34.289
plate it on a Petri dish and look for yeast or

00:13:34.289 –> 00:13:36.840
fungus or things. things like that. Within three

00:13:36.840 –> 00:13:39.899
to five days, you got an answer. Yes. Yes. Although

00:13:39.899 –> 00:13:42.700
I do, we typically leave it for yeast. We do

00:13:42.700 –> 00:13:44.580
have to sometimes leave it a little bit longer.

00:13:45.500 –> 00:13:48.379
But yes, so even if you don’t have a microscope,

00:13:48.720 –> 00:13:52.419
Worry not, That’s another way to do it. And I

00:13:52.419 –> 00:13:55.100
think your point that no matter what rash you’re

00:13:55.100 –> 00:13:57.820
talking about, within a certain amount of time,

00:13:57.879 –> 00:14:00.440
you almost always get colonization where the

00:14:00.440 –> 00:14:03.539
yeast is living on the skin. So you kind of have

00:14:03.539 –> 00:14:06.720
to build that into any treatment plan for a rash

00:14:06.720 –> 00:14:08.419
that’s there more than a couple of days. Is that

00:14:08.419 –> 00:14:12.059
fair? Correct. And not just yeast, but also you

00:14:12.059 –> 00:14:15.240
have other organisms like Strep or Staph that

00:14:15.240 –> 00:14:18.259
also can infect the area too. Talk a little bit

00:14:18.259 –> 00:14:20.960
about sort of “cradle cap” in the diaper area.

00:14:21.639 –> 00:14:24.659
So our term for that is “Seborrheic Dermatitis”

00:14:24.659 –> 00:14:29.220
or “seborrhea.” And so on the scalp, it’ll present

00:14:29.220 –> 00:14:32.399
with flaking, sort of like a greasy, scaly plaque

00:14:32.399 –> 00:14:34.500
that often extends sort of onto the facial area

00:14:34.500 –> 00:14:37.039
as well. But kids with this can also have the

00:14:37.039 –> 00:14:40.139
same condition. in the diaper area. We like to

00:14:40.139 –> 00:14:43.500
say a “salmon-colored” red as opposed to the beefy

00:14:43.500 –> 00:14:46.720
red of the previous one. And this one will tend

00:14:46.720 –> 00:14:49.879
to be a lot more scaly, a little bit greasier

00:14:49.879 –> 00:14:52.539
in color. And the clue is often that you do have

00:14:52.539 –> 00:14:54.679
rashes elsewhere on the body in these cases.

00:14:55.220 –> 00:14:58.559
And it can look just like eczema or atopic dermatitis.

00:14:59.100 –> 00:15:01.899
Correct. Correct. And so what, what, what’s also

00:15:01.899 –> 00:15:04.279
always helpful in a baby is not to just examine

00:15:04.279 –> 00:15:06.679
their diaper area, but do an exam elsewhere on

00:15:06.679 –> 00:15:08.740
the skin. Even sometimes parents don’t even realize

00:15:08.740 –> 00:15:11.240
it’s elsewhere, but you can look in the, in the

00:15:11.240 –> 00:15:14.480
folds of the armpit neck, look at the scalp behind

00:15:14.480 –> 00:15:17.779
the ears, et cetera. And, you know, correct me

00:15:17.779 –> 00:15:19.799
if I’m wrong, but in my mind, what I’m trying

00:15:19.799 –> 00:15:23.419
to figure out is this seborrheic dermatitis versus

00:15:23.419 –> 00:15:26.960
something else or eczema versus seborrheic dermatitis.

00:15:27.399 –> 00:15:31.620
I’m thinking – relative to seborrheic dermatitis –

00:15:31.799 –> 00:15:35.000
atopic dermatitis or eczema tends to spare, not

00:15:35.000 –> 00:15:39.820
involve the diaper area as much. Is that fair

00:15:39.820 –> 00:15:42.779
to say? I’m much more likely, if it looks like

00:15:42.779 –> 00:15:45.419
eczema and it’s in the diaper area, I’m leaning

00:15:45.419 –> 00:15:47.779
towards seborrheic dermatitis. At the same time,

00:15:47.799 –> 00:15:51.340
you can often have both. Yeah, right. They run

00:15:51.340 –> 00:15:56.129
together. It can be really tricky. Let’s talk

00:15:56.129 –> 00:15:58.049
a little bit about “eczema/atopic dermatitis”

00:15:58.049 –> 00:15:59.570
in the diaper area. What are some clues there?

00:16:00.470 –> 00:16:03.570
Usually these are very, very dry patches. You

00:16:03.570 –> 00:16:07.690
don’t have as many pustules or greasy look. It’s

00:16:07.690 –> 00:16:12.600
just a dry. scaly, often scratched area. Sometimes

00:16:12.600 –> 00:16:14.940
there’s thickening of the skin from frequent

00:16:14.940 –> 00:16:19.000
scratching. And the key with that is, you know,

00:16:19.039 –> 00:16:21.320
you very rarely have isolated to the diaper as

00:16:21.320 –> 00:16:23.120
well with eczema. You’ll have clues elsewhere,

00:16:23.220 –> 00:16:26.700
sort of in the antecubital popliteal fossa, there

00:16:26.700 –> 00:16:29.700
will be rashes. The child might have a sibling

00:16:29.700 –> 00:16:33.509
with eczema or atopic dermatitis. Or even the

00:16:33.509 –> 00:16:36.769
child or siblings might have other conditions

00:16:36.769 –> 00:16:40.169
in the atopic family. And when I say atopic family,

00:16:40.289 –> 00:16:43.090
I mean things like asthma, hay fever, things

00:16:43.090 –> 00:16:48.149
like that. Yeah, and classically, you are taught

00:16:48.149 –> 00:16:52.129
that eczema does tend to spare the diaper area

00:16:52.129 –> 00:16:54.549
because it’s that occlusive, humid environment.

00:16:54.669 –> 00:16:58.090
But to your point, if it’s bad enough, it can

00:16:58.090 –> 00:17:00.429
be in the diaper as well. One of the things that

00:17:00.429 –> 00:17:03.330
I think I see… in the diaper area when it’s

00:17:03.330 –> 00:17:06.609
eczema more than other rashes is this sort of

00:17:06.609 –> 00:17:08.630
thickening of the skin or lichenification, which

00:17:08.630 –> 00:17:11.349
can be a clue that this is long-standing chronic

00:17:11.349 –> 00:17:14.450
inflammation that’s caused the skin to almost

00:17:14.450 –> 00:17:16.690
thicken up in response to getting rubbed and

00:17:16.690 –> 00:17:20.069
scratched as much as it has been. But that can

00:17:20.069 –> 00:17:22.990
be pretty tricky, I think. And to make it even

00:17:22.990 –> 00:17:25.769
trickier, they can also have a thick condition

00:17:25.769 –> 00:17:28.029
in their diaper area called “psoriasis,” which

00:17:28.029 –> 00:17:30.630
can also manifest there. That’s one of the, that

00:17:30.630 –> 00:17:33.589
I stand by the fact that it took me longer to

00:17:33.589 –> 00:17:35.650
be able to pull the trigger and make the diagnosis

00:17:35.650 –> 00:17:38.430
of psoriasis in a kid. But now you’re talking

00:17:38.430 –> 00:17:40.430
baby. It’s even more because in my head, I’ve

00:17:40.430 –> 00:17:42.369
told, I’ve talked about this. I’ve had that in

00:17:42.369 –> 00:17:46.390
my brain as an adult problem. And even in pediatric

00:17:46.390 –> 00:17:48.670
dermatology fellowship, it was just hard for

00:17:48.670 –> 00:17:51.369
me to say, “Geez, this is probably psoriasis.”

00:17:51.390 –> 00:17:53.710
Now I make the diagnosis a couple of times a

00:17:53.710 –> 00:17:56.029
week and I’m comfortable with it, but it really

00:17:56.029 –> 00:17:58.490
took me a long time to get comfortable saying

00:17:58.490 –> 00:18:01.130
this is, this is probably psoriasis. What clues

00:18:01.130 –> 00:18:03.529
are you looking for for something to be labeled

00:18:03.529 –> 00:18:07.150
psoriasis? One of the first things I’ve noticed

00:18:07.150 –> 00:18:09.809
is with the psoriasis kids is a lot of it extends

00:18:09.809 –> 00:18:12.670
up onto the pubic area a lot more, a lot higher.

00:18:13.809 –> 00:18:17.329
It typically has very sharp or we call it well

00:18:17.329 –> 00:18:20.470
demarcated borders.. So with eczema, so basically

00:18:20.470 –> 00:18:23.059
imagine you took a pen. With psoriasis, you

00:18:23.059 –> 00:18:25.700
can literally take a perfect outline of the edge

00:18:25.700 –> 00:18:29.019
of the lesion, usually, and tell where the skin

00:18:29.019 –> 00:18:31.859
of psoriasis ends and the normal skin begins.

00:18:32.019 –> 00:18:34.380
Whereas in eczema, we call it ill-defined. You

00:18:34.380 –> 00:18:37.279
know, it’s hard to, it almost melts into the

00:18:37.279 –> 00:18:39.460
surrounding skin. Whereas, you know, really with

00:18:39.460 –> 00:18:42.759
psoriasis, you can see a sharp outline. Yeah,

00:18:42.799 –> 00:18:45.779
and psoriasis is unique, at least compared

00:18:45.779 –> 00:18:48.680
to atopic dermatitis and seborrheic dermatitis

00:18:48.680 –> 00:18:52.140
and irritant contact dermatitis, because it often

00:18:52.140 –> 00:18:55.099
can do something called “koebnerize,” which is wherever

00:18:55.099 –> 00:18:59.180
there is friction or trauma to the skin. In this

00:18:59.180 –> 00:19:01.220
case, it’s the friction of the diaper rubbing

00:19:01.220 –> 00:19:05.140
on the kid. You can actually see a totally perfect

00:19:05.140 –> 00:19:09.250
match of rash to diaper. And it takes it right

00:19:09.250 –> 00:19:11.009
up to the waistband, all the way down to the

00:19:11.009 –> 00:19:13.849
waistbands, or I guess what you call them, leg

00:19:13.849 –> 00:19:16.450
bands. And you can say, geez, that looks exactly

00:19:16.450 –> 00:19:18.589
like where the diaper would be. Yeah, that’s

00:19:18.589 –> 00:19:21.309
exactly right. Absolutely. And two of my other

00:19:21.309 –> 00:19:24.250
favorite clues for baby psoriasis especially

00:19:24.250 –> 00:19:28.869
is looking in two other folds, armpit and groin.

00:19:28.910 –> 00:19:31.849
So if there’s another well demarcated plaque

00:19:31.849 –> 00:19:33.990
elsewhere, that’s really helpful. And then the

00:19:33.990 –> 00:19:37.640
third most favorite area. uh sort of on the torso

00:19:37.640 –> 00:19:41.339
is actually in the umbilical – the “bebo” – yep yep

00:19:41.339 –> 00:19:46.339
on and then with psoriasis too that often not

00:19:46.339 –> 00:19:49.019
always but often runs in families so does grandma

00:19:49.019 –> 00:19:52.160
does mom dad have any history of psoriasis and

00:19:52.160 –> 00:19:54.160
then the last thing that’s always important to

00:19:54.160 –> 00:19:57.559
check is Sometimes you can get ridging or little

00:19:57.559 –> 00:20:00.559
dots we call pits in the fingernails or toenails.

00:20:00.700 –> 00:20:02.660
But again, not all of these things are always

00:20:02.660 –> 00:20:04.839
present. So that’s why it’s so hard to diagnose.

00:20:04.839 –> 00:20:08.400
And to treat, right? I mean, they can all be

00:20:08.400 –> 00:20:11.500
hard to treat, even irritant contact if the

00:20:11.500 –> 00:20:13.680
poop and pee just keep coming, you’re really

00:20:13.680 –> 00:20:15.900
kind of behind the eight ball. But psoriasis,

00:20:15.900 –> 00:20:20.339
I feel like that definitely requires longer treatment,

00:20:20.599 –> 00:20:23.819
longer direct treatment than some of these other

00:20:23.819 –> 00:20:26.609
conditions. Probably in part because of that

00:20:26.609 –> 00:20:29.490
koebnerization phenomenon where if the rubbing

00:20:29.490 –> 00:20:32.369
is still there, so is the skin condition. That’s

00:20:32.369 –> 00:20:34.450
just my take. I don’t know. Absolutely. And often

00:20:34.450 –> 00:20:36.650
prescription strength medicine is needed, whereas

00:20:36.650 –> 00:20:38.930
many of these other things, especially if we’re

00:20:38.930 –> 00:20:40.670
talking steroids and things like that, stronger

00:20:40.670 –> 00:20:42.589
medicine is needed for psoriasis, certainly.

00:20:43.970 –> 00:20:46.470
Now, one thing that I don’t feel is as common

00:20:46.470 –> 00:20:48.130
as these other things that we just have been

00:20:48.130 –> 00:20:52.230
talking about is a true allergy to the diaper,

00:20:52.390 –> 00:20:54.849
right? For whatever reason, it seems the most

00:20:54.849 –> 00:20:57.849
common question I get when I see patients with

00:20:57.849 –> 00:21:00.650
diaper rashes from families, and I understand

00:21:00.650 –> 00:21:03.470
why. “Is my child allergic to something we’re

00:21:03.470 –> 00:21:05.849
using?” Is it an allergy to the diaper? Is it

00:21:05.849 –> 00:21:08.990
an allergy to the butt paste? Is it an allergy

00:21:08.990 –> 00:21:12.890
to the wipes? Certainly these are possible, but

00:21:12.890 –> 00:21:17.309
actually quite rare. Yeah, yeah. I mean, it makes

00:21:17.309 –> 00:21:20.150
sense. You’re putting a plastic sheet on your

00:21:20.150 –> 00:21:23.549
kids – on your newborn baby’s most sensitive skin

00:21:23.549 –> 00:21:27.049
area. As a new mom or dad, I would certainly

00:21:27.049 –> 00:21:29.009
understand why someone could think, geez, they

00:21:29.009 –> 00:21:31.549
must be allergic to the plastic. But where it’s

00:21:31.549 –> 00:21:35.230
very common for older kids and adults to develop

00:21:35.230 –> 00:21:38.250
allergies to the chemicals in their sneakers

00:21:38.250 –> 00:21:40.890
or their gloves that they wear for their occupation,

00:21:40.950 –> 00:21:44.089
it’s pretty rare to have a kid with true allergy

00:21:44.089 –> 00:21:47.269
to their diaper. thankfully. Yeah especially if

00:21:47.269 –> 00:21:49.470
it’s not the whole way around towards the back

00:21:49.470 –> 00:21:53.809
on the bottom um and but but if it is going to

00:21:53.809 –> 00:21:55.390
be an allergy some of the things that can do

00:21:55.390 –> 00:21:58.130
it are is it a wipe that has a lot of fragrance?

00:21:58.130 –> 00:22:00.410
Fragrances are never a good idea when you’re

00:22:00.410 –> 00:22:05.680
talking about baby wipes um. Does your diaper

00:22:05.680 –> 00:22:09.059
rash cream have lavender in it or something extra

00:22:09.059 –> 00:22:11.440
that you don’t need? Those are some of the culprits

00:22:11.440 –> 00:22:12.640
if there is going to be something. That’s a great

00:22:12.640 –> 00:22:15.339
point. And thankfully, we have the ability, even

00:22:15.339 –> 00:22:18.640
in babies, to do what’s called patch testing.

00:22:19.160 –> 00:22:21.200
Do you have an age limit that you go down to

00:22:21.200 –> 00:22:25.420
for patch testing? You know, we’ll do it on babies,

00:22:25.500 –> 00:22:27.519
but it’s not my favorite thing to do. Just there’s

00:22:27.519 –> 00:22:30.849
not much room on the back to do testing. Right.

00:22:30.970 –> 00:22:34.529
I mean, at may be a year or two. I would probably,

00:22:34.569 –> 00:22:35.910
you know, I’m not doing it much younger than

00:22:35.910 –> 00:22:37.730
that because the risk is you might sensitize

00:22:37.730 –> 00:22:40.170
them also, right, with some of the testing products

00:22:40.170 –> 00:22:42.569
that you’re using. But I don’t have a problem

00:22:42.569 –> 00:22:46.289
if it’s a one and a half year old and mom or

00:22:46.289 –> 00:22:48.450
dad thinks that they’re allergic to their diaper.

00:22:48.750 –> 00:22:51.119
I mean, you can always just test for. the diaper

00:22:51.119 –> 00:22:53.519
as a use test as well. Right. So you don’t have

00:22:53.519 –> 00:22:55.700
to do it. Correct. I’d rather do something like

00:22:55.700 –> 00:22:58.660
that or, or, or do a trial and error of elimination.

00:22:58.839 –> 00:23:00.799
Right. Right. Exactly. Does it get any better

00:23:00.799 –> 00:23:03.319
when you don’t wear this diaper or, or a different,

00:23:03.359 –> 00:23:05.240
different kind? You have to be, if you’re going

00:23:05.240 –> 00:23:07.039
to switch out the diaper, then you have to make

00:23:07.039 –> 00:23:09.980
sure you’re completely switching it out so that

00:23:09.980 –> 00:23:12.200
it’s, if it was a plastic diaper before, maybe

00:23:12.200 –> 00:23:14.400
you’re going to an all cotton diaper instead,

00:23:14.500 –> 00:23:18.460
or a, or even one of those washable cotton cloth.

00:23:19.039 –> 00:23:21.839
napkins that they call, right? So try that for

00:23:21.839 –> 00:23:23.619
a couple of weeks. Yeah, which unfortunately

00:23:23.619 –> 00:23:27.200
rarely solves the problem, but can. One infection

00:23:27.200 –> 00:23:29.779
that we see, not infrequently, I don’t know about

00:23:29.779 –> 00:23:34.039
you guys out in San Diego, but beefy red, right

00:23:34.039 –> 00:23:40.059
around the sort of perirectal area, Strep. Strep

00:23:40.059 –> 00:23:45.680
bacteria. Correct. And in these kids, it’s often

00:23:45.680 –> 00:23:47.740
persistent despite, you know, multiple different

00:23:47.740 –> 00:23:50.779
creams that they’ve tried, switching diaper paste,

00:23:50.960 –> 00:23:54.460
etc. It’s quite a bright rash. Sometimes you

00:23:54.460 –> 00:23:57.839
have little fissures around the area. And it’s

00:23:57.839 –> 00:24:00.339
typically just in the perianal area, not elsewhere.

00:24:00.640 –> 00:24:03.160
What I usually do is take a little swab and culture.

00:24:03.559 –> 00:24:07.200
And it usually responds pretty well to oral antibiotics

00:24:07.200 –> 00:24:10.079
in the penicillin/amoxicillin family, barring

00:24:10.079 –> 00:24:12.680
allergies. Sometimes in these kids, throat cultures

00:24:12.680 –> 00:24:15.059
can be positive. I’ve been fooled and it’s not

00:24:15.059 –> 00:24:17.960
Strep and it’s actually Staph. For point of clarification,

00:24:18.180 –> 00:24:19.799
when you say that they are walking around with

00:24:19.799 –> 00:24:21.640
strep in their throat, you would do a culture

00:24:21.640 –> 00:24:23.380
and it’s positive. Doesn’t necessarily mean they

00:24:23.380 –> 00:24:26.339
have to show symptoms of strep throat. Yes, there’s

00:24:26.339 –> 00:24:28.400
no sore throat. They’re not otherwise ill. They

00:24:28.400 –> 00:24:31.319
just sometimes are even carriers. Yeah, another

00:24:31.319 –> 00:24:35.599
place I’ve seen. Strep also kind of land is in

00:24:35.599 –> 00:24:38.140
the neck crease and sometimes the armpits. I

00:24:38.140 –> 00:24:40.019
mean, it’s rare, but sometimes usually it’s just,

00:24:40.019 –> 00:24:43.519
it’s just in that diaper area. And when it’s,

00:24:43.519 –> 00:24:45.980
when it’s just there and nothing else is involved,

00:24:46.160 –> 00:24:48.259
it’s, I think that’s the strongest clue that

00:24:48.259 –> 00:24:50.119
you’re probably dealing with something infectious,

00:24:50.160 –> 00:24:52.599
like, like perianal strep. And the good news

00:24:52.599 –> 00:24:56.160
is it gets very better, very quickly with, as

00:24:56.160 –> 00:24:58.339
you said, I usually just use Keflex. I don’t

00:24:58.339 –> 00:25:01.660
know about you, but. Yeah, Keflex. Because that

00:25:01.660 –> 00:25:04.619
way it covers for Staph if it happens to be Staph

00:25:04.619 –> 00:25:07.819
as well, in most cases. Well, the next one I’ll

00:25:07.819 –> 00:25:12.660
throw at you is not a common diagnosis, but quite

00:25:12.660 –> 00:25:16.880
severe if you’re suffering from it. And that’s

00:25:16.880 –> 00:25:19.160
a “zinc deficiency,” of which there can be a lot

00:25:19.160 –> 00:25:21.500
of different versions of how you can end up being

00:25:21.500 –> 00:25:24.720
zinc deficient. But tell us how you might expect

00:25:24.720 –> 00:25:27.420
someone to come into your clinic as a child with

00:25:27.420 –> 00:25:30.009
zinc deficiency. So first of all, this is super

00:25:30.009 –> 00:25:32.609
rare. I maybe see it once every year or two.

00:25:32.710 –> 00:25:35.549
So it’s not something that, you know, most families

00:25:35.549 –> 00:25:37.829
need to worry about, but they’ll come in with

00:25:37.829 –> 00:25:40.069
the, you know, sort of a diaper rash, but they’ll

00:25:40.069 –> 00:25:44.259
also have. basically a similar looking rash on

00:25:44.259 –> 00:25:46.819
the perioral area. So it’s not just in the diaper

00:25:46.819 –> 00:25:49.839
area. It can be on the perioral area or also

00:25:49.839 –> 00:25:54.640
even on the hands or feet or other areas. They

00:25:54.640 –> 00:25:59.000
are very scaly, very red, resistant to sort of

00:25:59.000 –> 00:26:01.140
the typical treatments that you might give. So

00:26:01.140 –> 00:26:03.279
it’s not the first thing that I think of. I wouldn’t

00:26:03.279 –> 00:26:06.720
go jump right to that diagnosis, but I’ll ask

00:26:06.720 –> 00:26:11.200
mom’s history. Is the baby breast? fed or not?

00:26:11.200 –> 00:26:13.660
Did it start after you stopped breastfeeding?

00:26:13.660 –> 00:26:18.380
um Was the baby born early any other issues medically

00:26:18.380 –> 00:26:21.839
like you know syndromes of malabsorption things

00:26:21.839 –> 00:26:24.000
like that and the reason you’re asking about

00:26:24.000 –> 00:26:25.960
if the baby was breastfed because sometimes mom’s

00:26:25.960 –> 00:26:28.220
breast milk just simply doesn’t have enough zinc

00:26:28.220 –> 00:26:31.359
in it To get the baby’s zinc levels up, right?

00:26:31.519 –> 00:26:34.579
Right. Or sometimes the mom’s breast milk has

00:26:34.579 –> 00:26:36.640
enough and you don’t notice it until the mom

00:26:36.640 –> 00:26:39.119
stops breastfeeding. Stops breastfeeding. And

00:26:39.119 –> 00:26:42.700
then premature, they just can’t stack the amount

00:26:42.700 –> 00:26:45.240
of zinc that they need. Correct. To not get deficient.

00:26:45.319 –> 00:26:48.849
Correct. If this is on my differential, which

00:26:48.849 –> 00:26:50.869
again, it is not the first thing I think of in

00:26:50.869 –> 00:26:55.009
most cases, but if it is, oftentimes a way to

00:26:55.009 –> 00:26:57.390
figure it out is to do labs and blood work, which

00:26:57.390 –> 00:27:01.009
what we look for is low alkaline phosphatase

00:27:01.009 –> 00:27:03.890
levels. We check zinc levels, which would be

00:27:03.890 –> 00:27:07.250
low. There’s good treatment available. This is

00:27:07.250 –> 00:27:09.650
totally fixable, but the labs are really helpful

00:27:09.650 –> 00:27:12.670
in this case. Well, that’s the miracle of zinc

00:27:12.670 –> 00:27:14.970
deficiency. I mean, the couple of kids that I’ve

00:27:14.970 –> 00:27:18.869
had, actually have zinc deficiency when you supplement

00:27:18.869 –> 00:27:22.210
them with zinc what, what looks like the most

00:27:22.210 –> 00:27:26.950
horrific diaper rash in three, five, seven days

00:27:26.950 –> 00:27:29.349
it’s gone i mean it just gets better it’s amazing!

00:27:29.349 –> 00:27:33.809
So it’s important to make that diagnosis and

00:27:33.809 –> 00:27:36.750
i don’t know about you but i always kind of think

00:27:36.750 –> 00:27:39.509
of the rash on the face that you mentioned as

00:27:39.509 –> 00:27:41.509
being an important part of this it’s sort of

00:27:41.509 –> 00:27:44.630
got this distinct “U-shape” to it. And it’s, I

00:27:44.630 –> 00:27:46.410
don’t know, it’s always looked pinkish yellow

00:27:46.410 –> 00:27:48.349
to me whenever I’ve seen it in real life. Now,

00:27:48.410 –> 00:27:50.650
how many have I seen? Not that many, but you

00:27:50.650 –> 00:27:53.950
know. Right, right. And again, in most of these

00:27:53.950 –> 00:27:56.410
cases, it’s not that. It’s probably just eczema

00:27:56.410 –> 00:27:58.650
on the face as well, but definitely something

00:27:58.650 –> 00:28:01.430
to have in your differential and not to be forgotten.

00:28:01.789 –> 00:28:04.589
So now I’m going to get your pulse up because

00:28:04.589 –> 00:28:08.349
I know you and I know you always think of what

00:28:08.349 –> 00:28:13.140
the worst case scenario could be. When you have

00:28:13.140 –> 00:28:15.200
a kid that comes in with a diaper rash that’s

00:28:15.200 –> 00:28:17.720
not responsive to treatment, the zinc’s normal,

00:28:17.920 –> 00:28:20.180
everything that we’ve talked about up to this

00:28:20.180 –> 00:28:23.559
point is just not making sense. What are you

00:28:23.559 –> 00:28:27.519
concerned about? So there’s this really rare

00:28:27.519 –> 00:28:31.440
condition called “Langerhans Cell Histiocytosis.”

00:28:31.460 –> 00:28:37.019
We call it LCH. And most of these children, something

00:28:37.019 –> 00:28:40.829
doesn’t… look right on their rash. So the first

00:28:40.829 –> 00:28:43.690
thing you’ll notice on kids with this condition,

00:28:43.869 –> 00:28:47.490
which basically what it is, it’s this inflammatory

00:28:47.490 –> 00:28:51.609
myeloid condition that the reason it’s significant

00:28:51.609 –> 00:28:54.170
is it not only affects the skin, but it can affect

00:28:54.170 –> 00:28:56.990
the child’s bones, blood cell counts, livers,

00:28:57.009 –> 00:28:59.829
etc. What you’ll do on your exam, you’ll see…

00:29:00.269 –> 00:29:03.190
just the usual scale redness plaques but there’s

00:29:03.190 –> 00:29:05.809
sometimes these little bumps called “purpura” which

00:29:05.809 –> 00:29:08.309
like the name it looks almost like a little darker

00:29:08.309 –> 00:29:11.849
red or purple in color, or something called “petechiae”,

00:29:12.009 –> 00:29:15.670
which is these little dark red, purple, flat

00:29:15.670 –> 00:29:18.789
lesions that do not blanch when you touch them,

00:29:18.849 –> 00:29:21.109
which means when you push on them, the color

00:29:21.109 –> 00:29:24.369
doesn’t go away at all. And then some of the

00:29:24.369 –> 00:29:28.450
lesions will be very open sores that scab or

00:29:28.450 –> 00:29:31.569
crust, whereas most typical rashes don’t have

00:29:31.569 –> 00:29:34.390
that presentation. And so if a baby comes in

00:29:34.390 –> 00:29:36.849
with this type of rash, doesn’t respond to the

00:29:36.849 –> 00:29:39.630
usual treatment, I usually recommend to the family.

00:29:39.690 –> 00:29:42.910
to consider taking a small biopsy of the skin.

00:29:43.509 –> 00:29:46.910
And the reason this is very important is these

00:29:46.910 –> 00:29:49.710
babies can get very sick, not really from the

00:29:49.710 –> 00:29:51.730
skin lesions, but from what can be happening

00:29:51.730 –> 00:29:55.609
inside their body. Yeah, and we don’t… We don’t

00:29:55.609 –> 00:29:57.670
just biopsy kids willy-nilly. I mean, if you’re,

00:29:57.670 –> 00:29:59.710
you know, if you’re talking about doing a biopsy

00:29:59.710 –> 00:30:02.029
in the diaper area where again, poop and pee

00:30:02.029 –> 00:30:03.609
can get into an open wound. Now you’re putting

00:30:03.609 –> 00:30:05.809
that kid at risk for infection. So, you know,

00:30:05.910 –> 00:30:08.869
or you should know if you’re a parent and a pediatric

00:30:08.869 –> 00:30:11.950
dermatologist is suggesting a biopsy in the diaper

00:30:11.950 –> 00:30:14.150
area to make sure it’s not that we’ve already

00:30:14.150 –> 00:30:17.299
considered the worst case scenario, and that’s

00:30:17.299 –> 00:30:19.660
what we’re trying to make sure it’s not. Right,

00:30:19.740 –> 00:30:21.559
right. And there’s usually some other clues with

00:30:21.559 –> 00:30:23.839
this too. Often they have skin lesions on the

00:30:23.839 –> 00:30:26.660
palms or soles as well. So sometimes we actually

00:30:26.660 –> 00:30:28.880
can get away with not biopsying the diaper area.

00:30:29.619 –> 00:30:31.640
I’ve had a couple diagnosed elsewhere. Oh, that’s

00:30:31.640 –> 00:30:33.980
interesting, yeah. Yeah, and I’ve had a couple

00:30:33.980 –> 00:30:38.180
with also scalp lesions. And for me, one of the

00:30:38.180 –> 00:30:41.599
worst things to see is to open up a baby’s diaper.

00:30:42.299 –> 00:30:44.140
When you’re looking at the rash and you’re trying

00:30:44.140 –> 00:30:46.640
to figure out if it’s this Langerhans Cell Histiocytosis,

00:30:46.660 –> 00:30:52.039
LCH, and what do you see in those folds are huge

00:30:52.039 –> 00:30:55.259
hulking lymph nodes. You can actually see their

00:30:55.259 –> 00:30:59.319
swollen glands in the creases, and that’s not

00:30:59.319 –> 00:31:01.859
a good thing. Yeah. Often these children also

00:31:01.859 –> 00:31:05.200
have systemic symptoms. Sometimes they’ll have

00:31:05.200 –> 00:31:08.799
weight loss. Sometimes if you palpate their tummy,

00:31:08.839 –> 00:31:11.119
they’ll have elevated or enlarged, excuse me,

00:31:11.119 –> 00:31:14.059
liver, things like that too. So often there’s

00:31:14.059 –> 00:31:18.279
other clues as well. Yeah, I’m not, and I’ve

00:31:18.279 –> 00:31:21.380
really never been great at feeling a liver or

00:31:21.380 –> 00:31:24.000
a spleen for what we call hepatosplenomegaly.

00:31:24.359 –> 00:31:27.450
When in doubt. I’ll get an ultrasound and find

00:31:27.450 –> 00:31:30.130
out if the liver and the spleen are within normal

00:31:30.130 –> 00:31:32.710
size for that kid. And that’s reassuring. It

00:31:32.710 –> 00:31:35.630
doesn’t mean it’s not LCH, but you certainly

00:31:35.630 –> 00:31:37.470
don’t want to see something being bigger than

00:31:37.470 –> 00:31:39.569
normal in those kids that you’re concerned with.

00:31:39.769 –> 00:31:42.589
And sometimes, let’s say I’m really suspicious

00:31:42.589 –> 00:31:45.690
and I order blood work to look for anomalies

00:31:45.690 –> 00:31:49.450
there. If it does end up being, you know, just

00:31:49.450 –> 00:31:51.470
to go down this rabbit hole, if it does end up

00:31:51.470 –> 00:31:54.789
being LCH. It’s a condition that you involve

00:31:54.789 –> 00:31:57.069
other specialists with, like oncologists, to

00:31:57.069 –> 00:31:59.690
look inside the body as well. Yeah. This is managed

00:31:59.690 –> 00:32:02.009
by cancer doctors. I mean, let’s, right, this

00:32:02.009 –> 00:32:05.509
is, we’re outside of the realm of a skin doctor

00:32:05.509 –> 00:32:07.589
at this point. This is a systemic illness that

00:32:07.589 –> 00:32:10.549
has to be managed as if it was a cancerous process.

00:32:10.809 –> 00:32:12.829
Right. The good news is a lot of them actually

00:32:12.829 –> 00:32:15.269
have really good prognosis. So when I hear the

00:32:15.269 –> 00:32:18.329
word cancer, it’s almost not the right word or

00:32:18.329 –> 00:32:20.509
there almost needs to be an adjacent word for

00:32:20.509 –> 00:32:23.920
it. but we treat it very seriously nonetheless.

00:32:24.319 –> 00:32:28.599
Yeah. Now the good news is that again, you know,

00:32:28.619 –> 00:32:33.019
upwards of 50-70 % of your diaper rash cases

00:32:33.019 –> 00:32:36.799
are really just, again, the basic irritant contact

00:32:36.799 –> 00:32:40.099
dermatitis from the feces and urine in that area.

00:32:40.740 –> 00:32:44.940
Knowing that just with some basic routine diaper

00:32:44.940 –> 00:32:48.920
area skincare, most of the time you can knock

00:32:48.920 –> 00:32:51.630
out. 90% of the problem, even before they become

00:32:51.630 –> 00:32:56.250
larger ones. So, give me your sort of gold standard

00:32:56.250 –> 00:32:59.950
routine for how you approach diaper area skincare.

00:33:00.250 –> 00:33:02.329
What are you recommending to your families? So

00:33:02.329 –> 00:33:05.289
the first thing is to talk about is how are they

00:33:05.289 –> 00:33:08.529
cleaning the area? So a lot of the times parents

00:33:08.529 –> 00:33:11.210
are actually cleaning too aggressively, using

00:33:11.210 –> 00:33:15.940
too much soap. So, while gentle soap and water

00:33:15.940 –> 00:33:17.660
are good, you don’t want to use anything with

00:33:17.660 –> 00:33:20.980
fragrance. And sometimes you can do soap not

00:33:20.980 –> 00:33:23.980
every day, maybe every other day or every third

00:33:23.980 –> 00:33:28.019
day. You want to make sure they’re using wipes

00:33:28.019 –> 00:33:33.160
that are gentle and fragrance-free. Um, and

00:33:33.160 –> 00:33:35.420
that they’re not wiping too hard. Sometimes I’ll

00:33:35.420 –> 00:33:38.279
watch parents change diapers in front of me and

00:33:38.279 –> 00:33:41.099
the – how, how much friction and rubbing is going

00:33:41.099 –> 00:33:44.200
on is just far too much. So, you know, especially

00:33:44.200 –> 00:33:46.559
if there’s open areas, you want to almost dab

00:33:46.559 –> 00:33:49.880
instead of rub. The other thing I will do if

00:33:49.880 –> 00:33:52.380
soap is the issue, sometimes I’ll have them do

00:33:52.380 –> 00:33:55.759
a bath with no soap, you know, multiple times

00:33:55.759 –> 00:33:59.519
a week. Um, the, the, the next thing to make

00:33:59.519 –> 00:34:02.049
sure is that this child is not sitting in the

00:34:02.049 –> 00:34:06.109
diaper too long. I have some kids who go to daycare

00:34:06.109 –> 00:34:08.269
and they’re not changed as frequently and they

00:34:08.269 –> 00:34:10.570
come home rashy and then overnight things get

00:34:10.570 –> 00:34:14.369
better just because families are able to uh change

00:34:14.369 –> 00:34:17.650
the diaper more often so whenever possible frequent

00:34:17.650 –> 00:34:21.150
diaper changes um do the trick. I have some parents

00:34:21.150 –> 00:34:23.429
who i’m not saying you need to do it every hour

00:34:23.429 –> 00:34:26.329
but at least if you can when they’re having acute

00:34:26.329 –> 00:34:29.510
flares to do it as often as you can especially

00:34:29.510 –> 00:34:33.829
after bowel movements. You know urine you don’t

00:34:33.829 –> 00:34:35.570
have to do it quite as frequently but if possible

00:34:35.570 –> 00:34:37.889
the minute you notice a child has a bowel movement

00:34:37.889 –> 00:34:41.079
you want to do a clean and diaper change. Yeah,

00:34:41.079 –> 00:34:43.260
that’s, you know, this is a case where technology

00:34:43.260 –> 00:34:45.719
maybe is not our best friend. They have this

00:34:45.719 –> 00:34:50.119
super ultra-potent absorbing gel technology in

00:34:50.119 –> 00:34:52.239
the diapers now that it can suck up anything

00:34:52.239 –> 00:34:56.179
and hold it there for hours. And, you know, not

00:34:56.179 –> 00:34:59.260
saying it’s a matter of being lazy, but when

00:34:59.260 –> 00:35:02.480
you have that convenience, you do tend to let

00:35:02.480 –> 00:35:06.230
the kids sit in the diaper and have that. urine

00:35:06.230 –> 00:35:09.550
and poop sort of stew in the diaper area because

00:35:09.550 –> 00:35:11.909
it’s not dripping out. So you don’t need to feel

00:35:11.909 –> 00:35:13.650
like you have to change the diaper as much. But

00:35:13.650 –> 00:35:16.630
to your point, yeah, once an hour, take a peek.

00:35:16.909 –> 00:35:20.469
I get it. Diapers are expensive. You’re talking

00:35:20.469 –> 00:35:23.269
up to 50 cents a diaper now, I think, last time

00:35:23.269 –> 00:35:25.849
I looked. So I don’t want you to just have to

00:35:25.849 –> 00:35:27.429
feel like you have to change a diaper no matter

00:35:27.429 –> 00:35:30.300
what. taking a quick peek and making sure that

00:35:30.300 –> 00:35:33.239
your baby’s not, you know, carrying a huge load

00:35:33.239 –> 00:35:34.940
in there that you didn’t know about and it’s

00:35:34.940 –> 00:35:37.300
up against their skin can make a huge difference.

00:35:38.579 –> 00:35:42.280
Absolutely. And then if possible, every now and,

00:35:42.400 –> 00:35:45.039
you know, when at home, if you can give a little

00:35:45.039 –> 00:35:48.219
bit of time for some air drying or naked time,

00:35:48.440 –> 00:35:51.960
that always helps after a diaper change, if possible.

00:35:52.039 –> 00:35:54.219
And I get it, can’t always be done. But if you

00:35:54.219 –> 00:35:55.860
have a chance when they’re at home, let them

00:35:55.860 –> 00:36:00.539
run around for a little bit. Yeah, I do. I do

00:36:00.539 –> 00:36:03.800
try to encourage that as well. Letting them just

00:36:03.800 –> 00:36:05.840
take the diaper off and air it out. You know,

00:36:05.900 –> 00:36:09.340
that’s but invariably you hear the story. It’s

00:36:09.340 –> 00:36:12.480
like it was off for 30 seconds and kid went to

00:36:12.480 –> 00:36:14.340
the bathroom on the floor. Yeah, I’m sorry. Sorry

00:36:14.340 –> 00:36:19.500
about it. Sorry. We meant well. The other thing

00:36:19.500 –> 00:36:22.699
I did with my son, probably PTSD from seeing

00:36:22.699 –> 00:36:25.059
so many diaper rashes in clinic, is I made sure

00:36:25.059 –> 00:36:29.880
I had a barrier ointment at each change. So instead

00:36:29.880 –> 00:36:34.119
of just applying the diaper alone, I alternated

00:36:34.119 –> 00:36:37.139
every change. It was either a petroleum-based

00:36:37.139 –> 00:36:40.519
product or a zinc oxide-based barrier product.

00:36:40.920 –> 00:36:44.019
And if there was no diaper rash, I actually…

00:36:44.510 –> 00:36:46.750
would alternate them because the benefit of the

00:36:46.750 –> 00:36:49.170
petroleum-based ones is they’re more hydrating,

00:36:49.309 –> 00:36:51.969
not as good of a barrier. And then the benefit

00:36:51.969 –> 00:36:54.289
of the zinc oxide-based ones, better barrier,

00:36:54.369 –> 00:36:57.190
not as moisturizing. So I found if I alternated,

00:36:57.329 –> 00:37:00.550
I got a little bit of both. Yeah. Out of those

00:37:00.550 –> 00:37:02.789
two products, I like triple paste, something

00:37:02.789 –> 00:37:05.789
like that with the zinc oxide is there. The issue

00:37:05.789 –> 00:37:08.289
there is, my goodness, it gets everywhere. I

00:37:08.289 –> 00:37:11.019
mean, once you get that on your hands, It’s going

00:37:11.019 –> 00:37:13.840
to be on whatever furniture is closest to you.

00:37:13.920 –> 00:37:15.760
Then you got to change the diaper for that kid.

00:37:16.000 –> 00:37:18.440
I mean, I know what I’m putting the parent through

00:37:18.440 –> 00:37:21.860
when I suggest using zinc oxide. But to your

00:37:21.860 –> 00:37:25.159
point, to me, at least, it works the best. And

00:37:25.159 –> 00:37:26.980
the nice thing is some of those brands even have

00:37:26.980 –> 00:37:29.880
ones with, like, if there is a little yeast component,

00:37:30.119 –> 00:37:32.940
you can buy ones that have a little antifungal

00:37:32.940 –> 00:37:36.039
property to them, like triple paste AF. Yeah.

00:37:36.179 –> 00:37:40.619
What do you not do for your normal diaper care?

00:37:41.239 –> 00:37:43.880
Fragrance. I actually didn’t do any of those

00:37:43.880 –> 00:37:46.900
super absorbent disposal type, or excuse me,

00:37:46.920 –> 00:37:49.119
I didn’t do any of those cloth type diapers.

00:37:49.400 –> 00:37:52.159
Like if the diaper itself has a fragrance, is

00:37:52.159 –> 00:37:54.679
that something you’re? Oh, absolutely not. Yeah.

00:37:54.780 –> 00:37:57.019
I’ve seen that for whatever reason. I’ve been

00:37:57.019 –> 00:37:59.260
seeing that a lot in clinical of late – diapers

00:37:59.260 –> 00:38:01.619
coming in with actually a fragrance to them.

00:38:02.059 –> 00:38:05.119
Yeah. I just stuck with sort of the fragrance

00:38:05.119 –> 00:38:08.429
free, you know. pretty commonly available brand.

00:38:08.710 –> 00:38:11.170
Did not do the cloth diapers. Not that they’re

00:38:11.170 –> 00:38:14.050
bad. It’s just, I didn’t find honestly that there

00:38:14.050 –> 00:38:16.670
was much of an added benefit to them for the

00:38:16.670 –> 00:38:20.110
effort and expense. Well, let’s take a deeper

00:38:20.110 –> 00:38:23.349
dive into the topic of Candida or the yeast that

00:38:23.349 –> 00:38:25.090
we mentioned earlier, because that does require

00:38:25.090 –> 00:38:27.090
some special consideration. And again, you know,

00:38:27.110 –> 00:38:29.909
that’s living everywhere. You can throw a softball.

00:38:30.519 –> 00:38:32.500
right now in any part of your room and you could

00:38:32.500 –> 00:38:34.780
hit some yeast, it’s there. It normally doesn’t

00:38:34.780 –> 00:38:37.400
cause any problems because it’s not getting sort

00:38:37.400 –> 00:38:40.800
of into the skin or even, you know, really there

00:38:40.800 –> 00:38:43.380
at any given time for an extended period of time.

00:38:43.440 –> 00:38:46.820
But once you start talking about a diaper that’s

00:38:46.820 –> 00:38:49.860
occluding it, You’ve got, again, what I loved

00:38:49.860 –> 00:38:52.139
is you mentioned the antibiotics, more frequent

00:38:52.139 –> 00:38:55.179
pooping, diarrhea. Now all of a sudden you got

00:38:55.179 –> 00:38:57.460
a chance for that Candida to really take a

00:38:57.460 –> 00:38:59.900
hold and cause some problems. So what are you

00:38:59.900 –> 00:39:03.019
doing to treat yeast in the diaper area? The

00:39:03.019 –> 00:39:06.440
first thing that I usually will try is a topical.

00:39:07.900 –> 00:39:10.119
There’s a couple ointments available that treat

00:39:10.119 –> 00:39:14.480
yeast like Nystatin. There’s also an oral medication

00:39:14.480 –> 00:39:18.769
that you can prescribe – Diflucan being one of

00:39:18.769 –> 00:39:22.070
the more common ones that’s pretty safe and requires

00:39:22.070 –> 00:39:24.369
a pretty short treatment. A lot of the diaper

00:39:24.369 –> 00:39:27.510
paste versions of them that have an antifungal

00:39:27.510 –> 00:39:29.730
property. So some of the zinc oxide ones you

00:39:29.730 –> 00:39:32.090
can buy that way. But I try to avoid putting

00:39:32.090 –> 00:39:34.469
things like cornstarch or things like that on

00:39:34.469 –> 00:39:36.449
top because sometimes those actually make it

00:39:36.449 –> 00:39:38.949
worse. Yeah. And do you have a particular order

00:39:38.949 –> 00:39:40.590
that you’d be applying these things in? Like

00:39:40.590 –> 00:39:43.170
what would you put to the skin directly? Let’s

00:39:43.170 –> 00:39:45.210
say I was doing Nysatin. I might put that

00:39:45.210 –> 00:39:47.869
first and then I would put my diaper paste on

00:39:47.869 –> 00:39:51.010
top and then apply the diaper. And then maybe

00:39:51.010 –> 00:39:53.429
the next diaper change, I would do my Nystatin

00:39:53.429 –> 00:39:56.489
with a little petrolatum based product. Yeah,

00:39:56.510 –> 00:39:59.190
that’s exactly what I would do as well. That’s

00:39:59.190 –> 00:40:01.289
good. It makes me feel good when I hear smart

00:40:01.289 –> 00:40:04.349
people are doing what I’m doing. That’s great.

00:40:05.480 –> 00:40:07.480
Yeah. So, okay. So let’s talk a little bit about

00:40:07.480 –> 00:40:09.699
some of those other conditions. So psoriasis,

00:40:09.699 –> 00:40:12.519
seborrheic dermatitis, atopic derm. What’s the

00:40:12.519 –> 00:40:14.980
extra step there that you’re adding to try to

00:40:14.980 –> 00:40:17.639
treat that? So in many cases, we actually use

00:40:17.639 –> 00:40:20.800
very, very low potency steroids against the skin.

00:40:21.320 –> 00:40:24.360
And these are not like anabolic steroids that,

00:40:24.380 –> 00:40:27.309
you know you hear about it on social media.

00:40:27.389 –> 00:40:30.010
These are very low strength topical steroids.

00:40:30.190 –> 00:40:34.570
So even over-the-counter, you can buy them. Widely

00:40:34.570 –> 00:40:37.250
available is 1% over the counter hydrocortisone

00:40:37.250 –> 00:40:41.309
ointment, for example. When you buy those, it’s

00:40:41.309 –> 00:40:43.130
better to always do the thicker ointment than

00:40:43.130 –> 00:40:45.110
the cream versions. And you don’t want to buy

00:40:45.110 –> 00:40:48.070
one that has extra things added. Like if you

00:40:48.070 –> 00:40:50.510
look at the pharmacy aisle where hydrocortisone

00:40:50.510 –> 00:40:53.190
is located, you’ll see some that have aloe, some

00:40:53.190 –> 00:40:55.369
that have fragrance, some that have Neosporin.

00:40:55.429 –> 00:40:58.969
None of that. You want to buy the plain 1% hydrocortisone.

00:40:59.730 –> 00:41:01.969
I would always recommend getting your doctor’s

00:41:01.969 –> 00:41:05.239
advice first. But if that’s the way they want

00:41:05.239 –> 00:41:07.480
to go, I do that and I do it for a very short

00:41:07.480 –> 00:41:10.599
time, very thin layer underneath your, underneath

00:41:10.599 –> 00:41:13.260
whatever your selected barrier cream is. I might

00:41:13.260 –> 00:41:16.179
do it twice a day for maybe seven days max. And

00:41:16.179 –> 00:41:18.219
then it, you know, every now and then we have

00:41:18.219 –> 00:41:20.039
to do even stronger versions of that, but that

00:41:20.039 –> 00:41:22.929
would be under the guidance of your doctor. I

00:41:22.929 –> 00:41:25.190
love what you said about avoiding the additives

00:41:25.190 –> 00:41:28.650
to the 1% hydrocortisone. When you’re a parent

00:41:28.650 –> 00:41:31.289
going into the pharmacy looking for exactly that

00:41:31.289 –> 00:41:33.909
product, do you have a particular vehicle that

00:41:33.909 –> 00:41:36.190
you’re like, it comes as a lotion, it comes as

00:41:36.190 –> 00:41:38.030
a cream, it comes as an ointment? I love the

00:41:38.030 –> 00:41:39.949
ointments. The thicker, the better. You want

00:41:39.949 –> 00:41:42.329
to think of it like the old school Vaseline version

00:41:42.329 –> 00:41:44.550
of hydrocortisone. That’s great. So what would

00:41:44.550 –> 00:41:46.329
you do for a condition like psoriasis, where

00:41:46.329 –> 00:41:48.489
we said earlier, it’s even a little harder to

00:41:48.489 –> 00:41:52.219
treat? So psoriasis, we actually treat very similar

00:41:52.219 –> 00:41:54.940
to eczema or atopic dermatitis, but sometimes

00:41:54.940 –> 00:41:57.199
we have to use more potent medications, sometimes

00:41:57.199 –> 00:42:00.019
prescriptions, drinks, steroids. There’s also

00:42:00.019 –> 00:42:04.070
for actually both… and psoriasis, some prescription

00:42:04.070 –> 00:42:07.469
non -steroidal anti-inflammatories available

00:42:07.469 –> 00:42:11.570
that can decrease the inflammation without having

00:42:11.570 –> 00:42:14.349
to worry about the risk of thinning of the skin,

00:42:14.429 –> 00:42:17.909
which is the main concern with steroids. One

00:42:17.909 –> 00:42:21.570
of the oldest treatments on the market for psoriasis,

00:42:21.570 –> 00:42:24.090
for example, is a topical vitamin D-based ointment

00:42:24.090 –> 00:42:28.389
called calcipotriene. But even modern day, there’s

00:42:28.389 –> 00:42:31.530
even more effective a non-steroidal on steroid

00:42:31.530 –> 00:42:34.110
alternatives out there as well as systemic options.

00:42:34.570 –> 00:42:36.789
One that I like in the diaper area, if I know

00:42:36.789 –> 00:42:39.789
it’s going to require a long-term use is a topical

00:42:39.789 –> 00:42:42.769
calcineurin inhibitor called Protopic or tacrolimus.

00:42:43.150 –> 00:42:45.230
In this age range, you’re kind of stuck using

00:42:45.230 –> 00:42:48.630
0 .03% unless you have some trick that I don’t

00:42:48.630 –> 00:42:52.530
know about to get approved for the 0 .1%. You

00:42:52.530 –> 00:42:54.409
have to be – I do have a trick. You have a trick?

00:42:54.469 –> 00:42:57.880
What’s your trick? I have some specialty pharmacies

00:42:57.880 –> 00:43:00.019
available that you can get them for about $30

00:43:00.019 –> 00:43:03.219
cash. The tacrolimus 0 .1.%. 0 .1%, yeah. Technically,

00:43:03.280 –> 00:43:07.579
only for 16 years of age or older, we commonly

00:43:07.579 –> 00:43:09.880
would, as dermatologists, we commonly would love

00:43:09.880 –> 00:43:12.739
to use that stronger product on younger kids.

00:43:12.840 –> 00:43:15.219
But as soon as the insurance company sees that

00:43:15.219 –> 00:43:18.579
the child’s younger than 16, they can say, sorry,

00:43:18.760 –> 00:43:21.360
the FDA did not give approval for this medicine,

00:43:21.460 –> 00:43:25.219
so we don’t have to pay for it. So I have specialty

00:43:25.219 –> 00:43:27.179
pharmacies where I can get the generic version

00:43:27.179 –> 00:43:29.760
and you can also get them if needed through compounding

00:43:29.760 –> 00:43:31.840
pharmacies. Yeah, that’s great. That’s a good

00:43:31.840 –> 00:43:34.800
trick. Awesome. So when as a pediatric dermatologist,

00:43:34.960 –> 00:43:37.280
would you want a pediatrician or family medicine

00:43:37.280 –> 00:43:40.440
physician to absolutely refer these kids into

00:43:40.440 –> 00:43:43.539
you? When is it appropriate for you to be taking

00:43:43.539 –> 00:43:48.519
a look and doing something extra? So my favorite

00:43:48.519 –> 00:43:50.800
referral would be someone who’s been cultured,

00:43:50.800 –> 00:43:54.869
Someone who’s had a trial of you know, if you’re

00:43:54.869 –> 00:43:58.130
not sure, maybe a topical antifungal or a topical

00:43:58.130 –> 00:44:00.369
over -the -counter strength steroid that just

00:44:00.369 –> 00:44:02.550
hasn’t worked, that I’m happy to see a patient.

00:44:03.570 –> 00:44:06.929
I have pediatricians who sort of know my typical

00:44:06.929 –> 00:44:10.329
technique. We’ll do sort of the intro-level

00:44:10.329 –> 00:44:11.809
treatments, and if they don’t work, I’m happy

00:44:11.809 –> 00:44:15.750
to see the baby. Yeah, for me as well, I would

00:44:15.750 –> 00:44:18.670
add to that, you know, anytime you’ve got blisters

00:44:18.670 –> 00:44:22.510
in the area or, again, if you can see those lymph

00:44:22.510 –> 00:44:25.730
nodes, That’s something that we want to take

00:44:25.730 –> 00:44:28.590
a look at. And that’s not like a, hey, I’m just

00:44:28.590 –> 00:44:31.329
going to refer and whatever happens, happens.

00:44:32.440 –> 00:44:34.519
because it might be nine months before you get in to

00:44:34.519 –> 00:44:36.820
see me. I don’t want to wait nine months. You

00:44:36.820 –> 00:44:39.420
pick up the phone and either call my personal

00:44:39.420 –> 00:44:42.659
cell, which I give out to everybody, or use whatever

00:44:42.659 –> 00:44:46.320
your health system or clinic’s messaging system

00:44:46.320 –> 00:44:48.440
is and get a message to that person directly

00:44:48.440 –> 00:44:50.679
and say, hey, you need to see this person because

00:44:50.679 –> 00:44:53.179
they’ve got something really concerning sounding.

00:44:53.400 –> 00:44:56.909
Is that fair? Agreed. Well, I want to thank Scripps

00:44:56.909 –> 00:44:59.150
Clinic’s own Dr. Caroline Piggott for joining

00:44:59.150 –> 00:45:01.269
me today. I cannot have handled this “messy load,”

00:45:01.449 –> 00:45:05.469
so to speak, without her expert existence. And

00:45:05.469 –> 00:45:07.989
just always a pleasure speaking with you, Dr.

00:45:08.150 –> 00:45:10.610
Piggott. I look forward to doing many, many more

00:45:10.610 –> 00:45:12.670
of these things with you and getting smarter

00:45:12.670 –> 00:45:15.389
as a result. Thank you for having me, Dr. K.

00:45:15.530 –> 00:45:17.570
It’s good to see you and it’s a pleasure doing

00:45:17.570 –> 00:45:26.760
this anytime. Thanks for tuning in to this episode

00:45:26.760 –> 00:45:29.179
of the Don’t Be Rash Pediatric Dermatology Podcast.

00:45:29.559 –> 00:45:32.079
I’m your host, Dr. Andrew Krakowski. Don’t forget

00:45:32.079 –> 00:45:34.280
to subscribe to our show on your favorite podcast

00:45:34.280 –> 00:45:38.179
platform and check out don’tberash .org for more

00:45:38.179 –> 00:45:40.579
information. A special thank you to our nonprofit

00:45:40.579 –> 00:45:43.300
sponsor, the St. Luke’s University Health Network,

00:45:43.460 –> 00:45:45.920
for making this episode possible. Until next

00:45:45.920 –> 00:45:48.900
time, remember, keep calm and don’t be rash.