Approach to the Problem
Rashes in the perineal (diaper) area, some of the most common skin disorders in infants and toddlers, peak at age 9 to 12 months. A variety of acute inflammatory skin reactions in the diaper area may occur. Chafing or frictional dermatitis is the most prevalent cause of diaper rash, followed in frequency by irritant contact dermatitis. Older children and adolescents with groin rashes present with lesions predominantly caused by fungal infections, such as vulvovaginitis and tinea cruris. In most cases, frequent diaper changes and the application of topical barrier agents are the mainstays of therapy. Groin rashes that indicate the presence of infection require topical antifungal or antibiotic agents. It is crucial to perform an entire body examination when evaluating rashes in the perineal area.
Key Points in the History
• A rash elsewhere on the skin suggests the possibility of seborrhea, psoriasis, or, less likely, Langerhans histiocytosis.
• A history of recent antibiotic use often precedes a Candida albicans diaper rash or vulvovaginitis in an adolescent female.
• Extremes of moisture or heat in the groin area may lead to contact dermatitis, candidal diaper dermatitis, or tinea cruris.
• Seborrheic, atopic, and contact dermatitis disrupt the integrity of the skin and place the patient at risk for infection with C. albicans.
• A family history of psoriasis may provide a clue regarding the etiology of a persistent diaper rash.
• Chafing diaper dermatitis waxes and wanes quickly.
• Persistent diarrhea may contribute to contact diaper dermatitis.
• A diaper rash that does not respond to typical treatment may indicate psoriasis or Langerhans histiocytosis.
• Genital herpes presenting in prepubertal children should warrant an investigation for child sexual abuse.
Key Points in the Physical Examination
• Seborrhea, psoriasis, scarlet fever, and Langerhans histiocytosis are associated with rashes outside of the diaper region.
• The distribution of the diaper rash provides clues to the diagnosis: a red rash in the intertriginous areas indicates seborrhea, intertrigo, C. albicans, or tinea cruris, while a rash on the exposed convex surfaces is suggestive of contact dermatitis.
• Evaluation of the margins of the rash assists in making the diagnosis. Satellite lesions are seen with candidal dermatitis, and sharp borders are seen with tinea cruris.
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