Erosive Diaper Dermatitis

Here is a tough one:

Abstract: Thirteen yo boy with 6 month history of erosive diaper dermatitis.
HPI: The patient is a 13 yo boy with Down's Syndrome. As an infant he had Hirschprung's disease corrected by surgery. Subsequently, he has had problems with bowel movements and at this time is still incontinent of stool. He needs diapers to prevent soiling. Six months ago, he was diagnosed with Crohn's Disease. Since his colonoscopy, he has developed a painful and recalcitrant diaper dermatitis. See mother's note below*.

O/E: There is an erosive papular dermatitis of the perirectal area. Penis and scrotum not involved.

Clinical Photo:

(the artifact in the photo is a Maalox and Aquaphor mixture)

Diagnosis: Erosive papular dermatitis of perirectal area, most likely "Jacquet's Diaper Dermatitis."

Comment and Questions: The patient was difficult to examine and was very disruptive. Frustrating as the office visit was, I marveled at the patience of his mother for whom he is a full-time job. My experience with erosive diaper dermatitis is limited and this boy's mother told me her son has been seen by three pediatricians and a gastroenterologist and his problem persists. I suppose the Hirschprung's has set up a situation where he is incontinent of stool and his Down's makes management of that even more difficult. Ted Rosen described a similar patient (see references) and the management was fairly simple. I will get Ted's opinion. Please let me know your thoughts.

* Mother's note: Hi Doctor, Thank-you for today's appointment. I'm grateful for your taking the time to research this. My partner and I were at our wits end watching J. suffer with this. I forgot to mention one other product that I use on him is Caldesene powder. This has worked well but only if it is timed just right. Meaning, if we were lucky after applying it, Jarod would stay dry /continent for a long period of time, like through the entire night, and the powder would dry it out and it would begin healing. He has an average of 4 to 5 bowel movements a day, sometimes more sometimes less and his stool is the consistency of toothpaste most of the time. Is there any other info. I could share with you that would be helpful in figuring a treatment plan ?
Thank-you again for your help. I really appreciate it. Sincerely, W.

References:

1. Van L, Harting M, Rosen T. Jacquet erosive diaper dermatitis: a complication of adult urinary incontinence. Cutis. 2008 Jul;82(1):72-4.

Abstract: Jacquet erosive diaper dermatitis is typically described as a severe irritant dermatitis of the perianal region. However, Jacquet erosive diaper dermatitis, perianal pseudoverrucous papules and nodules, and granuloma gluteale infantum/ adultorum have been regarded as discrete entities or all part of the same clinical spectrum, representing the result of chronic, severe, irritant contact dermatitis. We present a case of Jacquet erosive diaper dermatitis and a discussion of the clinical spectrum of diseases to which it belongs.

2. Clinical Presentation and Treatment of Diaper Dermatitis (Full Text)