Newborn with Erosive Diaper Dermatits

Abstract:  5 week old girl with an erosive diaper dermatitis since day 2.

HPI:  The patient was born at 3200 grams to a P2G2 opioid-addicted mother who was on Suboxone (buprenorphine and naloxone) maintenance.  The infant is feeding well and gaining weight and the mother seems attentive.  At day 2 her mother noted the process seen below.  The child is bottle fed and had originally been on Enfamil but was switched to Nutramagen.  Treatment to date has been with a panoply of creams:  Neomycin (!), Desitin, clotrimazole.  The mother relates that stools seem unremarkable.

O/E:  There is a nodulo-ulcerative napkin dermatitis.  No other skin lesions are noted.

Clinical Photo:

Lab:  A culture was done and was negative.  KOH not done.

Diagnosis:  Jacquet-type Nodulo-ulcerative Diaper Dermatitis in an infant with possible narcotic abstinence syndrome (see reference).

Questions:

How many of you have seen a similar case of Jacquet’s Disease in an neonate?  What local care would you recommend?  Any work-up at this point?  Are you aware of the narcotic abstinence syndrome and if so have you seen an erosive napkin dermatitis like this?

My approach at this time is to try the alpha tocopherol, keep diaper changes simple, consider cloth diapers for 1 – 2 weeks.  KOH prep will be done.  If response is not favorable consider biopsy or admission to hospital for care.

One Month Follow-up:
The baby was treated in the following way, as recommended by Dr. Julianne Mann from Pediatric Dermatology, OHSU, Portland, Oregon:

1. Absolutely NO diaper wipes at all.  Have mom get a large pack of rectangular cotton makeup remover pads.  Have her apply mineral oil to the cotton pad and use this to clean the baby's bottom.  When she is away from home OK to have her use a damp cotton cloth (I tell parents to pack several damp soft cotton washcloths in a ziplock in their travel diaper bag).

2. With every diaper change, have mom liberally apply a thick barrier paste after cleaning the baby's bottom.  We have had the best luck with a compounded butt paste that our local pharmacy mixes up because we suspect that preservatives in OTC diaper pastes may also play a role with the dermatitis.  We do 25% corn starch, 25% zinc oxide, and 50% petrolatum and dispense one pound.

3. I emphasize the importance of stopping everything else that they've been using.  Most parents whose baby's butt looks like this have been desperately trying everything, including doing things like vinegar or baking soda soaks and trying a different cream almost daily.  I tell them the goal is to simplify.  KEEP IT SUPER SIMPLE!

Thank you, Lili!!

Reference:

[Effectiveness of topical acetate tocopherol for the prevention and treatment of skin lesions in newborns: a 5 years experience in a 3rd level Italian Neonatal Intensive Care Unit].  Manzoni P, Gomirato G.  Minerva Pediatr. 2005 Oct;57(5):305-11.

Divisione di Neonatologia e TIN Ospedaliera, Ospedale S. Anna, Azienda Ospedale OIRM-S. Anna, Turin. paolomanzoni@hotmail.com

Abstract:  Neonates in NICU (especially when premature) are particularly prone to skin damage by action of external aggressive conditions such as chemical, physical, infectious, radiant, mechanical and iatrogenic factors. Strategies for avoiding disruption of the skin barrier are thus highly needed in such patients.

METHODS: We evaluated the effectiveness of a acetate tocopherol (AT) ointment for topical use in 21 neonates admitted to our NICU and affected by neonatal abstinence syndrome with severe diaper exulcerative and erosive erythema with ulcer and granulation tissue at the bottom of the lesion (group A), and compared them to 19 matched neonates affected by the same condition and treated with a commonly used skin ointment (emollient type, water-in-oil category) (group B). For all newborns we calculated: the dermatological severity score (using a clinical score from 0 to 9 points according to the increasing severity of the lesions) at time 0, 4 and 7 days; the mean days for achieving complete recovery; the rate of therapeutical failures.

RESULTS:  Mean score at day 0 was 7.8 in group A vs 7.9 in group B (P=0.35 NS). At day 4 it was 4.6 in group A vs 6.5 in group B (P=0.03), at day in 7 it was 3.1 in group A vs 5.2 in group B (P=0.04). A complete recovery with restitutio ad integrum occurred after 9.1 mean days in group A vs 12.2 mean days in group B (P=0.04). The rate of therapeutical failures was significantly lower in group A (4.2% vs 30.6%; OR 0.235; P<0.01) than in group B. No adverse effects related to AT use were reported.

CONCLUSIONS:  AT in our experience proved to be safe and more effective than the commonly used skin ointments in the topical treatment of exulcerative skin lesions in NICU neonates.