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  Issue 1 (2005)


Measures for the prevention from napkin dermatitis
Primary target is stabilization of the natural skin barrier

The so-called napkin dermatitis belongs to the most frequent dermal infantile diseases in spite of the modern disposable diapers. In the majority of cases, it concerns an irritative phenomenon which is caused by a disturbed barrier function and not as commonly presumed by a fungal infection as primary cause. Questions referring to which measures are adequate to prevent from napkin dermatitis and which properties the preparations should feature were subject of a noontime seminar in the course of the GD's 9th Annual Meeting in Vienna on 14 and 15 March 2005.
Professor Dr. Uwe Wollina, Dresden, described the barrier function and non-specific defence as most important function of the skin which is ensured by desquamation, humidity, pH-value, resident micro flora and antimicrobial peptides. Without a barrier of the kind, a life in the country would not be possible - and this is exactly the problem for neonates and infants. Until their birth they lived in an aquatic surrounding and underwent the most fundamental change in the course of their lives by passing over to the terrestrial way of living.

It is obvious that a considerable change of the type may entail problems. Starting on the first day of life the humidity content of skin reduces considerably. By thermal strain as it is applied on newborns this effect is even intensified. First of all the newborns' skin is not yet able to produce sufficient humidity, only within approximately 30 days after birth the perspiratory glands reach a plateau.

Skin problems even
shortly after birth

Within the first days after birth, when the body is still in the process of adaptation to the new living, napkin dermatitis is frequently developed which is characterized more aptly by irritation dermatosis. Already after few days, clinical signs of a skin irritation can be assessed at neonates. According to estimation by Wollina, an essential disposition takes place at this point of time. In case of correct proceedings diaper dermatitis may abate very quickly, in an adverse case it may become chronical.

Prevention of diaper dermatitis according to the A-E-standard

A - Air: when changing the diapers, infants should be able to lie for a while without diaper. A blowing-dry of the diaper region is no longer recommended due to the danger of burning.

B - Barrier: As the skin barrier is disturbed, no skin care products containing irritative substances should be used. W/O emulsions rich in lipids are in the normal case more favourable than O/W-emulsions and pastes rich in solids. Alcoholic solutions, powder and perfumes should equally be refrained from as from disinfecting measures.

C - Cleansing: Cleansing is required after each dejection but not after each changing of diapers. It should preferably be made by using clear water and only in case of real need by means of surfactant-containing washing solutions.

D - Diaper: The diaper should be changed frequently. Disposable diapers offer the advantage to better drain humidity compared to tissue diapers. They should however have a semi-permeable outer skin so that a part of the humidity can evaporate internally.

E - Education: Parents should be trained and informed and wash their hands before and after each change of diapers.

According to the definition of napkin dermatitis the share of the infants concerned under the age of two is specified by two to forty percent. The age peak is at the age of the 9th to 12th months of life. Girls are earlier and to a higher degree affected by the skin disease than boys. While for girls the vulva region is more afflicted, diaper dermatitis often spreads at the boys' interior thighs. Similar skin irritations as at small children develop at adult incontinence patients and may also occur at women during their menses.

High irritation potential
by faeces and urine

First minor irritations mostly develop perianally and are triggered by faeces owing to the fact that the lipases, proteases and bacteria contained attack the skin. This phenomenon is distinctly enhanced by the occlusive effect of the diaper, the body heat and the additional presence of urine. For the urine alkalinizes the diaper content thus activating many enzymes first so that the irritation by urine increases by the factor five.

Professor Dr. Uwe Wollina of the Clinic for Dermatology at the Hospital Dresden-Friedrichstadt was referee and moderator of a noontime seminar dealing with novel interdisciplinary approach concerning therapy management and prevention of napkin dermatitis at 9th GD-Annual Meeting in Vienna.

Consequently as obvious preventive measure the diapers should be frequently changed, in particular after each excrement. The appearance of diarrhoea is oftentimes the beginning of diaper dermatitis due to the fact that the concept of changing diapers is then only difficult to realize. In fact there is a correlation between the bacterial population density and the severity of the diaper dermatitis; however a pronounced bacterial flora is an implication and not the cause of the disease.

The same applies to candida infections. Even if characteristic skin alterations raise suspicion towards a candida albicans infection, an antimycotic therapy - e. g. by means of nystatin-containing topical preparations - should only be commenced after establishing a mycological secured diagnosis. A mycological examination is in particular indicated if measures for the restitution of the disturbed skin barrier have shown ineffective.

Diaper dermatitis may also be triggered or aggravated by numerous exogenous factors besides inducing through the diaper content. Young skin is especially irritable and reacts already often to slight stimuli as can be triggered for example by scents, surfactants, agglutinated powders or rough diapers.

Requirements to suited
topical preparations

To date there has been no evidence-based concept for the prevention and treatment of diaper dermatitis, however recommendations were given resting on empirical experience. Essential advice can be resumed by using the A-E rule which had been established in the course of an interdisciplinary expert workshop in September 2004 (please refer to insertion on page 27). According to this rule the care preparations used are to render a verifiable contribution to the upkeep respectively recovery of the barrier function. Moreover, they are to show a clear composition and not contain ingredients with known irritating effect.

As professor Dr. Dr. Erhardt Proksch, Kiel, informed, meanwhile numerous substances and preparations have been tested as to their barrier stabilizing properties, among them also various physiological lipids and antimicrobial peptides. In the group of lipids, ceramides are of particular interest, however it could so far not been proven with certainty that ceramides are incorporated into the relevant bilamellar lipid layers of the stratum corneum after external application.

Though there is large evidence that a disturbed skin barrier can be improved by using active-agent-free topical preparations, preferably of the type w/o emulsion. This emulsion type has also shown beneficial in the application at diaper dermatitis. Inappropriate are however desiccating oils and pastes rich in solids as for instance the frequently used zinc paste as the solids may agglutinate and irritate the skin further.

Therapy option dexpanthenol

Dexpanthenol has been examined as active agent in the form of a five-percent w/o emulsion (Bepanthen® wound and healing ointment). This formulation already entailed improved hydratation and reduced reddening of the skin after experimental impairment of the skin by sodium lauryl sulfate within one day. Furthermore, a regulating effect on the increased transepidermal water loss could be determined which was more substantial than for the corresponding formulation without Dexpanthenol.

To prevent the emerging of diaper dermatitis different recommendations should be considered. Hereunto belongs the advice that babies' skin is gently cleaned and dried in the air when changing diapers.

The clinical effectiveness of the formulation at diaper dermatitis has been investigated by Putet and colleagues in two studies at newborns. The result showed that the preparation reduces the frequency of erythema in prophylactic application and improves the healing rate if it is applied in complementation of care measures and in an eosine solution at already present diaper dermatitis. tmb/jk

Cosmetical consultation for skin problems

Meanwhile every other citizen of the Federal Republic of Germany complains about dermal problems. Allergies, pimples, dry skin and many additional phenomena - almost everybody can contribute to this topic. However, where can optimal skin consultation be obtained? On whom do persons suffering from skin diseases rely for questions concerning skin care? The frei-skin research institute has conducted a survey involving more than 1,000 men and women.

The result has turned out to be sign of confidence for dermatologists and pharmacists: 68.7 respectively 48.6 percent of the respondents turned to them if advice was required as to the appropriate skin care for skin problems. Cosmeticians follow (42 percent), chemist's shops (13.2 percent), perfumeries (9.5 percent) and department stores (6.8 percent).

Compared to a survey regarding the same questions in the year 2000 there are three times as many persons seeking advice for skin problems in pharmacies. At that time the dermatologist was uncontested at the first position, but the pharmacist had only been named by 15 percent of the respondents.

A particularly positive image in questions concerning skin advice falls today to pharmacies. 52.6 percent of the female respondents reckon on pharmacies for being particularly competent in questions aiming at skin care. Also 52.4 percent of the interviewees with general qualification for university entrance and/or university degree indicated the pharmacy when requiring advice in questions relating to skin.

These results are to motivate dermatologist and pharmacists to further commit themselves in the field of cosmetic consultation.


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