The pathophysiologic quaternity of diaper dermatitis is also proposed as an alternative approach to identify targets for treatment in this skin condition. In this review, nonsteroidal, nonantibiotic topical agents with known therapeutic effects on diaper dermatitis are discussed. However, the excessive, persistent, and irrational use of these agents have documented adverse effects (e.g., skin atrophy, pigmentary alterations, suppression of the hypothalamic–pituitary–adrenal axis, and bacterial resistance), which may preclude the positive effects of treatment ( Sharifi-Heris et al., 2018a) Hence, novel approaches and combinations have been explored as a replacement for the usual options for this condition. Modern topical agents (e.g., corticosteroids and antimicrobials) are known to have potent and quick effects on symptoms of diaper dermatitis. Therefore, to prevent IDD and IAD, the most recommended modalities are disposable, superabsorbent, and breathable diapers, frequent diaper changing, gentle cleansing, and the application of protective emollients and agents that promote the restoration of the natural and physical skin barriers ( Beguin et al., 2010, Blume-Peytavi and Kanti, 2018). The aim of appropriate skin care practices to prevent IDD and IAD is to support skin barrier function, maintain appropriate dryness, reduce friction, and limit exposure to irritants. Additionally, overt malnutrition or micronutrient deficiencies, which are common in the aged population, may further restrict reparative responses to harmful stimuli ( Beguin et al., 2010). In addition to these changes, age-associated skin changes lead to a prolonged recovery of the epidermal barrier, the skin becomes prone to xerosis, and the surface pH shifts away from the protective acidic state. Eventually, fecal enzymes attack the skin, further adding to the damage. Like IDD, moist occlusion leads to increased susceptibility for skin friction and increased skin hydration, as well as alkalization of skin pH, which strongly impair the barrier function of the stratum corneum. Pathophysiologic quaternity of diaper dermatitis.Ĭoncurrently, due to an aging population, a growing number of adult patients have incontinence associated dermatitis (IAD), which has much in common with the infant variant. These factors, which summarily may be referred to as the pathophysiologic quaternity of diaper dermatitis, are believed to contribute to the disease process in varying degrees ( Fig. Friction from wet diapers can lead to a breakdown of the skin barrier and increased cutaneous permeability to potential irritants or inflammatory triggers. Prolonged exposure to urine and feces leads to a more alkaline pH in diapered skin, which results in changes in microbial colonization, activation of fecal protease and lipase enzymes, and stratum corneum impairment. This milieu promotes damage to the structure of the stratum corneum, which directly contributes to the impaired barrier function. Furthermore, the skin in the diaper area is predisposed to prolonged contact with urine and feces, as well as diaper occlusion, which leads to overhydration and alterations in skin pH. Because newborn skin exhibits cutaneous immaturity, there exists an increased susceptibility to skin barrier disruption or percutaneous absorption of irritants. Various etiologic factors have been identified and considered important in irritant diaper dermatitis (IDD), namely maceration, friction, and the presence of both urine and feces ( Blume-Peytavi and Kanti, 2018).
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