Diaper Dermatitis and Pinworms PDF

Diaper Dermatitis and Pinworms Tara Higgins, PharmD, BCPPS, FPPA, FFSHP Objectives Define exclusions for self care treatment for diaper dermatitis and pinworms Identify nonpharmacologic treatment strategies for diaper dermatitis and pinworms Summarize pharmacotherapy treatment strategie...

Diaper Dermatitis and Pinworms Tara Higgins, PharmD, BCPPS, FPPA, FFSHP Objectives Define exclusions for self care treatment for diaper dermatitis and pinworms Identify nonpharmacologic treatment strategies for diaper dermatitis and pinworms Summarize pharmacotherapy treatment strategies for diaper dermatitis and pinworms Apply therapeutic intervention to a patient case scenario Diaper Dermatitis Epidemiology Most common dermatologic disorder of infancy 1 million primary care provider office visits per year Majority affecting infants 2 years of age and less Can occur in association with any age group Can appear as early as 7 days after birth Incidence is likely underreported Prevalence rates 7-50% with a peak between ages 9-12 months Decline in rates of diaper dermatitis started in 1970s and accelerated in 1980s-1990s Pathophysiology Perineal region skin is ~1/2-1/3 the Occlusion thickness of adults Frequent urination and defecation plus Friction Moisture infrequent diaper changes contribute to skin moisture Younger the infant the more frequent the elimination Skin that becomes waterlogged or Dermatitis hyperhydrated plugs sweat glands which Mechanical increases susceptibility to abrasion and chafing Microbes frictional harm and diminishes barrier function of stratum corneum Diminished barriers make the skin more GI tract susceptible to irritation, injury and proteolytic infection Alkaline pH enzymes and bile Factors implicated in pathogenesis salts High Risk Medications or Foods Medications Affect the motility or microbial flora of the gastrointestinal tract (i.e. antibiotics) Hinder autonomic control of urination and defecation Foods High in hexitols, sorbitol, sucrose, and fructose may induce diarrhea Lactose Breastfed infants have decreased incidence in comparison to formula fed Less copious, less alkaline, and less caustic to the skin Transition to solid food Clinical Presentation Erythematous Shiny, wet-looking patches and lesions Dusky maroon or purplish lesions on darker skin Appears in matter of hours Takes days to resolve Severe Maceration, papule formation vesicles or bullae, oozing, ulceration Location: perineum, buttocks, lower abdomen, and inner thighs Complications: Secondary infection or genital damage Infections of the penis or vulva and urinary tract infections Differential Diagnosis Allergic contact dermatitis Usually only appears in area of contact with allergen Often spares the inguinal skin folds Other Disease Manifestations Kawasaki syndrome Granuloma gluteale infantum Cytomegalovirus infection Nutritional deficiencies Infants born to immunocompromised mothers (HIV or genital herpes) Primary infections in the infant can be misdiagnosed as diaper dermatitis Co-exist with other skin conditions Psoriasis and seborrhea Treatment Goals Relieve symptoms Rid the patient of the dermatitis Prevent secondary infection Prevent recurrence Self-Treatment Measures Limit to uncomplicated Absence of comorbid conditions or constitutional symptoms Mild-moderate Absence of oozing or blood at lesion sites Lesions present for less than 7 days ABCDE A = Air B = Barrier C = Cleansing D = Diaper E = Education Goals of Non-Pharmacologic Treatment Reduce occlusion Reduce contact time of urine and feces with skin Reduce mechanical irritation and trauma Protect the skin from further irritation Encourage healing Prevent secondary infection Nonpharmacologic Therapy Increase diaper changes to minimum of 6 per day Diaper holiday Gentle patting when cleansing using a chemical-free soft cloth or low- abrasive baby wipe Sensitive-skin wipe product Alcohol, perfume and soap free Do not use unsoiled area of diaper to wipe area Air dry before rediapering Limit cleansing to only when stool is present Disposable vs Cloth diapers Disposable diapers feature absorptive materials that pull moisture away from skin and some contain a protectant (petrolatum) Want to stay away from disposable diapers with dyes as can cause allergic contact dermatitis Cloth diapers have been associated with more diaper dermatitis but if need to use should launder with a mild detergent, with extra rinse cycles if sanitizing agents are used Pharmacologic Therapy FDA Approved Skin Protectants Allantoin Hard fat Aluminum hydroxide Kaolin Calamine Lanolin Cocoa butter Mineral oil Cod liver oil (in combination) Petrolatum Colloidal oatmeal Topical cornstarch Dimethicone White petrolatum Glycerin Zinc carbonate Zinc oxide  Pros and Cons to Common Skin Protectants Zinc oxide Most commonly used Drawback- hydrophobic nature makes necessity for soap to remove the product from the skin Weigh ease of use vs adequately protecting the skin Petrolatum or white petrolatum are commonly used oleaginous ingredient and are ubiquitous ointment bases May be active or inactive ingredient in skin protectant Lanolin bacteriostatic product obtained from fatty substance found in wool Drawback - contact sensitizer so risk for sensitization should be considered if lanolin is applied in the diaper area where the skin is inflamed and more vulnerable to contact allergens Calamine is a mixture of zinc and ferrous oxides- it is absorptive, antiseptic and antipuritic properties and available in numerous dosage forms Mineral oil coats skin with water-impenetrable film that must be washed off with each diaper change Drawback- can block pores causing folliculitis Select Other Ingredients in Skin Protectants Aloe Jojoba Beeswax Lavender Calendula Peruvian balsam Castor oil Sweet clover Chamomile Tea tree oil Comfrey Vitamin A Flower extract Vitamin D Honey Vitamin E Goldenseal May be unsafe or no value Suggest simplest possible product that contain FDA approved ingredients What about Baby Powder? Loose powders Topical cornstarch or talc Benefit reducing moisture and friction Warning against inhalation of powder because of associated risk of severe respiratory disease Infection Cancer? Aluminum Hydroxide-Magnesium Hydroxide Not studied for safety and efficacy Mix oral aluminum-hydroxide-magnesium hydroxide oral antacid suspension with Aquaphor 1-2-3 paste Burow’s solution (aluminum acetate in water) compounded with petrolatum and zinc oxide Application Inspect product for color and review expiration dates Apply liberally to the skin in the diaper area Do not remove remaining protectant from previous diaper change Unless stool present Overapplication is not a concern Underapplication can reduce the protective effect of the product Reapply as needed with every diaper change No interactions with other agents Ointment preparations will impede retention of other topically applied products What about Topical Antimicrobials? Nonprescription antibiotic and antifungal agents are not appropriate for use in the self-treatment Medical referral is advised if an infection is suspected Contraindicated Topical analgesics are not recommended as can alter sensory perception Excoriate macerated skin, cause pain, retard healing and further complicate diaper dermatitis Hydrocortisone Do not use without healthcare provider supervision Increase risk for secondary infection via immune response suppression Diaper area is large proportion of infant's body surface area may lead to systemic absorption Avoid in children < 2 years of age Complementary Therapies Not recommended for use in newborns and infants Insufficient evidence for safety and effectiveness Rates of systemic absorption is unknown Honey for woundcare? Manuka honey Found to have hygroscopic, fungicidal and antibacterial properties and regulate the mildly acidic pH of the skin Honey, beeswax and olive oil have initial studies showing may be effective in management of diaper dermatitis Need more robust studies before recommending as therapeutic agents Follow up Usually does not necessitate medical referral Dramatic improvement is seen within 24 hours of initiation of pharmacologic and nonpharmacologic treatment Pinworms Enterobius vermicularis Pinworm, seatworm or threadworm Intestinal roundworm (nematode) Nuisance but presents little risk to infected person or public Epidemiology Most common intestinal helminthic (parasitic worm) infestation in the US 40 million persons infected in childcare settings and urban areas Highly contagious ~50% cases occur among persons who are institutionalized and among household members Seen at all socioeconomic levels No apparent tendency for specific race or cultural group Pathophysiology Humans are the only known hosts of E. vermicularis Most common pinworm transmission route is: Fecal-oral ingestion of eggs from direct anus-to-mouth transfer by fingers or Indirect egg transfer from perianal region through fomites Reinfection occurs readily because eggs often are found under fingernails of infected children who have scratched the anal area Finger sucking, nail biting and nose picking Eggs can remain viable outside the intestinal tract for up to 20 days and can be spread during that time particularly under humid conditions Life Cycle Clinical Presentation Minor infections are often asymptomatic Most common symptom Nocturnal perianal or perineal pruritis Caused by inflammatory reaction to the presence of adult worms and eggs on the perianal skin Major infections may produce signs and symptoms ranging from: Abdominal pain, insomnia, and restlessness to anorexia, diarrhea and intractable localized itching Medical Referral Needed Severe symptoms Extraintestinal infestation Differential Diagnosis Diaper dermatitis Constipation Hemorrhoids Complications Secondary bacterial infections Extraintestinal infections Genitourinary: Endometritis, salpingitis, tubo-ovarian abscess, pelvic inflammatory disease, vulvovaginitis, and potentially infertility Peritoneal cavity: Granulomas, appendicitis Exclusions for Self Treatment Liver disease Pregnancy Breastfeeding < 2 years of age unless pediatrician has approved OTC treatment Weight < 11 kg unless PCP has approved OTC treatment Vague symptoms and negative visual inspection Helminthic infections other than pinworm infection Hypersensitivity to pyrantel pamoate Need for repeat dosing Treatment Goals Eradicate the pinworm infection and relieve symptoms Prevent reinfection Prevent transmission to other persons Nonpharmacologic Therapy Educate on personal hygiene Keep fingernails short to prevent harboring of eggs and autoinoculation Discourage biting nails and scratching anorectal region Ensure blinds or curtains are open in the affected room(s) to enhance cleansing the environment Wash bed linens, underwear, bedclothes, and towels of the infected person and entire household in hot water daily during treatment Bathe daily in the morning- showers are preferred Change underwear, nightclothes, and bed sheets daily for several days after treatment Clean and vacuum (do not sweep) the house daily for several days after treatment Wet mopping before may limit spread of pinworm eggs into the air Pharmacologic Therapy- Pyrantel Pamoate First used in veterinary practice Cure rate of 90-100% Depolarizing neuromuscular agent Drug is poorly absorbed with 50% excreted unchanged in the feces Indicated for 2 years and above who weigh at least 11 kg Weight based dosage chart on the package label Dose can be repeated in 2 weeks if symptoms do not resolve Only after consultation with primary care provider Take at any time of day without regards to meals May be mixed with milk or fruit juice Shake liquid before measuring dose with provided measuring device Dosage Chart Adverse Most common: Effects Nausea, vomiting, abdominal cramps, diarrhea, and anorexia Less common Headache, dizziness, drowsiness, insomnia, rash, fever and weakness Rare Increase in AST Consult Provider Pre-existing Before Taking Severe liver malnutrition Pyrantel dysfunction Pamoate Anemia Pregnancy Breastfeeding Prescription Pharmacotherapy- Mebendazole Children > 2 years and adults Dose: 100 mg PO once; repeat in 2 weeks Administer without regard to meals Tablets may be chewed, swallowed whole or crushed and mixed with food Adverse effects: Abdominal pain, anorexia, diarrhea, flatulence, nausea, vomiting, hepatitis 10%: headache; increased liver enzymes 1-10%: dizziness, vertigo, alopecia, abdominal pain, nausea/vomiting