beginning of the diaper dermatitis
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Abstract
Diaper dermatitis (DD), an acute inflammatory reaction of skin in the
perineal area, is an extremely common pediatric condition. Nurses
practice of preventing and treating DD is inconsistent and often not
evidence-based. In addition, a 2008 Skin Injury Prevalence Study at
our hospital revealed that 24% of inpatients had DD. The authors
developed a project to determine a consistent and evidence-based
approach to DD prevention and treatment including the availabi lity of
products. A complete literature review was conducted in addition to
benchmarking with other pediatric hospitals, consultation with topic
experts, and evaluation of current nursing practice prior to revis-
ing the existing perineal skin care nursing standard. The evidence
supports frequent diaper changes, use of super absorbent diapers,
and protection of perineal skin with a product containing petrolatum
and/or zinc oxide. As supported by the literature, we revised the
standard to include improvements in practice as well as product
updates for prevention and treatment. Hospital-wide implementation
of the revised standard included training Skin Care Champions to
educate staff and support practice improvements. Ongoing education
and monitoring by the Skin Care Champions is necessary to further
improve the prevention and treatment of DD for our patients.
Key Words: Diaper dermatitis, Diaper rash, Infant, Pediatric patient.
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expressed dissatisfaction with the lack of zinc-basedproduct availability. Additionally, medical care teams fre-quently ordered individual pharmaceutical ingredientsthat nurses mixed together at the bedside to create theirown concoctions. The Nursing Practice department
viewed these bedside concoctions asa patient safety issue and, therefore,a priority for the hospital to address.In addition, a 1-day Skin Injury Prev-alence Study conducted in our hospi-tal reported 24% of inpatients hadDD (unpublished data). This infor-
mation supports our hospitals incon-sistent approach toward preventionand treatment of this commonlyoccurring problem.
To address this issue, we formedan interdisciplinary team comprisedof a wound ostomy continence nurse,nurse researcher, pharmacist, and
clinical nurse specialists (CNSs) from surgery, oncology,complex chronic/integrated care, and neonatal intensivecare. With a team formed and problem areas identified,we extensively reviewed the literature to determine thebest evidence for DD prevention and treatment.
Synthesis of Literature andAdditional EvidenceThe team conducted a broad literature search throughCINAHL and Ovid, with no age or date limitations.Search terms included diaper rash, diaper dermatitis,nappy rash, irritant contact dermatitis, perineal skinbreakdown, oncology, neonatology, surgery, petrolatum,zinc oxide, cholestyramine, baby powder, and cornstarch.Incontinence-associated dermatitis (IAD), a term used forDD symptoms in older pediatric and adult patients, wasnot included in this search (Gray et al., 2007). A reviewof article reference lists provided additional sources. Wealso reviewed national neonatal skin care guidelines. Inaddition to the literature, we searched for additional evi-
dence by querying pharmacy and nursing listserves,consulting with topic experts in our hospital, andbenchmarking with other pediatric hospitals for theirDD prevention and treatment practices.
The literature search yielded 96 articles dating from1962 to 2011 of which we evaluated 82 that specifi-cally addressed DD prevention and treatment. We usedthe rating scale as described by Melnyk and Fineout-Overholt (2011) to level the evidence. Less than 12%of the articles were systematic reviews or randomizedcontrolled trials (Levels I & II) and the remaining ar-ticles were nonrandomized trials, single descriptivestudies, literature reviews, or expert opinions (Levels
Diaper dermatitis (DD), an acute inflammatoryreaction of skin in the perineal area, is anextremely common pediatric condition. Theetiology of DD is multifactorial and includes
moisture, warmth, friction, urine, and feces. Skin contactwith urine and feces plays an integralrole as moisture trapped against theskin causes increased permeabilityand susceptibility to damage fromfriction (Berg, Milligan, & Sarbaugh,1994). The skin therefore loses itsability to provide an effective barrier
against irritants and microbes. Urinecontact with diapered skin causes anincrease in skin pH thus increasingskin permeability and activating fecalenzymes, known irritants that cancause skin destruction. As the stratumcorneum becomes damaged, microbesare more likely to cause inflamma-tion and can lead to the development of a secondaryinfection (Shin, 2005). The signs and symptoms of DDrange from generalized erythema to skin breakdownleading to an open wound. Above all, DD causes discom-fort for the child as well as significant caregiver distress.
Age and health status influence DD risk. DD can occurin diapered and/or incontinent patients of varying ages.Neonates, specifically premature neonates, are at in-creased risk (Lund et al., 2001), as well as patientsbetween 9 and 12 months of age (Jordan, Lawson, Berg,Franxman, & Marrer, 1986). DD commonly affectshealthy children; however, acutely and chronically illchildren may be at higher risk due to factors includingmedications that can cause diarrhea, underlying diagno-ses such as cancer, gastrointestinal anomalies, neurologi-cal disorders, genetic syndromes, and malnutrition. In apoint prevalence study, Noonan, Quigley, and Curley(2006) found 60% of hospitalized children less than 18years of age incontinent of urine and/or stool with 16%of these patients having hospital-acquired DD. McLane,Bookout, McCord, McCain, and Jefferson (2004) found
excoriation/DD as the most common type of skin break-down (42%) in their prevalence study of hospitalizedchildren aged birth to 17 years old.
The DD frequency cited in the literature, the suspicionthat our hospitals rate was high, and observed practicevariations encouraged us to look at our own prevalencerates and prevention and treatment tactics. We utilizedthe Iowa Model of Evidence-Based Practice (EBP) as theframework for our project (Titler et al., 2001). Problem-focused triggers included nursing and physician requestsfor barrier products not carried by the hospital and fre-quent changes to the treatment plan from shift to shift.Nurses, physicians, and pharmacists, as well as families,
Lauren M. Heimall, MSN, RNC-NIC, PCNS-BC, Beth Storey, MSN, RN, CPON,Judith J. Stellar, MSN, CRNP, PNP-BC, CWOCN, and Katherine Finn Davis, PhD, RN, CPNP
Diaper dermatitis
causes discomfort for
the child as well assignificant caregiver
distress.
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found petrolatum to be an effective barrier against skinbreakdown.
Other factors to consider include the type of diaperand frequency of diaper changes. A Cochrane Review didnot find definitive evidence to support or refute the useand type of disposable diapers for prevention of DD(Baer, Davies, & Easterbrook, 2006). However, multipledescriptive and expert opinion articles recommend usingsuper absorbent diapers containing gelling materials,which keep moisture away from skin (Davis, Leyden,Grove, & Raynor, 1989; Lund et al., 1999; Nield & Ka-mat, 2007; Scheinfeld, 2005). Caregivers should changediapers frequently, as often as every 2 hours or soonerif the diaper is wet and/or soiled (AWHONN, 2007;Atherton, 2004; Borkowski, 2004; Nield & Kamat;Visscher, 2009).
The literature supports certain processes for cleansingthe diaper area and subsequent application of diaper areaproducts. Some authors encourage the use of soft clothsand water for cleansing the diaper area due to preserva-tives in baby wipes that have the potential to cause skinirritation (AWHONN, 2007; Borkowski, 2004). How-
ever, many authors continue to supportthe use of baby wipes due to advancesin manufacturing that have decreasedthe number of additives that they con-tain (AWHONN, 2007; Atherton, 2004;Ehretsmann, Schaefer, & Adam, 2001;Nield & Kamat, 2007; Odio, Streicher-Scott, & Hansen, 2001). Appropriateapplication of prevention and treatmentproducts is also an important factor toconsider. Several experts (Lund et al.,1999, 2001; Taquino, 2000) advisecaregivers to apply barrier productsthickly and refrain from rubbing offcompletely during diaper changes toprevent further skin damage. Coveringbarrier products with a thin layer of pet-rolatum may help prevent the diaperfrom sticking to the product (Borkowski,2004). When a fungal infection is pres-ent, caregivers should apply the anti-fungal first with the barrier productlayered on top. Antifungal powder can
also be layered with skin protectant/sealant, referred to as crusting (Gray,2007).
Current PracticeIn conjunction with searching for evi-dence, our team developed a survey tocollect baseline data prior to any prac-tice changes (Titler et al., 2001). Thissurvey included data regarding diaperedstatus, DD products at the bedside,and presence and type of DD as de-scribed by Noonan et al. (2006). The
IIIVII). See Table 1 for a summary of select recom-mendations from the literature.
Although the literature supports that DD is a commoncondition in the hospitalized child, definitive Levels I andII evidence supporting the most effective prevention andtreatment options is not available (Rowe, McCall, &Kent, 2008). However, there is some consensus of lowerlevels of evidence around effective barriers. The literaturesupports that petrolatum and/or zinc oxide provide effec-tive barriers against potential perineal skin irritants andmaceration (Association of Womens Health, Obstetricand Neonatal Nurses [AWHONN], 2007; Hoggarth,Waring, Alexander, Greenwood, & Callaghan, 2005;Lund, Kuller, Lane, Lott, & Raines, 1999; Nield &Kamat, 2007). Baldwin et al. (2001) studied disposablediapers that delivered a continuous zinc oxide- and
petrolatum-based formulation to the skin. Infants wear-ing these diapers had reduced DD and skin erythemacompared to the control group wearing regular diapers.Baldwin also found that an increased concentration ofzinc oxide in an impregnated diaper led to an increasedtransfer of zinc oxide to the skin. Hoggarth et al. (2005)
Table 1.Summary of Literature Recommendations for
Diaper Dermatitis Prevention and Treatment.
Positive recommendations
Zinc oxide AWHONN, 2007; Baldwin, et al., 2001;Hoggarth et al., 2005;Lund et al., 1999; Nield & Kamat, 2007;Wananukul et al., 2006
Petrolatum AWHONN, 2007; Atherton, 2001;Hoggarth et al., 2005; Lund et al., 1999;Odio et al., 2000
Ilex Lund et al., 1999
Antifungal products Lund et al., 1999
Frequent Diaper Changes AWHONN, 2007; Atherton, 2004; Borkowski, 2004;Kazaks & Lane, 2000; Nield & Kamat, 2007;Visscher, 2009
Super Absorbent Diapers Atherton, 2001a; Atherton, 2004
a; Baer et al., 2006a;
Davis et al., 1989a; Lund et al., 1999;Nield & Kamat, 2007; Scheinfeld, 2005
a
Application proceduresfor use of barrierproducts & antifungalproducts
Borkowski, 2004; Gray, 2007; Lund et al., 1999, 2001;Taquino, 2000
a
Diaper Wipes Atherton, 2001a; Atherton, 2004
a; Borkowski, 2004;
Ehretsman et al., 2001a; Nield & Kamat, 2007,
Odio et al., 2001a
Neutral or Negative Recommendations
Open to Air Lund et al., 1999
Antibacterial Products AWHONN, 2007; Lund et al., 1999
Powder Darmstadt & Dinulos, 2000a; Farrington, 1992
a
aThese references are also included in AWHONNs Neonatal Skin Care Evidence-BasedClinical Practice Guidelines (2007)
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4. What do you like/dislike about the revised standard?5. What would make the revised standard more adapt-
able to practice? More user-friendly? More helpful oraccessible?Based on the feedback, many nurses were unaware of
our current standard or had read it once during orientationand had not accessed it again. Primary obstacles were inac-cessibility, including difficulty searching the nursing intranetor having no direct links to the standard. Regarding feed-back on the revised standard, nurses commented positivelyabout the inclusion of photos of DD, as well as the algo-rithm for prevention and treatment. The nurses offeredmany ideas to improve the revised standard, chiefly sur-rounding clarification of product application and removal.
Product SelectionUsing the evidence, we moved forward to update ourcurrent products. We consulted our hospital allergy,dermatology, and infection control experts regardingcommon additives and tubs versus tubes for prod-uct containers. Following the EBP process, we also con-
sidered caregiver preferences and availability of productsin the community so treatment could be continued athome (Melnyk & Fineout-Overholt, 2011). Next, weobtained approval from the hospital product evaluationcommittee and collaborated with materials distributionto plan product availability, location, and switch-out.Titler et al. (2001) recommends piloting an EBP changein a small sample, such as a single unit; however, this wasnot feasible with our hospitals system for changingproducts house wide. The hospital stocked petrolatum(Vaseline), but did not designate it as a DD product. Pet-rolatum, the first-line product for prevention, is nowavailable on each units open supply cart. We replaced
survey included 195 patients from six in-patient units specifically chosen due to
their high risk of DD as shown in ourhospitals previous Skin Injury PrevalenceStudy. Results filtered for only diaperedand incontinent patients showed that16% had DD, of which 76% were Type Iand a variety of products existed at thebedsides (Figure 1, January 2010 data).
Changing PracticeChanging practice to reflect the currentevidence is not without challenge. Cullenand Titler (2004) state that initiating aproject and effectively changing practicecan take 18 to 24 months. This is especially
true regarding the prevention and treat-ment of DD because many clinicians haveset ideas based on past experiencebothas clinicians and as parents. In addition,caregivers have opinions on how to pre-vent and treat DD for their child. EBPmodels do account for these patient andfamily preferences along with clinical exper-tise and research evidence (Melnyk & Fineout-Overholt,2011). Despite these challenges, nursing practice needs toreflect the evidence. Therefore, our team forged aheadwith updating our perineal skin care standard based onthe current evidence.
New Practice GuidelinesAfter a comprehensive review of the evidence, we revisedour nursing standard. The new perineal skin care stan-dard focuses on prevention and the importance of clearlyidentifying patients at risk for DD in order to employprevention strategies early in the hospitalization. Forpatients with DD, a clear time frame was developed todiscourage constant changing of products and allowone particular product time to exhibit effectiveness. Inorder to improve user-friendliness, we added a single-page, step-by-step algorithm (Figure 2) with photos andproduct application instructions. Detailed instructionselaborating on the algorithm and routine diaper care areincluded in the body of the standard.
Prior to implementation, we sought feedback from
frontline staff as end users regarding use of the currentstandard as well as information on format, understand-ability, and ease of use for the revised standard (Titleret al., 2001). To gather this information, we conductedfocus groups with key stakeholders. Forty-three nursesand one advanced practice nurse across six units fre-quently caring for diapered patients participated in thediscussions. We drafted a standard script to guide thediscussion. Questions included:1. Were you aware of the current Perineal Skin Care
Standard?2. How do you use the current standard?3. What are the obstacles to using the current standard?
Figure 1. Diaper Dermatitis Prevalence & Severityin High-Risk Units
Type 1: erythema, intact skin, no Candida; Type 2: erythema, intact skin, Candida;Type 3: erythema, denuded skin, no Candida; Type 4: erythema, denuded skin, Candida.
0%2008Dec 2010Jan 2010June 2010Sept 2010Dec
5%
10%
15%
20%
25%
30%
TotalDiaperDermatitisRate
% Type IV
% Type III
% Type II
% Type I
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practice changes. In light of our initial finding of 24%prevalence of DD, we reassessed our high-risk units prior
to implementing our revised standard and found a 16%prevalence rate. These rates from high-risk units closelymirror hospital-wide data. Following implementationof the revised standard, our prevalence rate was 15% at3 months, 18% at 6 months, and 11% at 9 months.Therefore, over a 2-year period, the prevalence rate forhigh-risk units dropped from 24% to 11%. Preimple-mentation, prevalence assessments of Type IV DD were11% and 5%. In the 9 months following implementa-tion, the prevalence of Type IV DD decreased to 0% (seeFigure 1). To capture compliance with the standard, wecollected information regarding products at the bedside.
Prior to implementation of the revised standard, 14% ofhigh-risk patients had other products at the bedsidenot currently identified in the standard. Postimplementa-tion, data revealed a decrease of other products to6% potentially reflecting increased compliance with therevised standard.
Clinical ImplicationsThe hospital Skin Care Champions were integral inbringing DD prevention and treatment to the forefront ofnursing care. They will continue with this work as nurs-
ing staff needs frequent reminders of the importance ofperineal skin care within the busy demands of bedsidecare. Routine collection of skin condition data serves as areminder and offers another opportunity for Skin CareChampions to discuss perineal skin care with nurses. Uti-lizing multiple avenues for information disseminationhelps ensure that the message is heard.
DD continues to affect hospitalized children andshould remain a priority for nurses caring for diaperedand incontinent patients. DD is often a preventable con-dition if appropriate attention and care are provided.Most importantly, nurses have the opportunity to influ-ence DD rates through preventative evidence-based care.
our second-line product with a 40% zinc-based product(Desitin Maximum Strength Original Paste), which is
available in each units Pyxis MedStation. In addition tobeing evidence-based, this change saves the hospitalapproximately $8,000 per year. Nurses order products inthe third line of prevention and treatment (Triple Paste,etc.) from materials distribution for individual patients.Our algorithm encourages the use of first- and second-line products and reserves the use of third-line productsfor when frontline products fail or as determined bypatient needs.
Communication and DisseminationOnce we finalized revisions to the standard, we devised ahospital-wide rollout plan. This plan included presenta-
tions to the hospital CNS group, nursing departmentshared governance councils, and approximately 60 unit-based Skin Care Champions who are responsible for skincare education on their units. The team presented the en-tire EBP project during Nurses Week as both a poster andoral presentation. All nursing units received a tip sheethighlighting the major changes to the standard, color post-ers of the algorithm to post, and cameras to document DDvisually and see improvements with healing over time.
ChallengesAlthough DD is a common condition in the hospitalizedchild, definitive optimal prevention and treatment strate-gies are still debatable as there is a lack of randomizedcontrolled trials. This lack of high-level evidence makesrecommendations more difficult. Additionally, much ofthe evidence available is dated; therefore, more studiesare needed to identify the best options available.
The implementation of EBP changes proved to be achallenge in such a large pediatric hospital. Thousands ofstaff required education and training that spanned mul-tiple disciplines. The risk of staff information overloadwas ever present as there were many competing prioritiesthroughout the hospital at the time we disseminated thenew standard. Buy-in from staff and consistency in prac-tice were essential for the implementation of practicechanges and important for patients and families to haveconsistent, evidence-based care.
Clinicians often have preferences for DD prevention
and treatment based on clinical and personal experience.Straying from those preferences, especially when believedto be the best method or product, can be difficult. Addi-tionally, caregivers may also have personal preferencesfor their child and may want to continue with their ownprevention or treatment strategies. While acknowledgingclinician and caregiver preferences, we sought to educatethrough the evidence-based revision of the standard andpatient/family education materials.
EvaluationAs part of the EBP implementation process, Titler et al.(2001) recommend reevaluation after implementation of
Buy-in from staff and
consistency in practice were
essential for the implementation
of practice changes and important
for patients and families to have
consistent evidence-based care.
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Our hospital demonstrated improvement in the preva-lence of DD and the severity of cases, but there is always
room for additional improvement.
Lauren M. Heimall is a Clinical Nurse Specialist in theNewborn/Infant Intensive Care Unit, The ChildrensHospital of Philadelphia, Philadelphia, PA. She can bereached via e-mail at [email protected].
Beth Storey is a Clinical Nurse Specialist in the Inpa-tient Oncology/Blood and Marrow Transplant Unit, TheChildrens Hospital of Philadelphia, Philadelphia, PA.
Judith J. Stellar is a Wound, Ostomy, ContinenceAdvanced Practice Nurse at The Childrens Hospital ofPhiladelphia, Philadelphia, PA.
Katherine Finn Davis is a Nurse Researcher, TheCenter for Pediatric Nursing Research & Evidence-Based
Practice, The Childrens Hospital of Philadelphia, Phila-delphia, PA.The authors declare no conflicts of interest.
DOI:10.1097/NMC.0b013e31823850ea
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For 13 additional continuing nursing education articles onevidence-based practice, go to nursingcenter.com/ce
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