Diaper Dermatitis: Appropriate Evaluation ... - ModernMedicine

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Diaper Dermatitis: 

Appropriate Evaluation & 

Optimal Management Strategies 

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Diaper Dermatitis - Appropriate Evaluation 

& Optimal Management Strategies 

Sheila Fallon Friedlander, Md 

Moderator/Chair 

Clinical professor of pediatrics and 

Medicine (Dermatology) 

rady Children’s Hospital, San Diego 

University of California, San Diego 

Lawrence F. Eichenfield, Md 

professor of pediatrics and 

Medicine (Dermatology) 

Chief, pediatric and Adolescent Dermatology 

rady Children’s Hospital, San Diego 

University of California, San Diego 

April 2009 

James Leyden, Md 

Emeritus professor of Dermatology 

Department of Dermatology 

University of pennsylvania 

philadelphia, pennsylvania 

Jennifer Shu, Md, FAAP 

Children’s Medical Group, p.C. 

pediatrician and Author 

Atlanta, Georgia 

Mary c. Spellman, Md 

Dermatologist and pharmaceutical 

Development Advisor 

San Francisco, California 

Diane Kebabjian 

NATIONAL SALES MANAGER 

Steve Farrell 

NATIONAL SALES MANAGER 

Leonardo Avila 

ASSOCIATE PUBLISHER 

R. Steve Morris 

EXECUTIVE VICE PRESIDENT 

Laura Wagner 

VICE PRESIDENT, 

OPERATIONS & PRIMARY CARE 

Peggy K. Onstad 

GENERAL MANAGER AND 

GROUP PUBLISHER 

John C. Marlow, MD 

CHIEF MEDICAL AND 

COMPLIANCE OFFICER 

The views and opinions expressed by the participants of 

this supplement do not necessarily reflect the views and 

opinions of Contemporary Pediatrics or Medisys Health 

Communications Inc. 

©2009 Medisys Health Communications, Inc. 

E0012z 

IntroductIon 

Irritant diaper dermatitis (IDD) is a localized form of contact dermatitis 

caused by several factors, including warmth, chafing, prolonged contact with 

urine and feces, and overhydration of the upper portion of the skin (stratum 

corneum). 1 Many experts believe that the presence of Candida yeast infection 

also plays a primary, as well as a secondary, role in the development of this 

frequently troublesome and sometimes painful eruption. 1 IDD is so common 

that infants in the United States have a 1 in 4 chance of being diagnosed with 

this condition. 2 In a recent UK study that included the parents of 532 hospitalized 

children in diapers, 52% of families reported a history of diaper dermatitis 

(DD), and multivariate analysis demonstrated the risk of DD to be 

associated with oral thrush, past history of disease, frequency of diaper 

changes, and diarrhea. 3 There were 4.8 million outpatient visits for DD from 

1990 to 1997; pediatrician visits accounted for 75% of these, and the remaining 

25% of visits involved family physicians, internists, dermatologists, and 

other specialists. 2 IDD is a therapeutic challenge for both parents and physicians 

because of its frequency and the difficulty in eliminating all of the 

causative factors in diapered infants. 

IDD is generally episodic and relatively self-limiting. It peaks 

in frequency at 9 to 12 months of age. 4 However, moderateto-severe 

IDD can be more problematic, and is 

frequently associated with Candida albicans. 

Although estimates of candidiasis- 

associated DD vary, early 

studies reported recovery of 

the organism in 41% to 

80% of infants with IDD, 

and a positive correlation

has been demonstrated between the clinical severity 

of IDD and the presence and level of C albicans in the 

diaper, mouth, and anus of infants. 5–8 

This panel agrees that IDD often can be managed 

effectively in its early stages by keeping the diaper 

area dry and the stratum corneum intact. This can 

be accomplished with frequent diaper changes, gen- 

IDD is so common that infants in the United 

States have a 1 in 4 chance of being diagnosed 

with this condition. 

tle cleansing, and use of barrier protection. In some 

cases, mild topical corticosteroids, such as hydrocortisone 

1%, may be useful. 9 If IDD worsens or persists 

for more than 3 days, candidiasis-associated DD 

should be strongly considered as a diagnosis. 10 

Candidiasis-associated DD can be severe, and it is 

important that the clinician recognize its associated 

signs and symptoms so that the rash can be treated 

appropriately with an antifungal agent. 

Practitioners should be aware that other less 

common, but potentially more serious, conditions 

can also “masquerade” as DD, including metabolic 

and nutritional disorders, malignancies, and a broad 

set of primary cutaneous disorders, such as psoriasis. 

11 These conditions should be considered as diagnoses, 

particularly if a patient does not respond 

to appropriate therapy. 

Prescribing patterns for moderate-to-severe DD 

demonstrate that topical antifungal agents, mid- to 

high-potency steroids, and combinations of both are 

often prescribed despite the fact that higher potency 

steroids may not be the best choice for use on the 

delicate, generally occluded diaper area of infants. 2 

B e c a u s e o f h i g h r a t e s o f c a n d i d a l 

colonization and infection associated with DD, patients 

may benefit from the use of a topical antifungal 

agent in addition to the traditional approaches for the 

treatment of persistent DD (appropriate cleansing 

and the use of barrier agents). A topical antifungal 

agent such as miconazole can be used for this purpose 

in conjunction with barrier products to protect the 

skin. A combination barrier antifungal ointment containing 

miconazole nitrate 0.25%, zinc oxide 15%, 

and white petrolatum 81.35% received FDA approval 

in February 2006 for the treatment of candidiasisassociated 

DD for pediatric patients aged ≥4 weeks. 12 

It is an alternative agent that provides a consolidated 

and simplified therapy for patients diagnosed with 

DD where secondary Candida involvement is likely. 

In severe cases of candidiasis-associated DD that is 

unresponsive to topical agents, oral agents such as 

nystatin may be useful in minimizing Candida species 

in the gastrointestinal (GI) tract, the primary 

reservoir of Candida spp. 

FActorS InvoLvEd In thE 

dEvELoPMEnt oF dIAPEr dErMAtItIS 

Diaper dermatitis arises from the interaction of several 

factors, the most important of which is prolonged 

contact of the skin with a mixture of urine 

and feces. The combination of diaper occlusion, fecal 

enzyme activity, urine, and diaper chafing leads 

to overhydration of the stratum corneum and chemical 

and mechanical abrasion, which compromises 

barrier function and makes the stratum corneum 

more susceptible to frictional trauma and the penetration 

of irritants and microbes. Hydrated skin is 

more likely to suffer frictional damage than dry skin, 

and frictional alterations in skin barrier function induced 

by overhydration can then subsequently 

change the balance of resident flora and promote 

growth and likely the invasiveness of C albicans, 

which is found in as many as 70% of infants 

with DD. 13,14 

Role of Urine And Feces 

Although urinary ammonia was traditionally 

thought to be an important etiologic factor 

in the development of IDD, a small study 

found no difference in the mean level of ammonia 

in the morning diaper obtained from 

26 infants with IDD compared with the mean 

level obtained from 82 control patients. 15 Furthermore, 

the experimental application of highly ammoniacal 

urine on intact infant and adult skin did not 

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Diaper Dermatitis | Appropriate Evaluation & Optimal Management Strategies 

April 2009 

elicit a dermatologic reaction. Erythema could be 

induced when ammoniacal urine was applied to skin 

that had been scratched sufficiently enough to compromise 

the skin barrier. In addition to the capacity 

of urine to irritate damaged skin, its most important 

role in the development of IDD is its proclivity for 

skin hydration. Thus, urinary ammonia on intact 

skin without secondary contamination does not appear 

to be a primary etiologic factor in IDD. 15 

However, the interaction of urine and feces is fundamental 

in the development of IDD. Berg and colleagues 

demonstrated that bacterial ureases in the 

stool degrade urea in urine, which releases ammonia; 

however, ammonia does not actually irritate the skin, 

but rather mediates irritation by increasing local pH. 16 

Increased pH reactivates fecal enzymes such as lipase 

and protease, which irritate the skin and disrupt the 

epidermal barrier. 16 It has also been demonstrated 

that the incidence and severity of IDD is significantly 

higher in infants with a 48-hour history of diarrhea. 

10,17 While it has been suggested that this higher 

rate of IDD could be due to increased exposure of the 

skin to irritation from fecal enzymes, it may be possible 

that additional moisture present in diarrhea 

versus normal stool could contribute to the increased 

incidence and severity of IDD in patients with loose 

stools. 17 Supporting this theory is the demonstration 

that skin wetness strongly correlates with both the 

risk and severity of IDD. 18 It is feasible that the excess 

moisture that accompanies diarrhea hydrates the 

skin, and when occluded, this increased hydration 

causes the skin barrier to further deteriorate. Thus, 

irritation may be enhanced by excess moisture in 

diarrheal stool, as well as the increased amount of 

fecal proteases and lipases in contact with the diaper 

area during bouts of diarrhea. 19 

cAndIdIASIS-ASSocIAtEd 

dIAPEr dErMAtItIS 

The cutaneous bacterial flora of the diaper area are 

abundant, regardless of the underlying condition of 

the skin. 6 Various organisms, including Staphylococcus 

aureus, Escherichia coli, and Proteus, have been recovered 

from the skin of infants with IDD, although 

these organisms are not considered causative. 6 C albicans, 

in contrast, has been widely implicated in 

moderate-to-severe DD. 7 

Candida is a genus of yeast-like fungi that is often 

part of the flora of the skin, mouth, and GI tract of 

infants. Excessive growth of Candida appears to 

increase the likelihood of invasive disease. Colonization 

by Candida spp appears to be significantly more 

frequent in children with IDD than in healthy controls. 

In a study by Ferrazzini et al, researchers compared 

the rates of colonization at 3 body sites in 

children with IDD and healthy controls. 8 The results 

demonstrated greater rates of colonization at 

all sites among the affected children versus the 

healthy controls: perianal, 75% vs 19%; inguinal, 

50% vs 10%; and oral, 68% vs 25%. 8 The same study 

also demonstrated a highly significant, positive correlation 

between the extent of Candida spp coloniza-

tion at all swab locations and disease severity. The 

researchers noted that relatively limited microbial 

colonization in the area of rash at the inguinal folds 

may not be relevant to disease severity, although 

extensive colonization is associated with disease 

exacerbation. 8 

Primary and Secondary Candida Infection 

The observation of relatively low levels of C albicans 

at some rash sites underscores the challenge 

in determining whether Candida is a causative factor 

in candidiasis-associated DD or if it is a secondary 

contaminant that flourishes in the moist, 

warm environment of the diaper area and then 

capitalizes on the disrupted skin barrier of the 

diaper environment. 

In support of the latter statement that Candida is 

a secondary contaminant, one study suggests that if 

sufficient moisture is present, adequate nutrients for 

the growth of C albicans exist on human skin. 20 In 

another study, Candida spp were identified in the 

diaper area of children who had healthy skin, which 

demonstrated that this area can be populated by 

Candida spp to a small degree without causing symptoms. 

8 In a study that used an experimental human 

infection model of erosio interdigitalis blastomycetica, 

it was demonstrated that recovery of C albicans 

decreased once the organism established itself on the 

skin and intense inflammation developed. 21 C albicans 

appears to be the initial contaminant, but infection 

was attributed to synergism of the organism with 

gram-negative rods, a synergy that might reproduce 

itself similarly with resident flora in candidiasis- 

associated DD. Once inflammation was present, the 

recovery of the organism decreased. 22 

Other observations support a primary role for 

Candida in the development of DD. It has been demonstrated 

that Candida does not require clinically 

inflamed skin to proliferate and cause infection. 

C albicans infection requires only moist occlusion on 

normal skin to grow. However, without moisture and 

occlusion, C albicans cannot compete against resident 

microflora. 21,22 

These studies illustrate that in a moist environment, 

Candida can colonize multiple areas on its 

own—even in a highly functional stratum corneum, 

and suggest that failure to recover the organism does 

not preclude the possibility of prior C albicans involvement. 

Although it is likely that an impaired stratum 

corneum is vulnerable to secondary colonization, 

a compromised skin barrier does not appear to 

be a prerequisite for colonization. It would seem that 

failure to consistently recover C albicans in clinically 

infected skin has been emphasized in the literature 

too heavily, and the colonization characteristics of 

C albicans too seldom. The data provide supportive 

evidence for both the primary and secondary contamination 

of C albicans in the diaper area. 

Candida and the Gastrointestinal Tract 

The consistently higher rate of recovery of C albicans 

from the GI tract relative to the rash site supports 

the GI tract as a reservoir for C albicans, with 

infection resulting from the spread of the organism 

onto the diaper area. There is a strong correlation 

between the level of C albicans in the feces and disease 

severity. 4,23 In a study assessing 30 infants with 

candidiasis-associated DD, the authors recovered 

C albicans from satellite pustules in all 30 infants, 

from the central area of erythema in 66% of patients, 

and from the rectum in 93% of infants. 23 

Candida and Antibiotic Use 

Clinical situations promoting C albicans growth in the 

GI tract presumably increase the risk of candidiasisassociated 

DD. In a study quantifying C albicans 

colonization before and after antibiotic therapy, a 

10-day course of systemic antibiotics administered 

to infants with otitis media who were otherwise 

healthy was associated with a 2-fold increase in 

C albicans recovery from the rectum and skin. 24 

Furthermore, the infants who developed IDD had 

significantly greater numbers of C albicans organisms 

recovered from these sites. The presence of 

thrush also is an important diagnostic clue in the 

evaluation of an infant with DD. 25 Thrush is highly 

correlated with GI colonization, and it has been 

demonstrated that 52% of infants with oral candidiasis 

develop candidiasis-associated DD. 25 

These studies demonstrate that candidiasis- 

associated DD is linked to predisposing factors including 

diarrhea, antibiotic exposure, and/or the 

presence of thrush, but can also present as primary 

disease. Candidiasis should be suspected in any 

case of IDD that lasts more than 3 days. 10 Potassium 

hydroxide (KOH) preparation and fungal culture 

should be collected from satellite lesions/satellite 

papules and pustules rather than the central area of 

rash, and though recovery of C albicans from the 

skin can be challenging, the GI tract usually manifests 

heavy growth. In the case of persistent dermatitis 

with a low yield from KOH and culture, the best 

chance of recovering C albicans is with a rectal swab. 

It is important that candidiasis-associated DD is 

treated immediately; clinicians should use their 

judgment in the case of a negative KOH and con- 

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April 2009 

sider treating with an antifungal agent if candidiasis 

is suspected clinically. 

dIFFErEntIAL dIAGnoSIS 

oF dIAPEr dErMAtoSES 

The diagnosis of diaper dermatoses is usually straightforward, 

but occasionally rarer, more serious disorders 

can “masquerade” as DD. Therefore, it is important 

to always consider other diagnoses, particularly if a 

patient does not respond to appropriate therapy for 

Diagnostic and Treatment Guide for IDD and Candidiasis-Associated DD 

Confluent erythematous papules 

Scaling 

Skin folds spared 

IDD 

Treatment 

Frequent diaper changes 

Gentle cleansing Barrier cream 

Insufficient response 

Rash >3 days 

Inflammation 

Patient History 

Topical antifungal or Vusion plus 

Short course of low potency topical corticosteroid 

No response – evaluate for other diagnosis 

Rash >3 days 

Irregular, scaly border 

Satellite lesions 

Skin folds involved 

Candidiasis-Associated DD 

Treatment 

Topical antifungal or 

Vusion 

Insufficient response 

Inflammation 

Add short course of 

low-potency topical corticosteroid 

FIGurE 1. Diagnostic and Treatment Guide for iDD and 

Candidiasis-Associated DD 

DD (Figure 1). Table 1 26 provides a comprehensive 

list of differential diagnoses, the important features of 

which are discussed in more detail below. 

IDD, the most common form of DD, presents 

with confluent erythema and papules (Figure 1). Severe 

cases may also exhibit areas of erosion. This 

dermatitis is usually localized to convex areas in contact 

with the diaper, including the buttocks, medial 

thighs, mons pubis, scrotum, and labia majora. IDD 

FIGurE 2. irritant Diaper Dermatitis. iDD showing 

sparing of the skin folds. Photograph courtesy of Baby411.com 

tAbLE 1. Differential Diagnosis for Eruptions 

in the Diaper Area 

Inflammatory 

irritant contact dermatitis 

Allergic contact dermatitis 

intertrigo 

Seborrheic dermatitis 

Atopic dermatitis 

psoriasis 

Jacquet’s dermatitis 

Granuloma gluteale infantum 

perianal pseudoverrucous papules and nodules 

Infectious 

Candidiasis 

Folliculitis 

Bullous impetigo 

perianal/intertriginous streptococcal disease 

Herpes simplex 

Scabies 

Congenital syphilis 

Nutritional/Metabolic 

Acrodermatitis enteropathica 

Biotin deficiency 

Kwashiorkor secondary to malabsorption/starvation 

Cystic fibrosis 

Malignancy 

langerhans’ cell histiocytosis 

Miscellaneous 

Miliaria 

Child abuse 

Source: Ref 33 

is often accompanied by perianal erythema, but the 

most distinctive feature of IDD is sparing of the skin 

folds (Figure 2). 

Tidewater-mark, Lucky Luke, and diaper-dye 

dermatoses are variants of contact dermatitis, and 

each has recognizable patterns to differentiate them 

from uncomplicated IDD. 

Diaper-dye dermatitis can be distinguished by 

its well-demarcated erythematous papules at the 

colored edges of the diaper. There may be crossover 

between this and tidewater-mark dermatitis, which 

presents as band-like erythema on the thighs and 

abdomen at the diaper edges, sparing the skin folds. 

Lucky Luke DD also has an easily recognizable 

pattern that resembles a cowboy’s gunbelt holster 

and is located on the outer buttocks and hips (Figure 

3a); it develops in response to rubber components 

in the diaper. Because of the potential for 

contact dermatitis, parents should be cautioned to 

avoid products with additives that are known to 

cause a reaction in their child. 

Both Jacquet’s dermatitis and granuloma gluteale

FIGurE 3A. lucky luke Dermatitis 

Photograph courtesy of Victoria Barrio, MD 

FIGurE 3c. Severe Candida infection 

Photograph courtesy of Sheila Fallon Friedlander, MD 

infantum are severe variants of IDD. Jacquet’s dermatitis 

presents with easily recognizable, punchedout 

ulcered papules and is usually associated with 

infrequent diaper changes. However, it has become 

increasingly rare with the advent of super-absorbent 

diapers. 27 Granuloma gluteale infantum can be distinguished 

from uncomplicated IDD by its asymptomatic 

violaceous papules and nodules on prominent 

areas of the groin, abdomen, genitalia, and thighs. 

Potential risk factors include a history of topical corticosteroid 

use, Candida infection, or use of occlusive 

plastic diaper covers. 26 

Candidiasis-associated DD consists of bright red, 

confluent areas of involvement with irregular, scaly 

border and papulopustular satellite lesions. The intertriginous 

areas are involved, which distinguishes it 

from uncomplicated IDD. Figures 3b and 3c illustrate 

presentations of candidiasis-associated DD. 

Candidiasis-associated DD is also differentiated from 

FIGurE 3b. Candida Diaper Dermatitis infection. (Note the intertriginous 

erythema and superimposed papules.) Photograph courtesy of Sheila Fallon Friedlander, MD 

FIGurE 4. Streptococcal intertrigo. (Note moist, red, 

eroded areas) Photograph courtesy of Sheila Fallon Friedlander, MD 

IDD by a rash duration >3 days (Figure 1). Many 

patients may have a history of recent diarrhea, concomitant 

oral thrush, or antibiotic exposure. 

Seborrheic dermatitis presents as salmon-colored, 

well-demarcated scaling plaques, especially at the inguinal 

folds. It can also be associated with candidiasisassociated 

DD, but it is often distinguished by the 

presence of greasy, scaling lesions elsewhere on the 

body, especially on the scalp, face, postauricular 

folds, neck, and axilla. 8 Seborrheic dermatitis usually 

appears by 3 to 4 weeks of age and often resolves 

spontaneously by 3 to 4 months of age. 

Intertrigo presents as moist and sharply demarcated 

erythema at the skin folds with minimal scale 

and can be distinguished from candidal infection 

by a lack of satellite lesions. Intertrigo is a superficial 

inflammatory process on skin surfaces in close opposition 

with one another arising from a combination 

of moisture, heat, sweat retention, and friction. 

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April 2009 

FIGurE 5. Bullous impetigo of the Diaper Area. 

(Note erosions and pustules.) Photograph courtesy of Sheila Fallon 

Friedlander, MD 

Secondary streptococcal infection can develop in 

the intertriginous folds of the diaper area (Figure 

4), as well as the neck and axillae. This infection is 

associated with a bright red and moist appearance 

with sharply demarcated borders. Bullous impetigo 

(Figure 5) can also develop in the diaper area, and 

may occasionally be mistaken for candidiasis- 

associated DD. S aureus folliculitis superimposed 

on IDD (Figure 6) is another bacterial infection 

that can involve the diaper area, and must be recognized 

so that appropriate antibiotic therapy can 

be instituted. This disorder can sometimes be confused 

with the more common candidiasis-associated 

dermatitis, but KOH and culture evaluation will 

distinguish between the two. Severe deep-seated 

bacterial infections, including furunculosis, and 

severe life-threatening infections such as Fournier’s 

gangrene can develop if the bacterial etiology of 

the skin findings is not recognized and treated 

appropriately. 28 

Atopic dermatitis presents as mild erythema and 

scaling, and can occasionally involve weeping crusted 

lesions. 8 Atopic dermatitis is usually associated with 

concurrent or previous flares of rash on the face and 

extensor limbs, and though it usually spares the diaper 

area, it can sometimes resemble IDD or seborrheic 

dermatitis. 8 Diagnosis is often based on a positive 

personal or family history of allergic rhinitis, hay 

fever, or asthma. In the differential diagnosis, concurrent 

or previous rash elsewhere on the body is its 

primary feature. 8 

Unfortunately, other more serious disorders can 

sometimes initially be mistaken for DD. Langerhans’ 

cell histiocytosis (LCH) is a rare and potentially lifethreatening 

condition caused by bone marrow- 

derived cells that are dendritic in nature and can ac- 

cumulate in other organs, including the skin. 11 LCH 

can present as either single, few, or disseminated erythematous 

papules, vesiculopustules, and/or 

petechiae. Erosions and/or ulcerations in the groin, 

scale, and crusting can appear either alone or in 

combination. 11 Scaly, red-brown or purpuric papules 

may appear on the trunk, which are more violaceous 

than seborrheic dermatitis (Figures 7 and 8). An extensive 

eruption may resemble severe candidiasis; 

however, violaceous papules near the umbilicus are 

typical of LCH. A biopsy must be obtained when this 

diagnosis is suspected. 11 

Other serious disorders include metabolic and 

nutritional deficiencies, including acquired or con- 

FIGurE 6. Staphyloccoccal Folliculitis Superimposed 

on irritant Diaper Dermatitis. (Note discrete follicular 

papules and pustules scattered over the buttocks 

area.) KOH and culture will distinguish between this 

disorder and the more common Candida diaper 

dermatitis. Photograph courtesy of Sheila Fallon Friedlander, MD 

FIGurE 7. langerhans’ Cell Histiocytosis. (Note the 

intertriginous involvement, erosions and purpuric 

papules.) Photograph courtesy of Victoria Barrio, MD

genital zinc defects. 11 Acrodermatitis enteropathica 

(Figure 9) is a congenital disorder in which there is a 

defect in zinc absorption from the gut. 11 Breast milk 

zinc deficiency can occur when maternal breast milk 

does not have sufficient zinc. 11 Affected children 

quickly recover from the latter disease when supplements 

are provided. 11 In contrast, children with 

classic acrodermatitis enteropathica may require 

significant zinc supplementation for life. 11 In these 

disorders, extensive refractory disease usually develops 

and involves the perioral, genital, and acral 

areas. 11 Erythema and peeling of the skin on the 

hands and feet, as well as paronychial changes of 

the nail may occur. 11 

One distinct subset of DD may occasionally be a 

harbinger of future psoriatic disease. 11 Napkin psoriasis 

presents as sharply demarcated erythematous 

plaques, especially at the inguinal folds and on the 

scrotum or convex areas. There is scaling, but this 

can be difficult to discern due to the moisture of the 

area. The initial lesion usually develops in the intertriginous 

groin area, followed by a secondary dermatitis 

that resembles psoriasis. 29 Involvement of the 

umbilical area is a clue to this diagnosis. Napkin psoriasis 

is due to koebnerization, and may resolve once 

the infant is toilet trained; however, a strong correlation 

between the appearance of psoriasis in infancy 

and later in life has been demonstrated. 30 

Distinguishing one form of DD from another can 

be challenging, but an accurate diagnosis can be 

made if the clinician concentrates on the location and 

morphology of the rash, particularly regarding involvement 

or lack of involvement of the skin folds or 

other sites on the body such as the scalp and umbilicus. 

The presence of papules, purpura, or petechiae is an 

important clue, as is the response to traditional barrier 

therapy with antifungal therapy added as appropriate. 

If a patient does not improve with such measures, 

less common but potentially more serious 

disorders should be considered. 

MAnAGEMEnt oF Idd 

The treatment of uncomplicated IDD is outlined in 

Figure 1. Educating caregivers about an optimal diapering 

routine is crucial to successful treatment. Extensive 

clinical practice has long supported a stepwise 

approach to the treatment of DD that includes a combination 

of frequent diaper changes, gentle cleansing, 

barrier protection, and antifungal/anti-inflammatory 

treatment (if the eruption lasts more than a few days) 

(Figure 1). First, it is important to emphasize prevention, 

and the most effective prevention is to ensure 

that the infant’s skin stays clean and dry. 

FIGurE 8. langerhans’ Cell Histiocytosis. 

Photograph courtesy of Victoria Barrio, MD 

FIGurE 9. Zinc Deficiency. (Note severe confluent 

erosions and scale.) This child did not respond to 

routine diaper dermatitis therapy, and developed 

periorificial and acral (fingers and toes) lesions. 

Photograph courtesy of Lawrence F. Eichenfield, MD 

Improved Diaper Technology 

It has been estimated that disposable diapers account 

for more than 90% of diapers used in developed 

nations. 31 Diaper technology has improved significantly 

over the last few decades and continues to 

evolve. Disposable diapers that contain superabsorbent 

gelling materials are associated with a reduced 

incidence and decreased severity of IDD. 4,31 Although 

studies have reached various conclusions 

regarding the benefits of disposable diapers over 

cloth diapers, it is intuitive that diapers with the 

capacity for maintaining normal skin pH and hydration 

are important in the prevention and treatment 

of DD. 4,13,32 One study demonstrated that infants 

diapered exclusively in disposable diapers developed 

less rash than those diapered exclusively or occa- 

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10 April 2009 

sionally in cloth diapers. 4 

Further innovations include a disposable diaper 

that provides continuous topical administration of a 

zinc oxide/petrolatum formulation. Use of this diaper 

is associated with improvements in erythema and 

diaper rash in patients with mild-to-moderate IDD. 33 

A helpful component in the treatment of moderate-tosevere 

candidiasis-associated DD is ensuring the use 

of a breathable diaper. Highly breathable diapers have 

been associated with a 38% to 50% reduction in severe 

IDD cases among infant patients, including those with 

confirmed candidiasis. 26 In a study involving adult 

volunteers, it was demonstrated that when C albicans 

cells were occluded with a patch from either a highly 

breathable diaper or a standard diaper on the volar 

forearm, Candida colonization was observed nearly 

two-thirds less in the highly breathable diaper-covered 

sites compared to the control sites. 26 

Cleansing 

Excessive washing of the diaper area should be 

avoided as a preventive and treatment approach for 

DD. Once the diaper is soiled, the feces should be 

removed from the skin as soon as possible with water 

and a soft cloth. If a barrier preparation has been 

used, the caregiver should focus on removing the 

stool from the barrier product rather than completely 

removing the barrier. Then an additional 

layer of cream or ointment should be applied to the 

remaining barrier preparation. Parents who work to 

remove all the ointment often induce more trauma 

and irritation at the site. 11 The use of baby wipes 

minimizes the risk of frictional injury. Baby wipes 

that contain alcohol should be avoided because some 

types of alcohol can be drying; however, most baby 

wipes are alcohol-free and contain 98% water. 11 pHbuffered 

baby wipes and products formulated for 

sensitive skin have minimized the likelihood of irritancy 

from these products. 34 

If the caregiver needs to wash the diaper area 

more thoroughly, a nonirritating cleanser such as 

Cetaphil ® (Galderma Laboratories) or mineral oil 

can be used. Many practitioners use cotton swabs or 

pads to apply the cleanser. Cloth or pressed cotton 

cosmetic pads are less likely to adhere to the skin 

surface and break apart, and are more effective for 

removing feces. 

Treatment Options for Irritant 

Diaper Dermatitis 

The management of all diaper dermatoses should 

include reducing moisture in the diaper area, minimizing 

contact with urine and feces, and eradicating 

infectious organisms (Figure 1). With the exception 

of candidiasis-associated DD, IDD is episodic and 

tends to be relatively self-limiting in nature if the offending 

irritants are removed. Occasionally, patients 

may have a true allergic contact dermatitis, in which 

case it is important to eliminate the causative agent, 

Baby wipes that contain alcohol should be 

avoided because some types of alcohol can be 

drying; however, most baby wipes are 

alcohol-free and contain 98% water. 

which may be present as a coloring additive or elastic/ 

rubber agent in the diaper. 

Numerous over-the-counter (OTC) barrier formulations 

are available. Table 2 lists some of the more commonly 

used products and their active ingredients. 35 

Petrolatum is a safe and effective OTC barrier product 

that protects the skin, reduces transepidermal 

water loss, and repels water. Petrolatum provides a 

thick, protective barrier and is useful in the prevention 

of IDD. It is also a commonly used ingredient in 

other OTC barrier products such as Vitamin A & D ® 

Ointment (Schering-Plough Healthcare) and in pre-

scription products such as Vusion ® Ointment (Barrier 

Therapeutics). Lanolin is another effective skin 

protectant that also is used in Vitamin A & D Ointment 

and other skin lotions and creams. Many infants 

will benefit from traditional lanolin-containing therapies; 

however, the healthcare provider must be 

aware that in children who are allergic to lanolin, 

such products may aggravate the condition. 

Zinc oxide preparations such as Desitin ® (Johnson 

& Johnson) are available in 10% and 40% ointment 

formulations (Table 2). For treatment of uncomplicated 

IDD, a petrolatum product, Vitamin A & D 

Ointment, or a product containing 10% zinc oxide 

may be sufficient. For moderate-to-severe IDD, a 

barrier ointment with a greater concentration of 

zinc oxide can also be used. Zinc oxide pastes are 

highly effective barriers, but they are difficult to 

wash off, and aggressive cleansing of the skin when 

removing a paste is very irritating. Mineral oil is 

more effective than soap and water to remove a 

paste. A thin layer of petrolatum can be applied to 

the paste to prevent opposing skin surfaces from 

sticking together and to ensure that the paste does 

tAbLE 2. Commonly Used Barrier preparations and Their Active ingredients 

not adhere to the diaper. 

The use of cornstarch is recommended over 

talcum powder to reduce frictional injury, especially 

if the caregiver uses cloth diapers. Although it has 

been suggested that powders and cornstarch enhance 

microbial growth, in a study by Leyden it was demonstrated 

that neither product is associated with proliferation 

of C albicans. 20 The use of talcum powder 

has been associated with severe respiratory distress 

caused by accidental inhalation. 36,37 

Treatment of Candidiasis-Associated 

Diaper Dermatitis 

In 2006, Vusion, the first antifungal agent indicated 

for the treatment of candidiasis-associated DD became 

available. This combination barrier-antifungal 

Barrier Active ingredient(s) 

Vitamin A&D ointment ® Vitamin A, vitamin D, lanolin, white petrolatum, paraffin 

A&D diaper rash cream with zinc oxide and aloe ® Zinc oxide (10%), dimethicone (1%) 

Aquaphor ® petrolatum, lanolin 

Aveeno diaper cream ® Zinc oxide (13%), dimethicone (5%) 

Balmex diaper rash ointment ® Zinc oxide (11.3%) 

Balmex daily protective clear ointment ® White petrolatum (51.1%) 

Balmex creamy lotion barrier ® Zinc oxide (13%) 

Boudreaux’s butt paste ® Zinc oxide (16%) 

Burt’s bees baby bee, diaper ointment with vitamin A and vitamin E ® Zinc oxide 

California baby diaper rash cream ® Zinc oxide (12%), lanolin 

Desitin diaper rash ointment, creamy ® Zinc oxide (10%) 

Desitin diaper rash ointment, original ® Zinc oxide (40%) 

Gerber diaper rash ointment with oatmeal soothers ® Zinc oxide (40%), petrolatum (33%) 

Johnson’s baby diaper rash cream with zinc oxide ® Zinc oxide (13%) 

Mustela bebe vitamin barrier cream ® Zinc oxide (10%) 

palmer’s diaper rash cream, cocoa butter formula ® petrolatum (30%), dimethicone (1%) 

Triple paste ® petrolatum 

Vaseline ® petrolatum 

Vaseline baby, baby fresh scent ® petrolatum 

Zinc oxide pastes are highly effective barriers, 

but they are difficult to wash off, and aggressive 

cleansing of the skin when removing a paste 

is very irritating. 

Weleda diaper care ® Zinc oxide (12%) 

Zinc oxide ointment Zinc oxide (20%) 

Source: Ref 33 

April 2009 11


1 April 2009 

product is an efficient means of treating candidiasisassociated 

DD. Until 2006, management consisted 

of off-label use of an antifungal agent unapproved 

for candidiasis-associated DD or a combination 

antifungal/corticosteroid topical product. Some 

practitioners still prescribe these and other medicat 

i o n s o f f - l a b e l t o t r e a t c a n d i d i a s i s - 

associated DD. 

The Risks of Mid- to High-Potency Steroids 

The use of a mid- to high-potency corticosteroid is 

a relatively common, and sometimes hazardous, 

practice for the treatment of pediatric dermatoses. 

Use of such agents in infants and children, particularly 

in occluded areas, can lead to a number of complications, 

including atrophy, striae, and adrenal 

axis suppression. Unfortunately, caregivers are not 

always aware of these risks, and clinicians may need 

further education. 

Until recently, clinicians had a limited choice 

of antifungal and antifungal/corticosteroid 

products in their armamentarium, none of 

which were formulated specifically to treat 

candidiasis-associated DD. 

Mid- to high-potency corticosteroids are generally 

contraindicated for use in intertriginous and occluded 

areas of the skin, especially in infants, as their 

use has the potential to cause a variety of adverse 

events including systemic absorption, skin atrophy, 

striae, tachyphylaxis, and growth delay. Furthermore, 

the abraded skin of the diaper area of an infant 

with IDD leads to an enhanced rate of percutaneous 

absorption of a topical agent, which is further increased 

by the occlusiveness of the diaper. 27,38 The 

risks of corticosteroid use in infants need to be communicated 

to clinicians, and safer therapeutic alternatives 

need to be developed. 

Commonly Used Antifungal Agents for 

Candidiasis-Associated Diaper Dermatitis 

Few well-designed comparator trials have assessed 

the efficacy of antifungal agents for the treatment of 

candidiasis-associated DD. Imidazole antifungal 

agents (eg, miconazole, econazole, ketoconazole), 

have varying fungicidal activity against cutaneous 

Candida spp. 38 Topical azoles are also well-tolerated. 

Side effects sometimes seen with systemic azole 

therapy are not associated with topical use of these 

types of drugs. 38 

If an infant has a rash secondary to antibiotic use 

and the infant must continue antibiotic therapy, a 

thick petrolatum ointment barrier may provide optimal 

protection. The practitioner also must consider 

the possibility of another diagnosis in patients who do 

not respond to appropriate treatment of candidiasisassociated 

DD. 

Until recently, clinicians had a limited choice of 

antifungal and antifungal/corticosteroid products 

in their armamentarium, none of which were formulated 

specifically to treat candidiasis-associated 

DD. Management considerations have been simplified 

for the clinician with the FDA approval of Vusion 

Ointment (miconazole nitrate 0.25%/zinc oxide 

15%/petrolatum 81.35%), which is a safe, effective, 

and convenient treatment option for candidiasis- 

associated DD. 12 

Vusion Ointment (miconazole nitrate 0.25%/ 

zinc oxide 15%/petrolatum 81.35%) 

Vusion Ointment is indicated for the treatment of 

candidiasis-associated DD and approved for use in 

immunocompetent pediatric patients aged 4 weeks 

and older with microscopic evidence of pseudohyphae 

and/or budding yeast. 12 Before prescribing 

Vusion Ointment, the role of the clinician is to ensure 

that the correct diagnosis is made, which includes 

considering the more uncommon causes of 

IDD and performing ancillary tests (eg, KOH), to 

confirm diagnosis if doubt exists as to the etiology 

of the eruption.

Vusion Ointment is formulated with a low concentration 

(0.25%) of miconazole, which limits 

exposure to the antifungal component. The level of 

systemic absorption is lower with 0.25% miconazole 

than with 2% miconazole cream. 39 Infant skin, as 

opposed to adult skin, can absorb a greater proportion 

of topical medication because infants have a 

greater surface-to-body weight ratio. 40,41 Thus, a 

lower concentration formulation of miconazole can 

provide effective antifungal activity on infant skin 

while theoretically decreasing the risk of extensive 

absorption of miconazole. Furthermore, the combination 

of miconazole and zinc oxide is synergistic; 

zinc oxide also has anti-Candida effects, which potentiates 

the antifungal activity of miconazole. 42 

Clinical Studies with Vusion Ointment 

The efficacy and tolerability of Vusion Ointment 

in the treatment of candidiasis-associated DD have 

been established in a double-blind, randomized, 

multicenter, vehicle-controlled study of 0.25% 

miconazole nitrate ointment. 41 The study included 

330 patients with an IDD average severity grade ≥3 

as assessed by the Diaper Dermatitis Severity 

Score, including a severity grade of ≥2 for erythema. 

Patients with a positive KOH preparation and positive 

culture of Candida (n=236) composed the 

modified intent-to-treat (MITT) group, on which 

efficacy analyses were based. Patients were randomized 

to receive active treatment or vehicle for 7 

days at every diaper change and after bathing. The 

primary end point of overall cure rate (clinical cure 

plus microbiologic cure) was assessed on post- 

treatment Day 14. 

Results demonstrated that 23% of the patients in 

the active treatment group achieved the primary end 

point, compared with 10% of those in the vehicle 

group (P=.005) (Figure 10). A total of 38% and 11% 

of patients in the active and vehicle treatment groups, 

respectively, achieved the secondary end point of 

clinical cure (P


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2. Ward DB, Fleischer AB Jr, Feldman SR, Krowchuk DP. Characterization of diaper 

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in vivo human skin irritation. Contact Dermatitis. 1994;30(3):152-158.) 

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21. Rebora A, Marples RR, Kligman AM. Erosio interdigitalis blastomycetica. Arch Dermatol. 

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22. Maibach HI, Kligman AM. The biology of experimental human cutaneous moniliasis 

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23. Rebora A, Leyden JJ. Napkin (diaper) dermatitis and gastrointestinal carriage of 

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J Am Acad Dermatol. 1988;19:275–279. 

25. Hoppe JE, Hahn H, for the Antimycotics Study Group. Randomized comparison of two 

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Dermatol. 1981;20(2):122–125. 

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Dermatol. 1986;3(3):237–243. 

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32. Baer EL, Davies MW, Easterbrook KJ. Disposable nappies for preventing napkin dermatitis 

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from continuous topical administration of a zinc oxide/petrolatum formulation by a 

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34. Adam R. Skin care of the diaper area. Pediatr Dermatol. 2008;25(4):427–433. 

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36. Brouillette F, Weber ML. Massive aspiration of talcum powder by an infant. Can Med 

Assoc J. 1978;119(4):354–355. 

37. Pfenninger J, D’Apuzzo V. Powder aspiration in children. Report of two cases. Arch Dis 

Child. 1977;52(2):157–159. 

38. Railan D, Wilson JK, Feldman SR, Fleischer AB. Pediatricians who prescribe clotrimazolebetamethasone 

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39. West DP, Worobec S, Solomon LM. Pharmacology and toxicology of infant skin. 

J Invest Dermatol. 1981;76(3):147–150. 

40. Spraker MK, Gisoldi EM, Siegfried EC, et al. Topical miconazole nitrate ointment in 

the treatment of diaper dermatitis complicated by candidiasis. Cutis. 2006;77(2): 

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42. Spectazole ® [package insert]. Skillman, NJ: Ortho Pharmaceutical Corporation; 2001.

VUSION ® 

(0.25% miconazole nitrate, 15% zinc oxide, and 81.35% white petrolatum) 

Ointment 

Rx only. 

FOR TOPICAL USE ONLY. 

NOT FOR OPHTHALMIC, ORAL, OR INTRAVAGINAL USE. 

DESCRIPTION 

VUSION Ointment contains the synthetic antifungal agent, miconazole nitrate 

(0.25%), zinc oxide (15%) and white petrolatum (81.35%) for topical use. 

The chemical name of miconazole nitrate is 1-[2,4-dichloro-�-{(2,4dichlorobenzyl)oxy} 

phenethyl] imidazole mononitrate with empirical formula 

C18H14Cl4N2��3 and molecular weight of 479.15. The structural formula of 

miconazole nitrate is as follows: 

Cl 

Cl 

Cl 

Cl 

O 

The zinc oxide has an empirical formula of ZnO and a molecular weight of 81.39. 

The white petrolatum, which is obtained from petroleum and is wholly or nearly 

decolorized, is a purified mixture of semisolid saturated hydrocarbons having the 

general chemical formula C nH 2n+2. The hydrocarbons consist mainly of branched and 

unbranched chains. White petrolatum contains butylated hydroxytoluene (BHT) as 

stabilizer. 

Each gram of VUSION Ointment contains 2.5 mg of miconazole nitrate USP, 150 mg 

of zinc oxide USP, 813.5 mg of white petrolatum USP containing butylated hydroxytoluene, 

trihydroxystearin and Chemoderm ® 1001/B fragrance. 1 

VUSION Ointment is a smooth, uniform, white ointment. 

1 Chemoderm ® is a registered trademark of Firmenich Inc. 

CLINICAL PHARMACOLOGY 

Pharmacokinetics: 

The topical absorption of miconazole from an ointment containing 0.25% miconazole 

nitrate, 15% zinc oxide and 81.35% white petrolatum was studied in male and female 

infants (n=18) with diaper dermatitis ranging in age from 1 month to 12 months. After 

application at every diaper change for 7 days, the plasma concentrations of miconazole 

were nondetectable (1% for subjects who were treated with VUSION were approximately the 

same in type and frequency as for subjects who were treated with zinc oxide/white 

petrolatum ointment. 

The potential for dermal toxicity of VUSION Ointment formulation was investigated in 

healthy adult volunteers in four topical safety studies. These studies were conducted 

to assess the potential for contact phototoxicity, photoallergy, sensitization, and 

cumulative irritation potential. Phototesting was conducted with UV-A only. Results 

indicated that VUSION Ointment did not induce a contact dermal phototoxic response, 

contact dermal photoallergic response, or contact dermal sensitization in adult 

subjects. In addition, VUSION Ointment did not show any evidence of cumulative 

irritation potential in adult subjects. 

OVERDOSAGE 

VUSION Ointment is intended for topical use only. Young children are at risk for accidentally 

ingesting VUSION Ointment. A health care provider or poison control center 

should be contacted in the event of accidental ingestion. 

DOSAGE AND ADMINISTRATION 

Before applying VUSION Ointment, gently cleanse the skin with lukewarm water and 

pat dry with a soft towel. Avoid using any scented soaps, shampoos, or lotions on the 

diaper area. 

VUSION Ointment should be applied to the affected area at each diaper change for 

7 days. Treatment should be continued for the full 7 days, even if there is improvement. 

The safety of VUSION Ointment when used for longer than 7 days is not known. 

Gently apply a thin layer of VUSION Ointment to the diaper area with the fingertips. 

VUSION Ointment should not be rubbed into the skin as this may cause additional 

irritation. Thoroughly wash hands after applying VUSION Ointment. 

VUSION Ointment should be used for the adjunctive treatment of diaper dermatitis 

only when complicated by candidiasis, as documented by microscopic evidence 

of pseudohyphae and/or budding yeasts, in immunocompetent pediatric patients 

4 weeks and older. VUSION Ointment should be used as part of a treatment regimen 

that includes measures directed at the underlying diaper dermatitis, including gentle 

cleansing of the diaper area and frequent diaper changes. 

VUSION Ointment should not be used as a substitute for frequent diaper changes. 

VUSION Ointment should not be used to prevent the occurrence of diaper dermatitis, 

since preventative use may result in the development of drug resistance. 

HOW SUPPLIED 

VUSION Ointment is a smooth, uniform, white ointment supplied in an aluminum 

tube, as follows: 

5g sample (NDC 13478-002-03) 

50g (NDC 13478-002-04) 

Storage Conditions 

Store at controlled room temperature between 20°C and 25°C (68°F and 77°F); with 

excursions permitted between 15°C and 30°C (59°F and 86°F). 

Keep out of reach of children. 

For additional information, please call toll free 1-866-440-5508. 

Manufactured By: 

DSM Pharmaceuticals, Inc. 

Greenville, NC 27834 

For: 

Barrier Therapeutics, Inc. 

600 College Road East 

Princeton, NJ 08540 

www.barriertherapeutics.com 

VU-501 April 2007 

U.S. Patent No. 4,911,932 

VUSION ® 

(0.25% miconazole nitrate, 15% zinc oxide and 81.35% white petrolatum) Ointment 

Patient Package Insert 

For Skin Use Only 

Read the Patient Information that comes with VUSION Ointment before you use it on 

your child. This leaflet does not take the place of talking to your health care provider 

about your child’s medical condition or treatment. If you have any questions or if you 

are not sure about any of the information on VUSION Ointment, ask your health care 

provider, or pharmacist. 

What is VUSION Ointment? 

VUSION Ointment is a prescription skin medicine used to treat diaper rash that also 

has a yeast infection in children who have a normal immune system. VUSION 

Ointment contains medicines that will help treat the yeast infection and the diaper 

rash, but you must also change your child’s diapers very often so that your child 

is not wearing a wet or soiled diaper. Even if you use VUSION Ointment, diaper 

rash will not go away if you do not keep your child’s diaper area clean and dry. You 

should use water or a very mild cleanser to clean your child’s diaper area. VUSION 

Ointment is not used to prevent diaper rash or to be used for more than 7 days. 

Who should not use VUSION Ointment? 

VUSION Ointment is not for treatment of all cases of diaper rash. VUSION Ointment 

is only for diaper rash that also has a yeast infection. Most cases of diaper rash 

do not need the yeast medicine that is in VUSION Ointment because most cases of 

diaper rash do not also have a yeast infection. 

Your health care provider will need to do a special test to tell if your child’s diaper 

rash also has a yeast infection. Do not use VUSION Ointment on your child’s diaper 

rash unless your health care provider tells you that there is also a yeast infection. 

Do not use VUSION Ointment on any other children. 

Do not use VUSION Ointment on your child’s diaper rash if they are allergic to anything 

in it. See the end of this leaflet for a list of ingredients in VUSION Ointment. 

How should I use VUSION Ointment on my child? 

VUSION Ointment is applied to the skin on your child’s diaper area at each diaper 

change for 7 days. 

Apply VUSION Ointment for the full 7 days even if the diaper rash starts to go away. 

Call your child’s health care provider if the diaper rash gets worse or does not go away 

with 7 days of treatment with VUSION Ointment. VUSION Ointment should not be 

used for more than 7 days. 

To apply VUSION Ointment: 

�� 

may also use a very mild soap. Pat the area dry with a soft towel. 

�� 

child’s diaper area at each diaper change. Do not rub VUSION Ointment into your 

child’s skin. Rubbing the skin can cause more irritation. 

�� 

VUSION Ointment is for skin use only. 

Call your child’s health care provider or poison control center right away if any 

VUSION Ointment is swallowed. Call your child’s health care provider if VUSION 

Ointment gets in the eye. 

What other steps will help diaper rash go away? 

�� 

�� 

from the front to back using warm (not hot) water. You may also use a mild soap. 

Rinse the diaper area well. Pat dry with a soft towel. 

�� 

��diaper rash will not go away if you do not keep 

your child’s diaper area clean and dry. 

What are the possible side effects of VUSION Ointment? 

Ointment may cause irritation, but this is not common. You should call your child’s 

health care provider if irritation appears or if the diaper rash gets worse. 

How should I store VUSION Ointment? 

�� 

30°C). 

��Keep VUSION Ointment out of the reach of children. 

General information about VUSION Ointment 

Medicines are sometimes prescribed for conditions that are not mentioned in patient 

information leaflets. 

Do not use VUSION Ointment for a condition for which it was not prescribed. Do not 

give VUSION Ointment to other children, even if they have the same symptoms your 

child has. It may harm them. 

This leaflet summarizes the most important information about VUSION Ointment. If 

you would like more information, talk to your child’s health care provider. You can ask 

your child’s health care provider or pharmacist for information about VUSION 

Ointment that is written for health care professionals. 

You can also call Barrier Therapeutics, Inc., Customer Information Center toll free 

at 1-866-440-5508. 

What are the ingredients in VUSION Ointment? 

Active Ingredients: miconazole nitrate, zinc oxide and white petrolatum 

Inactive Ingredients: trihydroxystearin, butylated hydroxytoluene (BHT) and 

Chemoderm ® 1001/B fragrance 

Marketed by: Manufactured By: 

Barrier Therapeutics, Inc. DSM Pharmaceuticals, Inc. 

Princeton, NJ 08540-6697 USA Greenville, NC 27834 

www.barriertherapeutics.com 

April 2007 VU-501 U.S. Patent No. 4,911,932 

April 2009 1

©2009 Medisys Health Communications inc. April 2009. 

All rights reserved. printed in USA. 

E0012Z 

Vusion is a registered trademark of STiEFEl

Diaper Dermatitis: Appropriate Evaluation ... - ModernMedicine

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