Diaper dermatitis, known as diaper rash, is an acute inflammatory skin eruption that occurs in the diaper area, such as perianal, buttocks, genitals, inner thighs, and waistline [1]. Diaper dermatitis appears with mild erythema, but if left untreated, the erythema can be more extensive with lesions in the form of papules. In severe cases, erythema is found over a larger area with severe desquamation, swelling, erosion and ulceration [2].

World Health Organization (WHO) reported in 2012 that the incidence of diaper dermatitis in infants is quite high, which is 25% of the 6,840,507,000 babies born in the world [3]. Diaper dermatitis is rarely a serious disease, but this condition causes itching and burning, which can make babies become fussy. This certainly causes the babies discomfort and anxiety for the caregivers [4].

Diaper dermatitis is caused by a combination of diaper environments such as overhydration of the stratum corneum and epidermis, irritants in urine and feces, friction against the skin, and high skin pH [5]. Many factors contribute to the occurrence of diaper dermatitis and one of the main risk factors for diaper dermatitis is diarrhea [6].

WHO (2019) reported that approximately 1.7 billion cases of diarrhea occur in children under 5 years of age each year. Riskesdas (2018), a study from Indonesia reported that diarrhea was most common in the age 1 – 4 years (11.5%) and in infants under 1 year (9%) [7]. The high incidence of diarrhea and diaper dermatitis in infants encouraged researchers to analyze the correlation between the duration of diarrhea and the severity of diaper dermatitis in children aged 0 – 24 months.

This was an analytic observational study with cross-sectional design. The study population in this study were all infants who visited Binjai City Health Center, Kebun Lada Health Center, and Tanah Tinggi Health Center in August – September 2022. This study used a consecutive sampling technique. The inclusion criteria included infants aged 0 – 24 months, were having or had a history of diarrhea and diaper dermatitis in the last 6 weeks, and parents willing to be respondents by signing the informed consent. Infants with active skin disease affecting ≥ 50% of the body surface area could not be sampled in this study.

The frequency distribution of subject characteristics based on age, gender, diaper type, frequency of diaper changing, duration of diarrhea, and severity of diaper dermatitis is given in Table 1.

A total of 58 patients were included in this study. Of these, infants aged 0-12 months were the most prevalent of all age groups (n=32, 55.2%) and the male was found to be more common (n=39, 67.2%). It was observed that most of the babies used disposable diapers (n=54, 93.1%). The frequency of diaper changing was mostly < 6 times a day (n=51, 87.9%). Duration of diarrhea was mostly < 2 weeks (n=55, 94.8%). The severity of diaper dermatitis was mostly very mild diaper dermatitis (n=37 infants, 63.8%). The following is an example of a diaper rash feature in this study, shown in Fig. (1A and B).

Fig. (1). (A, B) Diaper rash appearance.

Bivariate analysis was performed to examine the correlation between the duration of diarrhea and severity of diaper dermatitis using the Spearman analysis test as shown in Table 2.

Based on Table 1, the value of p = 0.0001 was obtained with r (correlation) = 0.536 for duration of diarrhea and severity of diaper dermatitis. It was concluded that there was a correlation between the duration of diarrhea and the severity of diaper dermatitis. This was a positive correlation, meaning that the longer the duration of diarrhea, the more severe the diaper dermatitis.

This study showed that there was a correlation between the duration of diarrhea and the severity of diaper dermatitis in infants who visited Binjai City Health Center, Kebun Lada Health Center, and Tanah Tinggi Health Center. The same results were obtained in a study conducted in China, which reported the negative effects of diarrhea on diaper rash. Diarrhea was identified as statistically significantly associated with diaper rash (P=0.032). Children who did not suffer from diarrhea were about 0.4 times less likely to develop diaper rash compared to children who suffered from diarrhea [6].

Based on a study conducted in Indonesia by Oliv and Jusuf, infants with diarrhea had higher probability of diaper dermatitis [8]. Similar results were obtained in a study conducted by Liu et. al where maternal reports of diarrhea experienced by infants in the last 7 days were positively associated with a higher probability of perianal diaper dermatitis [9]. Researchers have identified that the epidermal layer in newborns will undergo rapid evolution after 28 days of birth, so diaper dermatitis is one of the most common dermatologic problems in infants [10].

When babies have diarrhea, the increased frequency of diarrhea can damage the integrity of skin tissue due to prolonged exposure to urine and feces [11]. Urine and feces are the main contaminants in the diaper area. The combination of these two factors causes an increased pH of the diaper area to be more alkaline. The increased pH causes an increased activity of protease, lipase and urease which are highly irritating to the skin. The increased activity of lipase and protease in feces also occurs due to accelerated gastrointestinal transit, and therefore higher prevalence rates of diaper dermatitis were observed in infants who had diarrhea within the previous 48 hours [12].

Bacteria in feces cause worsening diaper dermatitis by aggravating the inflammation that already occurs, causing more severe diaper dermatitis. In addition, many factors can affect the susceptibility of infants to irritant diaper dermatitis or can worsen the condition of diaper dermatitis, such as infrequent diaper changes, using broad-spectrum antibiotics in infants, insufficient diaper area skin care, using liquid soap to clean the skin, and using talcum powder [12].

The results showed a positive correlation between the duration of diarrhea and the severity of diaper dermatitis, meaning that the longer duration of diarrhea experienced by infants, the more severe the diaper dermatitis.

It is recommended that parents who have babies take care of their babies' skin health, especially in genitalia to prevent diaper dermatitis; it is hoped that health workers will participate in preventing diaper dermatitis by increasing information and providing education to parents who visit the health center regarding problems related to diaper dermatitis and its prevention; this study can be continued by finding other factors related to the severity of diaper dermatitis when babies have diarrhea.