Diaper dermatitis is the most common dermatological problem of infancy , occurring in 25–65% of children , and is caused by the combined irritant effects of wearing a diaper, urine and faeces . Colonisation by Candida spp. is significantly more frequent in children with diaper dermatitis than in those with healthy skin, whereas colonisation by Staphylococcus aureus does not differ between these two groups . Corticosteroids, zinc paste and eosin are well-known topical agents for the treatment of diaper dermatitis. It has been suggested that topical antifungal agents are not indicated for diaper dermatitis; indeed, their safety and effectiveness have not been established in infants .
Olive oil, beeswax and honey are natural products, containing flavonoids, and antioxidant, antibacterial and antifungal compounds, that affect the production of cytokines by skin cells when applied topically [6–11]. Previous studies have demonstrated the efficacy of a mixture containing honey, olive oil and beeswax (in a ratio of 1:1:1 v/v) for the treatment of dermatitis, psoriasis and skin fungal infections [12,13]. In the present pilot study, the effect of using this honey mixture to treat infants with diaper dermatitis was investigated.
Eight boys and four girls, aged 3–18 months and suffering from diaper dermatitis, were selected randomly for a pilot study. The infants developed dermatitis despite immediate bathing with warm water and replacement of a diaper following urination or defaecation. Informed consent was obtained from parents. At baseline, a thorough medical history was obtained and a complete physical examination was conducted. A moistened swab was used to sample the rash, erosion or ulceration, for mycological culture on Sabouraud glucose agar and subsequent testing for Candida albicans. Sampling was performed immediately before and at the end of treatment. Rash severity was assessed on a five-point scale (none = 0; mild erythema = 1; moderate erythema = 2; moderate erythema plus maceration = 3; and severe erythema plus pustules or ulceration = 4) at baseline and at days 3, 5 and 7 during treatment. Any new sign or symptom that appeared during therapy was recorded as an adverse effect. A positive therapeutic effect was recorded when a severe or moderate rash became mild or disappeared.
The topical treatment was prepared by thoroughly mixing natural honey, olive oil and beeswax (1:1:1 v/v; equivalent to (w/v) honey 50%, olive oil 29%, beeswax 21%). The honey was dark yellow in colour, and of multifloral origin; it contained (/100 g); 38 g fructose, 28 g glucose, water 20% v/v, 2.3 g vitamin C, 0.098 mg copper, 0.6 mg zinc, < 0.5 g sucrose, and 0.51 mg glutathione reductase. Natural olive oil prepared with the cold press method was used. The mixture was stored in the dark at room temperature until use.
The parents were asked to apply the topical treatment four times daily with gentle rubbing for a maximum of 7 days, and to bathe the infant with warm water and change the diaper following urination or defaecation. All parents used the same brand of diapers before and during the study. Infants who did not respond within 7 days were given conventional therapy, and the failure of the topical treatment was recorded. No other topical product was used during the study. The study was open, and it was deemed unethical to use a placebo on infants. Furthermore, any comparison with the use of standard therapy was postponed until the results of this pilot study were evaluated. Lesion scores were expressed as means ± standard deviations. anova tests were used for the comparison of mean scores before, during and after treatment, with p < 0.05 deemed to be significant.
Culture of specimens collected from the lesions showed that C. albicans was present in four patients at baseline. C. albicans was associated with increased severity of rash. Of three infants who had severe erythema and ulceration, two were positive for C. albicans. Nine infants had moderate erythema, including five with maceration. The mean total rash score was 2.91 ± 0.79 at baseline (Table 1), decreasing to 2.0 ± 0.96 (p < 0.05) at day 3 and to 1.25 ± 0.96 (p < 0.05) at day 5. At the end of the study, the mean total score was 0.66 ± 0.98, and ten of the 12 patients had either mild or no diaper dermatitis. C. albicans was eradicated from two of the four positive patients by the end of therapy. The two patients who showed no response to the study treatment had moderate erythema and were positive for C. albicans; these infants were treated with conventional therapy. No adverse effects were recorded, and the parents reported that the treatment was easy to apply and well-tolerated.
|Patient||Before treatment||After commencement of treatment|
|Lesion score||Culture for Candida albicans||Lesion score||Culture for Candida albicans|
|3 days||5 days||7 days|
|Mean ± SD||2.91 ± 0.79||2 ± 0.98a||1.25 ± 0.96a||0.66 ± 0.98a|
The study treatment was effective in reducing the symptoms of diaper dermatitis, and eradicated C. albicans from 50% of culture-positive patients during the 7-day trial. Longer courses of treatment or more frequent topical applications might give even better results. C. albicans may not be the main causative agent of diaper dermatitis, and it is possible that bacteria could be involved in the aggravation of symptoms. However, patients who were culture-positive for C. albicans seemed to have aggravated symptoms of diaper dermatitis. The symptomatic improvement could be associated with the possible anti-inflammatory effects of the mixture, based on the properties of the ingredients.
The mechanism of the antimicrobial action of honey has not been fully-defined, although acidity, osmolality and hydrogen peroxide production have been proposed as important factors . Honey has been shown to increase nitric oxide levels and decrease prostaglandin levels in biological fluids [15–17]. A diet rich in olive oil has been shown to increase nitric oxide and decrease arachidonic acid production by resident rat macrophages . Nitric oxide released from the skin through the sweat glands has antimicrobial activity [19,20]. Therefore, the effects of the topical treatment might be caused by a reduction in prostaglandin synthesis at the site of application, elevation of nitric oxide concentrations in the lesions, inhibition of fungal or bacterial growth, and antioxidant and anti-inflammatory activities [6,7,11]. Considering the potential hazards of topical corticosteroids, it seems that use of this topical treatment, alone or in combination with other agents, is a possible alternative therapy for diaper dermatitis. This could result in reduced use of prescription drugs and a concomitant reduction in any associated adverse effects.