Topical calcineurin inhibitors appear to be an effective and safe option for treating granuloma gluteale infantum, a reemerging complication of diaper dermatitis associated with use of cloth reusable diapers, wrote Rita Ramos Pinheiro, MD, of Hospital Santo António dos Capuchos, Lisbon, and her associates.

An otherwise healthy 18-month-old girl was referred to the dermatology clinic with a 9-month history of severe relapsing diaper dermatitis, which responded to topical clotrimazole and zinc oxide cream. Nondisposable cloth diapers were used. She returned with a rash unresponsive to barrier creams, topical antibiotics and antifungals, and a variety of topical corticosteroids.

Upon examination, she had “multiple, either irregularly shaped or oval-shaped and rounded, red, infiltrated, nontender nodules and plaques, located in the convexities of the gluteal region and major labia,” said Dr. Pinheiro and her associates. “All lesions had surrounding erythema, some had a central ulceration, and others had an intact surface yet slightly elevated borders.”

Clinically, a diagnosis of granuloma gluteale infantum was suspected; this was confirmed by a skin biopsy of one of the nodules.

The parents declined to stop using cloth diapers, so general measures to alleviate diaper dermatitis were tried, including frequent diaper-free periods. All previous topical treatments were stopped. A 0.1% pimecrolimus cream applied daily for 1 month was well tolerated, and a more potent 0.03% tacrolimus cream then was applied; both medications are topical calcineurin inhibitors.

At 4 weeks, there was complete regression of the ulcerated lesions, with later thinning of the lesions. At the last examination, there remained only slightly hypopigmented residual patches.

The same general measures were continued, including use of barrier creams. The patient had a relapse at her 9-month follow-up, with three nodules occurring on the gluteal region; these resolved with application of topical tacrolimus cream for 1 week.

Although reusable cloth diapers are considered better for the environment and cheaper than disposable diapers, “purportedly” they are less absorbent than disposable diapers, the investigators said.

Characteristics of the clinical diagnosis of granuloma gluteale infantum are “red-purple to red-brown, round to oval, deep, firm nodules with central ulceration,” with a “classic distribution over the convexities of the gluteal region, sparing the inguinal folds,” Dr. Pinheiro and her associates observed. The case study is the first reporting the use of topical calcineurin inhibitors for treating granuloma gluteale infantum, the researchers asserted.

Read more at Pediatrics (2017 Jan 3. doi: 10.1542/peds.2016-2064 ).


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