What is the additional workup and treatment for a 1-year-old with a swollen rash in the perianal region, poor appetite, and minimal response to topical Nystatin (nystatin)?

From the Guidelines

For a 1-year-old with a swollen rash in the perianal region, poor appetite, and minimal response to topical nystatin, a comprehensive workup and treatment approach is necessary to address potential morbidity, mortality, and quality of life concerns. Given the limited response to topical nystatin, it is crucial to consider other etiologies and rule out systemic infections or underlying conditions.

Initial Steps

• Obtain a skin scraping or culture to identify the causative organism, as this could be bacterial, fungal (resistant Candida), or irritant dermatitis 1.
• While awaiting results, consider switching to a combination antifungal-steroid cream, but given the age and potential for side effects, this decision should be made cautiously and under guidance.

Management of Symptoms

• Ensure thorough but gentle cleaning of the area with warm water after each diaper change, avoiding wipes with alcohol or fragrances.
• Apply a zinc oxide barrier cream with each diaper change to protect the skin.
• Increase diaper changes to reduce moisture and irritation.

Addressing Poor Appetite

• Evaluate for oral thrush or systemic infection, which could be contributing to poor appetite.
• Consider a probiotic suitable for infants to support gastrointestinal health.

Further Evaluation

If symptoms persist beyond 2 weeks of treatment, referral to pediatric dermatology or gastroenterology is essential to rule out underlying conditions like inflammatory bowel disease or immunodeficiency. The approach should prioritize the identification of the underlying cause and address it specifically, while also managing symptoms to improve quality of life and prevent complications.

From the FDA Drug Label

If there is a lack of therapeutic response, KOH smears, cultures, or other diagnostic methods should be repeated. The patient is a 1 year old with a swollen rash of the perianal region, poor appetite, and minimal response to topical nystatin.

• The lack of therapeutic response to nystatin suggests that the diagnosis of cutaneous or mucocutaneous candidiasis may not be confirmed, or the infection may be caused by other pathogens.
• It is recommended to repeat diagnostic tests, such as KOH smears, cultures, or other diagnostic methods, to rule out infection caused by other pathogens and to confirm the diagnosis.
• Additional workup and treatment should be considered, but the FDA drug label does not provide specific guidance on this. 2

From the Research

Additional Workup and Treatment

For a 1-year-old with a swollen rash in the perianal region, poor appetite, and minimal response to topical nystatin, the following steps can be considered:

• Further evaluation to determine the cause of the rash, as the minimal response to topical nystatin suggests that the condition may not be a simple fungal infection 3
• Consideration of other potential causes of the rash, such as bacterial or viral infections, allergic reactions, or other skin conditions
• Additional diagnostic tests, such as swabs or biopsies, may be necessary to determine the underlying cause of the rash

Treatment Options

• If the rash is determined to be a fungal infection, alternative antifungal treatments may be considered, such as clotrimazole or other topical antifungals 4
• If the rash is determined to be a bacterial infection, antibiotic treatment may be necessary
• Supportive care, such as maintaining good hygiene and using topical creams or ointments to reduce discomfort and promote healing, may also be beneficial

Limitations of Current Evidence

• The available evidence is limited, and more research is needed to determine the most effective treatment for this condition 5, 6, 7
• The use of nystatin for the treatment of perianal rashes in children is not well established, and more studies are needed to determine its efficacy and safety in this population 3