Photo Quiz

Infant with Diaper Rash and White Bumps

FREE PREVIEW Log in or buy this issue to read the full article. AAFP members and paid subscribers get free access to all articles. Subscribe now.

FREE PREVIEW Subscribe or buy this issue. AAFP members and paid subscribers get free access to all articles.

Am Fam Physician. 2014 Jun 15;89(12):973-974.

A 14-month-old boy is brought to his physician's office because of a diaper rash. Three weeks earlier, he was seen in the emergency department for a beefy-red, plaquelike perineal rash with multiple erythematous papules. The rash did not improve with over-the-counter topical creams and topical nystatin alone, but responded briefly to a regimen of oral cephalexin (Keflex) and fluconazole (Diflucan) with topical nystatin cream. The patient subsequently developed white bumps and blisters in the diaper area and a fever of 105°F (40.5°C). His mother reported that she had recently developed lesions on her lip that crusted over and resolved within a few days.

Physical examination revealed multiple vesicles with discharge in the groin and perineum. There was significant erythema in the groin, perineum, and scrotal area with multiple ruptured and intact vesicles that were 0.3 × 0.3 cm in size (Figures 1 and 2). Ulcerated skin was observed in the gluteal cleft and intertriginous areas. The infant was admitted to the hospital for treatment.

Figure 1.

View Large

Figure 1.

Figure 1.

Figure 2.

View Large

Figure 2.

Figure 2.

Laboratory testing showed an elevated C-reactive protein level of 2.08 mg per L (19.81 nmol per L) and a white blood cell count of 23,000 mm3 (23 × 109 per L). Vesicle fluid was collected for bacterial and viral testing.


Based on the patient's history and physical examination findings, which of the following treatment options is most appropriate?

A. Acyclovir (Zovirax).

B. Fluconazole.

C. Mupirocin (Bactroban).

D. Vancomycin.

E. Zinc oxide cream.

Author disclosure: No relevant financial affiliations.

Address correspondence to H. Daniel Fahrenholtz, MD, at Dan. Reprints are not available from the authors.


1. Beauman JG. Genital herpes: a review. Am Fam Physician. 2005;72(8):1527–1534.

2. Usatine RP, Tinitigan R. Nongenital herpes simplex virus. Am Fam Physician. 2010;82(9):1075–1082.

3. Wald A, Zeh J, Selke S, et al. Reactivation of genital herpes simplex virus type 2 infection in asymptomatic seropositive persons. N Engl J Med. 2000;342(12):844–850.

4. Reading R, Rannan-Eliya Y. Evidence for sexual transmission of genital herpes in children. Arch Dis Child. 2007;92(7):608–613.

5. Smith JS, Robinson NJ. Age-specific prevalence of infection with herpes simplex virus types 2 and 1. J Infect Dis. 2002;186(suppl 1):S3–S28.

6. Langenberg AG, Corey L, Ashley RL, Leong WP, Straus SE. A prospective study of new infections with herpes simplex virus type 1 and type 2. Chiron HSV Vaccine Study Group. N Engl J Med. 1999;341(19):1432–1438.

7. Humphrey S, Bergman JN, Au S. Practical management strategies for diaper dermatitis. Skin Therapy Lett. 2006;11(7):1–6.

8. Drage LA, Bundrick JB, Litin SC. Clinical pearls in dermatology. Mayo Clin Proc. 2012;87(7):695–699.

Contributing editor for Photo Quiz is John E. Delzell, Jr., MD, MSPH.

A collection of Photo Quizzes published in AFP is available at

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at To be considered for publication, submissions must meet these guidelines. E-mail submissions to

Copyright © 2014 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

Article Tools

  • Download PDF
  • Print page
  • Share this page

CME Quiz

More in Pubmed

Navigate this Article