dermatitis, candida diaper dermatitis, and mixed dermatitis Acrodermatitis enteropathica, which is caused by zinc deficiency, psoriasis, and Langerhans cell histiocytosis, should also be considered in the differential diagnosis for diaper dermatitis that is persistent or does not respond to antifungals and antiinflammatory medications Treatment is determined by the cause of the dermatitis In general, optimized skin care, which includes decreased frequency of washing, use of mild soaps, and use of barrier emollients, will help with any diaper dermatitis With occlusive dermatitis, avoidance of tightly fitting diapers, plastic-covered paper diapers, and rubber pants is important When atopic dermatitis is present, the use of topical steroids is necessary It is important to avoid fluorinated or other potent steroids in the diaper area because occlusion by the diaper enhances the steroid effect and is more likely to produce skin atrophy and striae Antifungal–steroid combinations should also be avoided for these same reasons Therefore, 1% or 2.5% hydrocortisone cream or ointment no more than twice daily over a short period (5 to days) is recommended Hydrocortisone (1% or 2.5%) is also effective for seborrheic diaper dermatitis and can be used intermittently With candidal diaper dermatitis, the use of preparations such as econazole, miconazole, or nystatin twice daily is effective If thrush is also present, oral nystatin suspension, 200,000 units (2 mL) four times a day for days, is advisable This medication will also be useful if the infant is seeding C albicans from the GI tract onto the skin of the diaper area Secondarily infected dermatitis, such as bullous impetigo, should be treated with the appropriate systemic antibiotics or in some cases topical antibiotics Atrophic Patches Aplasia Cutis Aplasia cutis is a congenital defect that is characterized by localized absence of epidermis and dermis and, sometimes, subcutaneous fat It generally occurs on the scalp (80% near the hair whorl) but can occur on any location of the body Right after birth, aplasia cutis can appear as a scar or as a weeping, granulating oval or circular defect Small defects are the most common but larger ones sometimes occur and may extend to the dura or meninges Some lesions may present with an almost bullous appearance and when surrounded by dark hair or thicker hair (hair collar sign) may represent a form of neural tube defect Patients with these lesions should undergo an MRI of the brain to look for underlying connection to the brain Congenital absence of skin can also be seen with