Introduction

Nappy rash (or for the more technically minded Napkin dermatitis, and in the US diaper rash) is a term used to describe several disorders of the skin in the region of the nappy. Most commonly nappy rash is a form of contact dermatitis. It can be the result of:

  • Contact dermatitis – most common
  • Candida albicans (yeast)
  • Impetigo (staphylococcus)
  • Atopic dermatitis
  • Psoriasis
  • Infantile seborrheic dermatitis

It typically presents between 3 and 15 months of age, and is more common in those wearing cloth nappies. Modern disposable nappies are multi-layered and more breathable and reduce the risk of nappy rash.

Most babies have some sort of nappy rash at some stage.

Cause

The usual contact dermatitis from the nappy is the result of irritants (essentially urine and faeces) being in prolonged contact with the the delicate newborn skin, friction and abrasion cause by the nappies as the baby moves, and as a result of the chemical reactions which can occur between the urine and faeces.

  • Moist skin for prolonged periods also leads to the growth of candida species
  • Damaged skin from the above processes can also lead to impetigo (staphylococcus) infection

Nappy rash is NOT due to:

  • Allergy to nappies
  • Toxins in the nappies
  • Washing powders for cloth nappies (unless not thoroughly rinsed)

Preventative factors

  • Use of disposable nappies
  • Breast feeding
    • Produces faeces of a lower (more neutral) pH
    • As babies start to eat solid foods, stool pH rises and nappy rash becomes more common

Presentation

  • Rash in the nappy region!
    • Typically erythematous macule and papules
    • Skin folds often spared as they are not in contact with the urine and faeces
  • Waistband and thighs are often the worst affected region due to chaffing
  • Secondary infections can change the appearance of the rash
    • Candida – may cause plaques, satellite spots and superficial papules
    • Impetigo – irregular shaped blisters, pustules, yellow crust
  • Other causes will have a rash of slightly different appearance, but often can be difficult to differentiate clinically
    • Seborrhoeic dermatitis – often skin folds are affected. White plaques may be present. May be desquamation
    • Atopic dermatitis – evidence of dermatitis in non-nappies areas as well
    • Psoriasis – very resistant to treatment, red scaly plaques, other sites involved, family history

Investigations

None are usually required. In cases where there is a suspicion of secondary infection or which are resistant to treatment, skin swabs may be used to confirm the presence of candida or staphylococcus.

Management

  • BARRIER CREAMS!
    • The most important part of management
    • Thick creams applied copiously
    • Zinc-containing creams tend to be the most durable (e.g. sudocreme)
    • Don’t attempt to completely remove the cream with each change of nappy. Clean the area as normal and if there is any remaining cream, apply the next layer of cream on top
  • Frequent nappy changes with care taken to clean and dry skin thoroughly in between
  • Correct size nappies
  • Wet wipes often contain chemical which can cause a contact allergic reaction – so advise to ensure that dry wipes be used after to remove some of this (pat dry). In resistant cases suggest uses of aqueous cream, or water with cotton wool and allow air drying.
    • Ensure any wipes used are free from alcohol and fragrances
    • Water and cotton wool is just as effective at cleaning the skin as wet wipes
  • Avoid talc
  • Allow some nappy-off time in the day – as long as possible
  • Give evening fluids early to avoid prolonged night-time skin contact with urine
  • Consider removing some foods from diet temporarily until rash resolves if they are suspected of causing pH issues in the urine / faeces (orange juice is a common cause)
  • Avoid the use of plastic pants over the top of nappies

Medical management

  • Topical steroids (e.g. 1% hydrocortisone BD for max 7 days) may be useful in some cases
    • Avoid stronger steroids due to risk of striae and skin thinning
    • Cease once rash has settled
  • Topical antifungals – e.g. clotrimazole, ketoconazole – where candida is suspected
    • Continue for 7 days after cessation of rash
    • Often a combination cream with steroid is used
  • Aloe vera containing topical agents have been reported to be effective

References

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