Nappy rash: Comparisons of treatment and prevention

Irritant diaper dermatitis, more commonly referred to as nappy rash, is a generic term relating to skin rashes that are caused by various skin disorders or irritants. The dermatitis is not caused by the nappy itself but by the skin being exposed to prolonged wetness, ongoing exposure to urine and faeces (which causes the skin pH to increase), fungal skin infection or an allergic reaction. Nappy rash is occasionally misdiagnosed as seborrheic dermatitis and atopic dermatitis.

The use of some antibiotics also increases the risk of nappy rash in some children: a prospective study of 57 children showed that after 10 days of oral amoxicillin treatment, 16% of children developed nappy rash and there was a twofold increase in skin colonisation with candida.

A number of case studies have confirmed that oral Candida is associated with candida nappy rash due to the excretion of Candida in the faeces.

Treating nappy rash

Nappy - free time

The most effective treatment for nappy rash – although perhaps also the most impractical – is the removal nappies in order to allow the affected skin areas to air out.

Choose the right nappy

If it is not practically possible to leave nappies off at all times, choosing a nappy with the greatest absorbency can help reduce the severity of nappy rash. There are a number of randomised controlled trials that evidence that children who wear breathable, disposable nappies with a gel matrix experience significantly less nappy rash than children who wear non-breathable nappies.

Regular changing

Cleaning and changing the child immediately after wetting or soiling can help. Changing nappies on a regular basis has also been shown to reduce the incidence of nappy rash: a cross- sectional survey of approximately 1100 infants in a US study showed that both the incidence and severity was significantly lower in parents who reported more frequent nappy changes. Although not based on existing research, expert testimony and opinion from a number of review articles suggest that bathing a child for more than once a day can dry out their skin and may lead to the worsening of existing nappy rash.

Choose the right wipes

Alcohol and fragrance- free baby wipes – two clinical trials support their use, also noting that baby wipes have the added convenience of being soft and minimising frictional damage.

Use a barrier product

The routine use of a ‘barrier preparation’ at each nappy change is widely recommended in order to reduce the contact between a child’s skin and any urine or faeces that is in the nappy. Barrier preparations that contain zinc oxide or titanium dioxide are commonly used, with white soft paraffin and dexpanethol 5% ointment frequently used as alternatives.

Treatments for severe nappy rash

For children over the age of 1 month, there is some evidence that topical corticosteroids can help settle the symptoms of more severe nappy rash. However, clinicians are often reluctant to prescribe steroids for young children as they can cause some skin atrophy and growth retardation in the affected areas.

In more severe cases, some parents make a custom made thick paste, using ingredients such as an over the counter topical cream and stomahesive powder (containing carmellose sodium, gelatin and pectin).  Whilst there is very little available evidence for the use of stomahesive powder in conjunction with topical creams, it is a commonly used formulation in the treatment of stoma and is an effective, well researched barrier cream. 

Although occasionally used for nappy rash, it is more regularly used as a post-surgical long-term barrier cream treatment for children who have received surgery to their bowel and/or rectum. As such, its effectiveness as a barrier treatment option is not in doubt having been well recognised by a wide range of medical professionals, but specific evidence around the use of Stomahesive in the treatment of nappy rash in particular does not currently exist. Aside from its efficacy as a paste, stomahesive powder is also regularly used to absorb moisture and prevent skin irritation. Although efficacious, it is important that barrier treatments such as stomahesive are not used in some cases of nappy rash.

Candida Infection

For nappy rash where candida infection is either confirmed or suspected, no barrier cream should be used until the infection has settled. For such cases, topical antifungal creams such as clotrimazole, econazole or miconazole are more typically prescribed to alleviate discomfort.

Treatments to be avoided?

• ​ Talcum powder is not advised for use as expert opinion suggests that it contains a number of irritants. 
• There is also limited evidence to support the use of topical antibiotics.
• Oral antifungal treatments are not licensed for children under the age of 5 and are such not recommended.

References

1. Honig PJ, Gribetz B, Leyden JJ et al (1988) Amoxicillin and diaper dermatitis. Journal of the American Academy of Dermatology 19(2 Pt 1):275-279
2. Hoppe JE (1997) Treatment of oropharyngeal candidiasis and candidal diaper dermatitis in neonates and infants: review and reappraisal Pediatric Infectious Disease Journal 16(9):885-894
3. Davis JA, Leyden JJ, Grove GL, Raynor WJ (1989) Comparison of disposable diapers with fluff absorbent and fluff plus absorbent polymers: effects on skin hydration, skin pH, and diaper dermatitis Pediatric Dermatology 6(2):102-108
4. Odio M, Friedlander SF (2000) Diaper dermatitis and advances in diaper technology Current Opinion in Pediatrics 12(4):342-346
5. Baldwin S, Odio MR, Haines SL et al (2001) Skin benefits from continuous topical administration of a zinc oxide/petrolatum formulation by a novel disposable diaper Journal of the European Academy of Dermatology and Venereology 15(Suppl 1):5-11
6. Ehretsmann C, Schaefer P, Adam R (2001) Cutaneous tolerance of baby wipes by infants with atopic dermatitis, and comparison of the mildness of baby wipe and water in infant skin Journal of European Academy of Dermatology and Venereology 15(Suppl 1):16-21
7. Jordan WE, Lawson KD, Berg RW et al (1986) Diaper dermatitis: frequency and severity among a general infant population. Pediatric Dermatology 3(3):198-207
8. Atherton DJ (2004) A review of the pathophysiology, prevention and treatment of irritant diaper dermatitis. Current Medical Research and Opinion 20(5):645-646
9. Heimall LM, Storey B, Stellar JJ, Davis KF (2012) Beginning at the bottom: evidence-based care of diaper dermatitis MCN 37(1):10-16
10. Paige DG, Gennery AR, Cant AJ (2010) The neonate In: Burns T, Breathnach S, Cox N and Griffiths C. (Eds.) Rook's textbook of dermatology. 8th edn. Chichester: Wiley-Blackwell. 17.1-17.85