Nappy rash:an acute inflammatory reaction of the skin in the nappy area,…
Nappy rash:an acute inflammatory reaction of the skin in the nappy area, which is most commonly caused by an irritant contact dermatitis. It is also known as 'napkin dermatitis' or 'diaper dermatitis'.
Urine and occlusion lead to overhydration and skin maceration.
Faecal bile salts and enzymes break down stratum corneum lipids and proteins.
A mixture of urine and faeces creates ammonium hydroxide, raising pH.
The wet skin is colonised by micro-organisms, particularly candida.
Mechanical friction from limb movement may increase discomfort.
Pre-existing skin conditions such as atopic dermatitis or seborrheic dermatitis predispose a baby to napkin dermatitis.
Skin care practices (for example, how often the area is cleaned and the nappy changed) — prolonged skin contact with urine and faeces predisposes to irritant contact dermatitis.
Type of nappy used — disposable nappies or reusable cotton nappies.
Exposure to chemical irritants — such as soaps, detergents, or alcohol-based baby wipes.
Skin trauma — for example, mechanical friction from skin contact with nappies or over-vigorous cleaning.
Medication — recent broad-spectrum antibiotics, in particular, predispose to candida colonization; other drugs that increase stool frequency may also increase the risk.
Gestational age — pre-term infants are at increased risk of developing nappy rash and secondary infection due to the reduced barrier function of immature skin.
Diarrhoea — including conditions associated with increased stool volume and pH, such as gastroenteritis, malabsorption, and liver conditions such as hepatitis (rare).
Clinical features: rash itchy and painful, well-defined areas of confluent erythema and scattered papules over convex surfaces in contact with the nappy (the buttocks, genitalia, suprapubic area, and upper thighs), with sparing of the inguinal skin creases and gluteal cleft.
It may have a glazed appearance if acute, or fine scaling if more longstanding.
There may be skin erosions, oedema, and ulceration if there is severe involvement.
Exclude other conditions
location,features, site and length of time rash has been present
Candida secondary infection
Bacterial secondary infection — may be caused by staphylococcal or streptococcal infection.
Jacquet's erosive diaper dermatitis — presents with punched out ulcers or erosions with elevated borders.
Perianal pseudoverrucous papules and nodules — presents with multiple, shiny, smooth, red, moist, flat-topped papules or nodules in the nappy area, around the perianal skin, and involving genital, suprapubic, and buttock skin.
Granuloma gluteale infantum — presents as 0.5–4 cm asymptomatic cherry-red plaques and nodules (rare).
Self-management strategies, such as using a nappy with high absorbency; leaving nappies off for as long as possible; changing the nappy frequently and as soon as possible after wetting or soiling; using water, or fragrance- and alcohol-free baby wipes; drying gently after cleaning; avoiding potential irritants such as soaps and bubble bath.
Advising on sources of written information and support.
Use of a barrier preparation to protect the skin, if there is mild erythema and the child is asymptomatic. Zinc and castor oil ointment applied thinly at each nappy change
Prescribing topical hydrocortisone 1% cream once a day in addition, if the rash appears inflamed and is causing discomfort.
Prescribing a topical imidazole cream, if the rash persists and candida infection is suspected or confirmed on swab.
Prescribing oral antibiotics, if the rash persists and bacterial infection is suspected or confirmed on swab.
Arranging to review the child, the time interval depending on clinical judgement, to assess the response to treatment.
recurrent severe unexplained episodes
If uncertainty about diagnosis
Moderate- erythema. small areas of broken ulcers
Severe- erythema. large areas of bro
Mild- erythema. no broken skin
Perianal streptococcal dermatitis
Infantile seborrhoeic dermatitis
allergic contact dermatitis
Miliaria rubra (heat rash)
fungal skin infection