Nappy rash
Definition: nappy rash is an acute inflammatory reaction of the skin in the nappy area which is most commonly caused by an irritant contact dermatitis.
Diagnosis
Glazed appearance may be present if acute or fine scaling if more longstanding.
Skin erosions, oedema and ulceration may be present if severe.
Rash typically presents with well-defined areas of confluent erythema and scattered papules over convex surfaces in contact with the nappy.
Investigation such as swabs are not usually required for diagnosis of uncomplicated nappy rash.
The child may be distressed, agitated or uncomfortable as the rash can be itchy and painful
Assessment
Examination: Look for features of typical nappy rash. Oral candidiasis. Features of secondary infection.
Consider skin swab for culture and sensitivity if secondary bacterial infection is suspected.
Ask about: location, nature and duration of rash. Previous episodes, Risk factors. Any treatments previously tried.
Differential diagnosis
Eczema herpeticum
Perianal streptococcal dermatitis
Atopic eczema
Infantile seborrhoeic dermatitis
Allergic contact dermatitis
Psoriasis
Miliaria rubra (heat rash)
Lichen sclerosus
Scabies
Fungal skin infection
Zinc deficiency
Management
Inflamed and causing discomfort - children over 1 month consider hydrocortisone 1% cream once per day (max 7 days) in addition to barrier preparation.
If rash persists and Candidal infection is suspected or confirmed on swab - advise against use of barrier preparation until infection has settled, prescribe topical imidazole cream (frequency depending on preparation used).
Mild erythema and asymptomatic - use of barrier preparation to protect skin which are available to buy over the counter. Apply thinly at each nappy change.
If rash persists and bacterial infection suspected/confirmed by swab - prescribe oral Flucloxacillin for 7 days (Clarithromycin in penicillin allergy) (adjust according to swab result).
Advise on sources of written information: NHS A-Z
Review the child to assess response to treatment. Use clinical judgement to decide time interval.
Self-management: high absorbency nappy, proper fitting nappy, leave nappy off for as long as possible to help skin, clean skin and change nappy every 3-4 hours or asap after soiling.
In treatment failure: consider underlying cause of failure such as non-adherance to self-care or treatment regieme, secondary infection (skin swab for culture and sensitivity), alternative cause or immunocompromised host.
If rash persists following treatment for secondary infection adjust choice of preparation used depending on swab result.
Consider referral to paediatric dermatologist if uncertainty about the diagnosis, rash persist optimal treatment or recurrent severe unexplained episodes.