September 18, 2017
ARTICLE:

Nappy rash

By Dr Megan Yap - Paediatrician

Nappy rash is a really common problem that we see in infant children who still wear nappies (diapers). It can be uncomfortable and at times painful for the child, and distressing to parents who are trying to treat it.

The problem is caused by the child’s skin, reacting to:

  • Prolonged contact with bodily excretions (wee and poo)
  • Other chemicals in the nappy (eg soaps, nappy wipe residue, nappy powders or creams)
  • Excess moisture/hydration of the skin (alters skin integrity and makes skin more prone to break down)
  • Friction between the nappy and skin
  • Infection (eg candida – a type of fungal infection)

It can be more easily triggered in children who have a tendency to overly sensitive/dry skin or a concomitant skin condition that compromises skin integrity (eg eczema, psoriasis).

 

PREVENTION AND TREATMENT:

The BEST thing to do about nappy rash is to try to PREVENT it happening.

  • Change nappies frequently
  • Ensure the skin is clean (keeping irritants off the skin)
  • Keep the skin DRY
  • Use a barrier cream

Despite there being multiple causes (and thus multiple types) of nappy rash, the principles of management and treatment are fairly straightforward (and actually similar to the principles of prevention).

  1. Get rid of the trigger/irritant (regular cleaning and changing)
  2. Treat infection and/or inflammation
  3. Allow the skin time to dry and heal (use disposable nappies)
  4. Create a thick barrier to protect this skin from further exposure to the irritant

 

TYPES:

So there are several types of nappy rash and they all look a bit different.  This is how we distinguish between them and how the treatment varies…

  • Ammoniacal dermatitis – this is kind of like a contact dermatitis
    • Red skin &/or bumpy or little fluid filled blisters lesions, fissures (cracks in the skin) and erosions (areas of skin break down)
    • Skin folds (that is the skin creases) are spared (this is because in a chubby baby, direct contact with the irritant (poo and wee) often does not occur in the skin fold)
    • Caused by irritation from excretions and chemicals (specifically the ammonia in urine)
    • Secondary bacterial and fungal infection is common (that is, the skin integrity is compromised and it breaks down, allowing infection into the skin)
    • Treatment: regular washing and changing; exposure to air; use of barrier cream +/- antifungals/antiseptics
  • Candidal (fungal) nappy rash
    • Bright red rash with clearly demarcated edge
    • Satellite lesions beyond border (that is, separate red spots of rash that occur outside the generalised area of the the nappy rash itself)
    • Skin folds are usually involved, may have simultaneous oral thrush
    • Treatment: topical antifungal cream (eg nystatin) +/- systemic antifungal (must occur under medical direction), topical steroids

  Other diagnoses that can LOOK like nappy rash but are different: 

  • Psoriatic nappy rash
    • Appearance similar to seborrheic dermatitis
    • Silver scale
    • Family history of psoriasis
  • Seborrheic dermatitis
    • Pink, greasy lesions with yellow scale
    • Often in skin folds
    • Cradle cap may be present
    • Treat with mild topical steroids
  • Threadworm
    • Threadworms can cause an itchy rash around the genitals and bottom. Look for them at night time when children settle for sleep with a torch and treat with mebendazole (talk to your pharmacist)
  • Zinc deficiency
    • Sharply defined, red, often extensive, anogenital rash. Can be associated with dermatitis around the mouth and nose and also on hands and feet, hair loss, diarrhoea, and failure to gain weight
  • Cellulitis
    • Infection of the skin with bacteria; can cause painful passage of poo – with or without constipation, fissures and breakdown of the skin around the anus
  • Other medical causes
    • There are many other potential medical diagnoses that look like nappy rash. The serious ones are more rare and tend to be chronic (ie go on for a long time).  Seek the attention of your GP if you are concerned or the nappy rash does not respond to simple measures.

 

PRODUCTS

Here it is important to note that I HAVE NO AFFILIATION WITH ANY PRODUCT OR COMPANY and am not sponsored by any company that produces any of these products.

The products I describe and name below are just from my knowledge base, that I have found useful in the past in treating nappy rash.

 

Barrier preparations

 The purpose of these creams are just as the name suggests – to create a barrier.  Many barrier creams contain ZINC. This is not absorbed by the skin, but rather sits on it to protect it.  You want it to stick to and protect the skin – so do not worry if it doesn’t totally wash off, just reapply more over the top!

 

There are many different brands of barrier cream and they vary in thickness and how well they stick to/stay in contact with the skin.

  • If you are using a cream every day to prevent nappy rash, then a thinner cream is okay, easier to apply and washes off more readily (eg Sudocream).
  • Vaseline (petroleum jelly) is probably the oldest type of barrier preparation I know of. It still works really well to cover the damaged skin and protect it from irritants.  It is oily, and urine does not wash it off (which is what you want)
  • If you are treating a really bad nappy rash, then a thicker cream is indicated. A straight zinc cream from your chemist will be inexpensive and appropriate.  The thickest of them all (that I have used for patients before) is called Conveen (and was originally designed for adults with the same problem).  It is a VERY thick zinc paste, that is hard to get off even in the bath.  It is expensive, but very effective.  I have used it in children with chemotherapy induced diarrhoea, longstanding diarrhoea for other.

 

Antifungals

Fungal infections of nappy rash are common.  Candida can be a commensal (that is, a microbe that is normally present in the poo that does not usually cause a problem) in the intestine, but if it infects the skin can cause problems.

There are heaps of different antifungals – that differ in price and active ingredient. Most need to be applied at LEAST 3 times a day whilst the nappy rash is present, and then to be CONTINUED for 5-7 days after the rash has disappeared (or the rash will reappear).  I usually suggest sticking the tube with the nappies and applying at each nappy change (as often urine will wash it off).

Some examples of antifungal creams include:  Clotrimazole [Clonea, Canesten]; Miconazole [Daktarin]; Nystatin [Nilstat]

If a fungal infection is suspected in a nappy rash, an oral antifungal mixture is often taken and used to treat the infection systemically as well.  These are available over the counter at your pharmacy (in Australia) – but you need to chat to the pharmacist about it first.

The theory behind this is that the gut is really just one reeeeally long tube (from mouth à oesophagus à stomach à small intestine à large intestine à anus) and the microbe can therefor exist (and travel) to any part of this continuous tube.

Examples:  Nystatin [Mycostatin oral drops, Nilstat oral drops]; Miconazole [Daktarin Oral Gel]

 

Topical steroids

A steroid cream is used to reduce inflammation in the skin and also helps to reduce itching.

Steroid creams often get a bad publicity for various reasons and are labelled by some as “nasty” but often this reputation is unjustified.  Doctors use steroids for a WIDE variety of medical purposes and they are an extremely useful family of drugs.  It is true that when used for long periods of time in high doses, they have a long list of side effects, some of them serious (eg immune suppression, growth suppression etc).

Having said this, there are many TYPES of steroids that are used orally and intravenously in a huge range of doses for systemic indications like autoimmune diseases, croup, nausea/vomiting associated with pregnancy or chemotherapy, to prevent organ rejection in transplant patients… the list goes on.  When steroids are used systemically like this, they are typically in larger doses and for longer periods of time than when we use them topically (eg on the skin in creams or inhaled for asthma) and have a higher incidence of side effects for these reasons.

In the case of nappy rash, the steroid creams we use are generally relatively weak, contain steroids of low potency (eg hydrocortisone), we use them for only a very short period of time, they are applied to a limited area of the skin (ie not to the whole body, thus the total dose is much smaller), and the systemically absorbed dose is only less than 10% of the total dose contained in the amount of cream applied.

I almost never see significant side effects in children I treat with steroid creams for nappy rash.  They are well tolerated, and work very well if they are used appropriately.   Talk to your friendly local pharmacist about what they have available.

 

Example products:  Hydrocortisone 1% [Dermaid, Dermaid soft cream, Sigmacort, Resolve]

Stronger steroid preparations are available on prescription but are not often needed in nappy rash.  You should consult your GP or paediatrician to know if these are appropriate for your child.

 

Combination products

These were designed for convenience by companies so that you can use one cream instead of two.

The advantages are that it is usually cheaper than buying 2 separate products

  • There is usually less wastage of product at the end
  • They are premixed and easy to use

The disadvantages of these products are:

  • You may not have to use both products for a prolonged period of time which means you may either – unnecessarily continue to use a drug when you don’t need it (eg a steroid in a combination cream after the inflammation has subsided) whilst needing to continue the other agent (eg the antifungal cream that needs to continue for 7 days after the rash has disappeared)
  • You may end up thus buying 2 or 3 products anyway

Examples:  Steroid and antifungal together (eg Resolve Plus); barrier cream and antifungal together (eg Daktozin)

 

Antibiotics

Secondary bacterial infection of nappy rash is not all that common, but can occur.  If this is suspected (as suggested by red, angry rash that is not responding to other treatment, rapidly spreading redness, pustules (pimples) or purulent (ie pus) ooze, a golden “crust” to the abnormal skin, the child is systemically unwell eg vomiting/fever) then medical attention should be sought.

 

Summary

  • Nappy rash is common and can get quite nasty
  • It is relatively easy to treat if you use the right preparations
  • Talk to your local pharmacist or GP if you need help (GP can refer to a paediatrician if necessary)
  • Prevention is better than cure

Principles of management:

  1. Get rid of the trigger/irritant (regular cleaning and changing)
  2. Treat infection and/or inflammation
  3. Allow the skin time to heal
  4. Create a barrier to protect this skin from further exposure to the irritant

Until next time, keep those bottoms clean and dry!

xx Dr Megs

For more from Dr Megan Yap visit her blog – Kids Health Guru

 

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