Diaper Rash

Diaper rash - What is diaper rash (nappy rash)?

Diaper rash (also known as nappy rash) is called diaper dermatitis is medical parlance. It is a common condition affecting up to a third of babies wearing nappies at any given time.

The condition leads to sore, red and irritated skin around the nappy. The commonly affected areas include the convex surfaces of the buttocks and the bulge of the groin. Nappy rash may spare the groin folds.

It was found that diaper rash accounts for 4.8 million outpatient visits in the eight-year period from 1990-97. This shows that infants are estimated to have a one-in-four chance of developing diaper rash. In addition around 75% of the affected babies were brought to the paediatrician for management. 1-5

Symptoms of diaper rash

There may be pink or red spots or blotches over the area and on the whole the area may appear red and swollen. The most common time when a baby suffers from nappy rash is when they are between 9 and 12 months of age. Usually there is no pain or discomfort.

Most cases the symptoms are mild and it is termed mild nappy rash. Babies with mild nappy rash show a small part of their nappy area to be covered in pink or red rashes. These babies tend to feel a stinging sensation when passing urine or faeces and tend to cry out loud.

In babies with severe condition or accompanying secondary bacterial infections over the affected area there may be pain, itching or discomfort that leads to increased irritability and crying. The affected area shows bright red spots, dry, cracked and broken skin and ulcers, blisters and swellings over the skin.

The affected area is also more extensive and may extend to the legs below or abdomen above. A fever or refusal to feed is usually a warning sign when the physician needs to be contacted urgently.

Causes of diaper rash

Nappy rash is commonly caused when the baby’s skin around the groin and nappy area becomes exposed to urine and faeces in their nappy. It is found that the ammonia in the waste products may irritate the baby’s soft skin. If a soiled nappy is left on for a long time this kind of skin irritation is seen.

Sometimes nappy rash is also caused by a fungal infection. Since the nappy area is warm and damp for long periods of time, it can cause a fungus, known as candida, to grow. This infection also irritates the baby’s skin and leads to reddish rash and features of nappy rash.

Babies with allergic tendencies, skin allergies like eczema, seborrhic dermatitis (types of dandruff that affects scalps of babies), psoriasis, allergic dermatitis, bacterial skin infections etc. all may manifest with rash and redness around the nappy area.

Treatment and prevention of diaper rash

Most cases of nappy rash are detected early and are termed mild nappy rash. These can be treated using simple skin care methods. The nappy must be kept off the skin for as long as possible when the area is affected.

The baby may be made to lie on a towel or disposable absorbent sheet that is changed frequently as he or she soils it.

Ideally for prevention of nappy rash the nappies should be changed frequently. The baby’s bottom and nappy area should be washed with water and dried completely before putting on a new nappy.

There are barrier creams and ointments available at pharmacies over the counter to protect the skin from moisture. Severe cases of diaper rash may require steroid cream or ointment such as hydrocortisone for reduction of inflammation, an antifungal cream which kills Candida and even antibiotic ointments that fight bacterial infections.

Causes of diaper rash (nappy rash)

Diaper rash (also known as nappy rash occurs when your baby's skin comes into contact with urine and faeces usually for prolonged periods of time. There are many factors in addition that play a role in causation of diaper rash (also called diaper dermatitis in medical parlance).

The causes and aetiology of diaper rash include wetness, friction and so forth. 1-5

Wetness and diaper rash

Wetness is the commonest culprit behind diaper rash. Being soiled the nappy fails to absorb the expelled waste fluids completely. This causes the nappy to remain wet when it contact with the baby’s skin around the nappy area.

The wetness leads to destruction of the skin barrier and its penetration by irritants present in urine and faeces becomes easier.

Friction and diaper rash

Friction plays another important role in diaper rash. Constant rubbing and vigorous rubbing against the soft skin around the nappy area by the nappy may give rise to nappy rash.

Urine and faeces and diaper rash

The faeces contain enzymes like proteases and lipases. These enzymes act on the urine to release irritant chemical called ammonia. This raises the pH of the area within the nappy and skin irritation occurs.

Microorganisms - fungal, bacterial and viral infections and diaper rash

Fungal infections like Candida albicans is seen in up to 80% of infants with skin irritation around the nappy area. The area is damp and wet and this leads to breakdown of the skin barriers and commonly within 48-72 hours after irritation the infection occurs.

In babies who are already on antibiotics there is a risk of destruction of healthy good bacteria living in the nappy areas. This leads to increased likelihood of fungal infections.

Babies with diabetes, suppressed immunities with conditions like HIV/AIDS infection and other disease also have an increased risk of fungal infections around the diaper areas. Tinea (ring worm) is another fungal infection that may affect babies in their diaper areas.

Bacteria like Staphylococcus aureus or group A streptococci can also lead to eruptions in the diaper area. Staph infection is more common in children who have a tendency to develop skin allergies (atopic dermatitis).

These infections often go on to affect the vulva, vagina and surrounding tissues (vulvovaginitis) in female babies. This could lead to life threatening complications. Other bacteria include Shigella, Escherichia coli, and Yersinia enterocolitica.

Viruses like coxsackie, herpes simplex, human immunodeficiency viruses and parasites like pinworms, scabies may also lead to rash in the diaper area.

Nutrition and diaper rash

Babies lacking in biotin and Zinc in their diet are also likely to get diaper rash.

Chemical irritants and diaper rash

Harsh soaps, fragrances, preservatives, powders, oils, detergents (in which cloth nappies have been washed) and antiseptics often cause irritation of the soft skin around the nappy area and may lead to diaper rash.

Diarrhoea and diaper rash

Diarrhoea in the baby leads to frequent liquid faeces. Since the food passes undigested there is a large amount of residual digestive enzymes in these loose stools. These may lead to irritation around the anus and diaper rash.

Developmental abnormalities of the urinary tract and risk of diaper rash

In babies with anatomical defects of the urinary passage that leads to constant of frequent dribbling of urine also have a raised risk of diaper rash.

Eczema and diaper rash

Eczema is a skin condition that makes the baby’s skin dry and sore. This may be more widespread around the body. A family history of eczema and nappy rash despite skin care should alert for eczema as a cause for diaper rash.

Seborrhoeic dermatitis and diaper rash

Seborrhoeic dermatitis (also called cradle’s cap) leads to red, scaly skin in babies aged between two weeks and six months. It is commonly seen over the scalp, ears, eyebrows, armpit and neck. Sometimes it may also affect the nappy area.

Other conditions that may lead to a rash around the diaper area

Other disease conditions like psoriasis, Granuloma gluteale infantum, Letterer-Siwe disease, Cystic fibrosis and Kawasaki’s disease may all lead to rash around the diaper area.

Symptoms of diaper rash (nappy rash)

Diaper or nappy rash may affect one in four babies worldwide between ages 6 months to up to 18 months (commonly between 9 and 12 months of age). The symptoms of nappy rash vary depending on the severity of the condition. Most cases of nappy rash only produce mild symptoms.

This type of rash is confined to the area covered by the nappy. There is commonly a closed area of red or pink rash over the convex surfaces of the buttocks and pubic area. These are areas of skin in closest contact with the nappy. The groin folds are commonly spared. 1-4

Mild nappy rash symptoms

In babies with mild nappy rash there is usually the beginning of the pathology:

  • the rash is usually pink or red spots or blotches

  • the rash is confined to a very small part of the nappy area.

  • the child feels generally well and may experience a stinging sensation when passing urine or faeces. This is expressed as the baby crying out loud while passing urine or stool and remaining generally well and playful at other times.

Severe nappy rash symptoms

In case of an more advanced from of nappy rash there may be accompanying pain and itchiness:

  • the area is extensive and may extend below to the legs or above to the abdomen

  • there are bright red and large spots

  • the skin may be dry, broken and cracked in appearance - there may be a bumpy feel and often sores may bleed as well

  • some babies may develop ulcers (open sores), blisters (fluid filled swellings) and generalized swelling of the nappy area

  • the baby is usually irritable and may cry as the rash is painful, burning and itchy

Immediate medical attention may be needed if there are additional features like fever, refusal to feed, diarrhoea, pus filled spots etc. these could indicate a more severe infection.

Other conditions leading to rash in the diaper areas

Other conditions that lead to a rash in the diaper area include bacterial infections, Jacquet erosive dermatitis and so forth.

Bacterial infections

Those with bacterial infections like that with Staphylococcus aureus present with bullous impetigo. There are blisters and pus filled raised spots over the affected area.

Group A Streptococcus infection leads to a red rash around the anus. Other bacteris like E. coli may lead to pain on urination (manifested as the infant crying when passing urine) and vaginal itching, and vulvar inflammation.

Infections with Coxsackie virus causes raised flat red spots buttocks, palms and soles. There may also be open sores at the back of the throat.

Herpes is characterized by painful vesicles in the vulva and area around the anus. Babies with parasitic infestations with pinworms and scabies have intense itching. Scabies also affects other parts of the body like webs of fingers and toes, armpits and groin folds.

Jacquet erosive dermatitis

Those with diaper rash following diarrhoea are said to have Jacquet erosive dermatitis. This is the most severe form of diaper dermatitis and can occur in older babies as well. There are open red sores which are well-demarcated, punched out with raised borders.

Other conditions

Granuloma gluteale infantum occurs due to irritation and secondary infection with reddish purple spots.

Psoriasis shows well-demarked red flat sores. Normally psoriasis shows up with white scarrings and dry patches. This is not seen in diaper areas because of the wetness.

Seborrheic dermatitis shows a yellowish scales over the affected area. Other parts of the body like the head, neck, ears and eyebrows are also affected commonly.

Prevention of diaper rash (nappy rash)

Diaper rash is a common condition seen in babies between 9 to 12 months of age. Although mild cases may be easy to treat, more severe cases may become secondarily infected and lead to recurrences and long term therapy requirement.

Good skin care and hygiene often prevents occurrences of diaper rash and may also prevent recurrences. These methods are applicable for treatment of mild cases of nappy rash as well. Skin care regimen and routines for prevention of diaper rash include (1-6):-

  • The baby should be kept off the nappy for as long as possible. This keeps the skin dry and helps prevent nappy rash.

  • The baby should be placed over an absorbent towel without the nappy and the towel needs to be changed each time the baby soils it. While asleep the nappy may be avoided.

  • The baby should be allowed stomach time without the nappy to dry the buttocks and area around the anus.

  • Nappy should be changed frequently and the baby should not be allowed to remain in a soiled diaper. This is especially true if the nappy is soiled with faeces.

  • Only water should be used to wash the baby’s bottom. Soap can leave the skin dry and lead to increased risk of nappy rash.

  • After each wash the skin needs to be patted completely dry with a soft towel or cotton cloth.

  • A barrier cream containing zinc oxide or simple petroleum jelly may be applied after each nappy change. The barrier cream needs to be applied in a thin layer. This preserves the breathability of the skin while protecting it from the wetness.

  • Lotions, oils that may contain perfumes or other additives should be avoided.

  • Tight fitting plastic pants should not be put over nappies

  • Talcum powders are not recommended when changing nappies. Unlike a barrier cream the powders do not protect the skin from wetness, urine and faeces. In addition it may also cause friction and irritate the soft skin. Talcum powders in addition may also be breathed in by the baby leading to irritation of lungs.

  • All cloth nappies need to be washed in mild detergents and they should be rinsed thoroughly to remove the traces of the detergent completely. Fabric softeners, bleach, presoaks etc. should be avoided as they may remain on the clothes causing irritation.

  • In case the stools are loose fruit juices, apple juice etc. should be avoided. These are acidic and may irritate the skin around the anus and lead to diaper rash.

Disposable versus cloth diapers

It is believed that babies who never wear disposable diapers are not the ones who never get diaper rashes.

Both cloth nappies and disposable diaper wearing babies are equally susceptible to diaper rash. The advantage of cloth diapers is that they can be worn without plastic pants.