Nappy Rash - Causes and Cures

Many thanks to our guest blogger, Dr Emma Vieira, for this article tackling an age-old problem and answering the question, “What is nappy rash?” while offering tips to help prevent it.

Our note: It is always recommended to use a liner (disposable or reusable) when using any type of barrier cream with your modern cloth nappies. Biodegradable liners can be thrown in the bin or composted once solids have been flushed. Flushing of single-use liners is not recommended. Our Luxury Liners are a great alternative to single-use varieties.

One of the most common presentations in paediatric general practice is nappy rash – it is a condition familiar (and frustrating!) to most mums and dads. The purpose of this article is to give a brief overview of the current approach to preventing and managing infant nappy rash.

So what is nappy rash?

Nappy or diaper rash is an inflammatory condition of the skin underlying the nappy area. It most commonly affects pre-toilet-trained babies who are in nappies all the time, with the highest incidence in babies under the age of 12 months.

Why does it Occur?

It is currently believed that over-hydration under the nappy, resulting in an irritant dermatitis (skin inflammation), is the most likely cause of nappy rash.
Some risk factors for nappy rash include:

• leaving a child in the same nappy for longer than about two hours (even less if the nappy is soiled with faeces) – urine and faeces are irritating to the skin
• a family history of eczema or other skin problems such as psoriasis can predispose to nappy rash or cause other conditions which mimic nappy rash
• some commercial nappy wipes, bubble baths, soaps, and cleansers contain perfumed products and chemicals that are irritating to the skin

Cloth or Disposable Nappies?

There is an ongoing debate about whether modern nappies are more or less likely to cause nappy rash, and there is not enough evidence from good-quality trials to support the role of either cloth or disposable nappies in reducing the risk.

The most important factor in either case is the frequency of nappy changes. If you use cloth nappies, they should be washed in hot water (up to 60 degrees Celsius). It has been suggested that tumble-drying the inserts (on low heat) may help as it softens the fabric.

How to Manage or Deal with Nappy Rash

So how do we manage nappy rash?

I would always advise seeing your GP before starting anything over-the-counter– it is easy to get into a frustrating (and expensive!) cycle of trying many different treatments, only to find that none of them work, or at least not for very long.

This can be because the diagnosis is wrong – ie. it’s not really nappy rash after all – or because the treatments are either inappropriate or not being used for long enough.

It is important to appreciate that, very often, nappy rash is not a pure “irritant” condition – yeasts, in particular Candida albicans, frequently cause a superimposed fungal infection in babies with an underlying dermatitis. It is therefore usually necessary to treat both the irritant/inflammatory and the infective components of the rash – this requires a topical steroid plus a topical antifungal cream. My usual practice is to commence a combined steroid/antifungal cream for 1 week, then use the antifungal alone for another week.

In addition to the fungal infection, there can also be a bacterial infection – a “triple whammy”, which will need to be treated with antibacterial creams (occasionally oral antibiotics will be necessary, but this is rare). This kind of infection usually presents with small pus-filled lesions in addition to the angry, reddened irritation of the underlying rash.

If your doctor prescribes a steroid cream, it is important that you use it frequently and for the recommended period of time. While you may see an almost immediate response to the cream, it is necessary to continue because the inflammation and infection take at least this long to clear.

Steroid medications often get a lot of “bad press” due to their unwanted side effects – however, it is important to remember that these are usually only an issue with oral forms of steroids; topical preparations are poorly absorbed into the bloodstream and their systemic (ie. effect on the whole body) is negligible over such a short period of time.

The most common steroid preparation used for nappy rash is hydrocortisone 1%, which is very safe if used appropriately. Stronger preparations should not be used for this type of dermatitis.

Prevent Nappy Rash

Simple things you can do to prevent rash when using nappies:

• change your baby’s nappy every 2 hours – more often if they are soiled with faeces
• give your baby nappy-free time when possible – harder in winter and in cold climates
• use a barrier cream at every nappy change – zinc-based creams are useful, as are simpler options such as vaseline
• avoid commercial nappy wipes – where necessary, a soft cloth soaked in lukewarm water will do the same job and be less irritating to sensitive skin (bearing in mind that the skin should be completely dry when you put the nappy on)
• reduce frequency of bathing where possible, and bath baby in lukewarm rather than hot water

Next Steps

Nappy rash is a common, usually self-limiting, often chronic, condition which can be easily managed in most cases. The most important aspects are prevention and, where prevention has failed, perseverance with treatment. It has a tendency to recur even after treatment, often needs to be re-treated, and in some babies, will never completely disappear until they are fully toilet-trained.

Don’t forget that there are other rare conditions which may look like nappy rash, but which require further investigation or management – if there is any doubt, even if your child has had “typical” nappy rash before, it is always wise to see your GP.

© Emma Vieira 2011

Dr Emma Vieira is a GP in part-time practice in Wagga Wagga. She lives in regional NSW with her husband and their three daughters.

References:
Fischer, Gayle. “Nappy rash” in Medicine Today, vol. 11 no. 6, June 2010.
Murtagh, John. Murtagh’s General Practice. McGraw-Hill. Sydney: 2007.