Napkin rashes

Napkin rashes are a very common problem of early infancy. The main causes are:

• napkin dermatitis
• candidiasis
• infantile seborrhoeic dermatitis

Management of nappy rash:

• general principles:
  • frequent nappy changes and careful washing with warm water at each change; clean the child's bottom to remove residual urine and faeces (1)
  • topical creams in nappy rash:
  • frequent application of protective creams, for example, zinc oxide creams or ointments; application of these creams with every nappy change is advised (2)
  • if eczema, seborrhoeic dermatitis or psoriasis present add topical 0.5-1.0% hydrocortisone
  • if candidasis then add topical nystatin or topical imidazole
  • if clinical differentiation of type of dermatitis (e.g. irritant napkin dermatitis, candidasis napkin dermatitis, seborrhoeic dermatitis) is not possible then empirical therapy with
    • a barrier cream (e.g. conotrane (R) or sudocrem (R)) plus
    • a combined topical steroid with antimicrobial preparation for 7 days e.g. timodine (R) cream (has antibiotic as well as antifungal properties) or daktacort (R) cream (hydrocortisone 1%, miconazole nitrate 2%)
  • use disposable nappy liners
  • avoid plastic and rubber pants - which increase the penetrance of irritants

Notes:

• secondary bacterial infections may sometimes occur (particularly with S aureus and streptococcal spp.) and this should be managed with appropriate antibiotics (3)
  • secondary streptococcal infection can develop in the intertriginous folds of the napkin area, as well as the neck and axillae
    • this infection is associated with a bright red and moist appearance with sharply demarcated borders
  • bullous impetigo can also develop in the napkin area, and may occasionally be mistaken for candidiasis associated napkin dermatitis
  • S aureus folliculitis superimposed on napkin dermatitis is another bacterial infection that can involve the diaper area, and must be recognized so that appropriate antibiotic therapy can be instituted

Reference:

• (1) Davies MW et al. Topical Vitamin A, or its derivatives, for treating and preventing napkin dermatitis in infants. The Cochrane Database of Systematic Reviews 2005; 4:CD004300
• (2) Atherton D et al. What can be done to keep babies' skin healthy? RCM Midwives. 2004;7(7):288-90.
• (3) Friedlander SF et al; Contemporary Pediatrics (April 2009). Diaper dermatitis: appropriate evaluation & optimal management strategies