Clinical Practice Guidelines

Nappy Rash

  • Background

    Nappy rash is a dermatitis confined to the area covered by the nappy. It is most commonly characterised by confluent erythema of the convex surfaces of the buttocks, the areas of skin in closest contact with the nappy and it spares the groin folds.

    Nappy rash is not one distinct diagnosis, but is a multifactorial problem.

    nappy rash pic1   nappy rash pic2   nappy rash pic3

    Factors which contribute to Primary Irritant Napkin Rash:

    • Excess skin hydration 
      • water in urine & stool 
      • nappy change frequency
    • Skin trauma 
      • friction between nappy and skin.
    • Irritants
      • ammonia (produced from urine by urea splitting organisms in faeces)
      • faeces (especially diarrhoea)
      • soap & detergent residue
      • agents present in Nappy Wipes
      • napkin powders & creams
    • Candida albicans (present in faeces and infects damaged moist skin)

    The relative contribution of each factor may vary between cases. It is not generally helpful to distinguish between these causes of Primary Irritant Napkin Rash as the treatment principles do not depend on this.

    Treatment

    • Use disposable nappies.
    • Increase the frequency of nappy changing and cleansing the skin.
    • Use disposable towels or face washers soaked in water or olive oil to cleanse the area.
    • Application of a barrier cream at every change.  Effective barrier creams include zinc paste, white soft paraffin and vaseline.  Apply extremely thick and should not be removed completely after each nappy change, rather apply another layer over the top.
    • Letting the child spend as long as possible without a nappy on, lying on a soft absorbent sheet that is changed as soon as it is wet. Sunlight plays a role.
    • If there is associated candidal infection, leading to erythema in the folds and satellite pustules then topical anti-candidal therapy (an imidazole or nystatin) should be applied. This therapy is often combined with 1% hydrocortisone to reduce the associated inflammation. 
    • Consider differential diagnosis (see below)

    Differential diagnosis 

    • Seborrhoeic dermatitis - Non-itchy salmon pink flaky patches may appear on the face, trunk and limbs and involves skin folds. 
    • Atopic dermatitis
    • Psoriasis- sharply demarcated, non-scaly, bright erythematous plaques either isolated or similar lesions in other intertriginous areas such as the axilla etc, 
    • Perianal streptococcal cellulitis - localized well-demarcated erythema that covers a circular area 1-2 cm radius around the anus with fissuring and macerated skin.   Can present with painful defecation and/or constipation. 
    • Zinc deficiency - sharply defined, red, often extensive, anogenital rash. Look for perioral, peri-nasal and acral (hand and foot) dermatitis, alopecia, diarrhoea, and failure to thrive. 
    • Threadworms - In older children, threadworms (Enterobius vermicularis) are a common cause of an itchy anogenital rash. Look for the worms at night and treat with oral mebendazole. 
    • Langerhans' cell histiocytosis - a chronic inguinal or anogenital rash, with brownish/red scale and petechiae, which is often erosive and unresponsive to treatment. A scaly, papular, eruption on the scalp or trunk may appear. Purpura, fever, diarrhoea or hepatosplenomegaly may be present. 
    • Malabsorption syndrome - Malabsorption from any cause (e.g. cystic fibrosis) can present with diarrhoea, erosive dermatitis and failure to thrive. There may be a progressive intractable napkin rash contributed to both by the diarrhoea and by secondary nutritional deficiencies
    • Crohns disease Parent Information Sheet  (Print version - PDF)

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