See also   

Prepubescent gynaecology
Eczema

Key points

1. Effective treatment of nappy rash involves minimising skin contact with irritants and creating a barrier while skin heals
2. If nappy rash doesn’t heal with simple treatment measures, other causes must be considered

Background

• Commonly an irritant contact dermatitis
• Widespread red rash sparing the groin folds, with associated scaling, swelling, spotty areas and ulcers from broken skin
• Rash can be painful and cause infants to be unsettled

Factors which contribute to contact dermatitis:

• Moist overhydrated skin due to water in urine and stool (and frequency the nappy is changed)
• Friction between nappy and skin
• Additional irritants include soap residue, chemicals, fragrance, plant or food (eg vegetable, nut oil) products present in some nappy wipes, powders, barrier creams and moisturisers
• Pre-existing skin conditions such as eczema
• Candida albicans
• Cloth nappies can contribute as they are not as absorbent as disposable nappies

Assessment

History

• Duration and evolution of rash
• Frequency of nappy changes and type of nappies used
• Review of growth, feeding, solid intake and stool output
• Treatments previously tried
• Family history of atopy
• Past history of prematurity
• Vegan/vegetarian diet in Mother during third trimester (zinc deficiency)

Examination

• Assess rash features
• Skin: whole body including scalp for other areas of rash
• Mouth for thrush
• Weight, length and head circumference and plot over time

Differential diagnosis

• Infections
• Candida: erythema in skin folds with satellite pustules
• Impetigo
• Perianal streptococcal cellulitis: localised well-demarcated erythema around the anus with fissuring and macerated skin. Can present with itch, painful defecation and/or constipation
• Threadworms
• Viral eg hand foot and mouth, herpes simplex virus, other
• Primary skin disorders
• Eczema
• Psoriasis: sharply demarcated, non-scaly, bright erythematous plaques
• Seborrhoeic dermatitis: non-itchy salmon pink patches sometimes with greasy scale on top, found on scalp (cradle cap), face, body and skin folds
• Miliaria
• Nutritional deficiency and malabsorption
• Malabsorption: from any cause (eg lactose overload, cow’s milk protein intolerance, cystic fibrosis, inflammatory bowel disease) can present with diarrhoea, erosive dermatitis and poor growth. There may be a progressive intractable napkin rash contributed by the diarrhoea and secondary nutritional deficiencies
• Food allergy
• Zinc deficiency: sharply defined red, often extensive, anogenital rash. Look for perioral, perinasal and hand/foot dermatitis, alopecia, diarrhoea and failure to thrive
• Rarer causes:
• 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
• Immunodeficiency

Management

Investigations

• Generally, no investigations are required
• Skin swabs may be useful to confirm Candida albicans or bacterial infection

Treatment

• Consider using disposable nappies while rash is healing
• Increase frequency of nappy changing
• Use warm water ± bath oil and a soft cloth to cleanse the area after every change
• Pat gently or air dry, avoid rubbing
• Avoid soaps and bubble baths
• Apply a thick layer of barrier cream at every nappy change. Effective barrier creams contain zinc, white soft paraffin or petrolatum. Nappy rash not responding to a barrier cream with low zinc concentration may improve with switch to a higher zinc concentration (eg 40%)
• Do not remove barrier cream after each nappy change, apply another layer over the top
• Allow as much nappy free time as possible, using a soft absorbent sheet that is changed as soon as it is wet

Specific treatments

• Low potency topical steroid can be added to barrier cream regimen for nappy rash not responding to simple treatment
• Candida infection: topical anti-candidal therapy (imidazole or nystatin), often combined with 1% hydrocortisone to reduce the associated inflammation
• Topical or oral antibiotics for bacterial infections
• Treat threadworms

Consider consultation with local paediatric team when

• Rash is not improving with above treatment measures
• Concern that nappy rash is due to a cause other than irritant contact dermatitis needing investigation or treatment

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

Family aware of treatment plan and follow up is in place 

Parent information

Raising children network nappy rash
Kids health info nappy rash
RCH dermatology nappy rash also available in Vietnamese and Mandarin
Sydney children’s hospital network nappy rash

Last updated October 2020