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Advising parents on how to treat nappy rash

David Haslam
FRCGP GP
Ramsey, Cambs
Visiting Professor
Primary Health Care
DeMontfort University
Leicester
Chairman Elect
RCGP

Nappy rash can vary from a very mild redness to a severely inflamed and dreadfully sore area of redness extending over the whole of the baby's bottom, with spots, blister and broken skin. In nappy rash caused by candida, the fungus commonly known as thrush, there can be a white discharge and areas of redness away from the main rash. These are known as satellite lesions. A rash in the nappy area may also be caused by irritation of a pre-existing skin condition such as eczema, which is important to remember when advising parents and assessing children.

Causes
Dry bottoms rarely develop nappy rash. This is because the main cause of this condition is wetness of the skin that becomes irritated by the ammonia produced by stale urine. This then has the effect of breaking down the protective barrier normally formed by the skin, causing redness and rawness and allowing bacteria to progress to superinfection. The longer that wet or soiled nappies are left in contact with the baby's skin, the more likely it is for nappy rash to develop.

Treatment
When advising parents, there are a few rules that can make all the difference.

Keep the area dry
Fungal infections thrive on warmth and moisture, so the drier the napkin area stays, the better. Keeping the area clean and dry is by far the most important way of preventing nappy rash. The more air to which the skin is exposed, the less the rash will develop and spread. Leaving nappies off can be ideal, although probably not for the carpets.

Thrush-infected rashes
If the rash looks like it could be infected with thrush then this will almost certainly need treatment with an antifungal cream, obtained either from a GP on prescription or purchased from a pharmacist.

Detergent residue
If terry nappies are used, a one-way nappy liner may help to keep the skin dry. In addition, if terry nappies are not thoroughly rinsed, the detergent or softener may remain in the towelling even after a full wash cycle. Babies with sensitive skin may react to even minute amounts of these chemicals, especially if they contain a "biological" additive.

Elastic reactions
On rare occasions babies may react to the elastic at the waist and legs of disposable nappies or to other components.

Avoid irritants
Advise parents to avoid baby wipes and other chemicals for cleaning their baby's bottoms, unless simple cotton wool and water is not available. The fewer irritants applied, the better.

Steroid creams
If the skin is very inflamed, or there is evidence of eczema, then steroid-containing creams may be required. The parent should consult their GP for assessment and treatment.