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Nappy rash: not such a minor problem for babies

Mark Jones
MSc BSc(Hons)Nurs RN RHV
Primary Care Policy and Practice Adviser
Royal College of Nursing
London

At some point during their life in nappies most babies will suffer a nappy rash.(1) A baby's skin does not reach full thickness until around three years of age. Until then it is delicate and is particularly vulnerable to irritation from ammonia produced by stale urine.

Mild onset of nappy rash usually presents as a slight redness around the genitalia and bottom. Left untreated this progresses to a brighter red spotty appearance with the skin becoming moist and broken. Further progression involves secondary infection, usually from Candida albicans (thrush), although other organisms may be involved.

Treatment options range from simple palliative advice through to use of medication. The first option for mild inflammation is to advise parents to leave their child's nappy off wherever possible, allowing air to get to the skin. A barrier cream is advisable until the irritation subsides, and one with a mild antiseptic property might be advisable. Generic zinc oxide cream should suffice, although several proprietary versions are available dependent on parental choice. If the rash does not subside it is likely that candida has become involved.

Although some parental information sources directly equate thrush infection with their definition of nappy rash, candida is an opportunistic infection acquired as a result of the environment that first led to the initial rash. Some estimates put the rate of secondary infection with thrush as high as 75%,(2) and telltale signs of candida include a cluster-type rash with red spots around a clearly delineated margin of the main red area. In an ideal world, confirmation of the presence of candida would be made before treatment, but given the logistics of taking a swab and arranging for microscopy in each case, it is reasonable to turn to appropriate medication based on a visual diagnosis.

A topical antifungal cream of 1% clotrimazole is the preferred option; again generic and proprietary options are available. Dependent upon the degree of inflammation, a preparation combining clotrimazole with 1% hydrocortisone may be used.

Nurse prescribers have access to a range of topical antifungals and corticosteroid/antifungal combinations; otherwise parents can be directed to a community pharmacist for advice and supply, as these effective preparations are available as over-the-counter medicines.

Should antifungal treatment prove ineffective or a persistent nappy rash not exhibit the characteristics of fungal involvement, bacterial infection might be present. This is likely to be as a result of Staphylococcus aureus, and treatment with an appropriate oral antibiotic is the treatment of choice once the organism has been identified.

There is strong debate as to whether the move to disposable nappies has led to an increase in nappy rash, but the use of cloth nappies clad in a waterproof reuseable covering is just as likely to provide the environment needed for irritation and inflammation to develop. Parents should be encouraged to use a nappy option that best suits their child and should frequently change any nappy to minimise nappy rash.

Although nappy rash can progress to a quite serious condition, its presentation is generally mild and can be prevented by advising parents to take a few precautions, all of which are intended to eliminate the warm, potentially irritant environment within the nappy:(1,3,4)

  • Encourage parents to think of the nappy as a means of stopping bedding and clothes becoming wet or soiled, not as a means of allowing ­maximum time between changes.
  • Change the baby's nappy often (ideally as soon as possible after each soiling).
  • Keep the baby's skin clean and dry. If soap is used, rinse carefully to minimise drying the skin.
  • Use a barrier cream sparingly if the baby is ­particularly susceptible to nappy rash. It is usually enough to leave the skin clean and dry. Be aware that some babies may be sensitive to the creams themselves, leading to redness and irritation.
  • Avoid disposable wipes containing alcohol or moisturising chemicals.
  • Make sure the room is warm enough, and leave the baby without a nappy on the changing mat for a while so that the skin gets some fresh air.

Educating parents about basic hygiene and the appropriate use of treatment can easily keep nappy rash to a minimum.

References

  1. RCGP. FactSheet 6: Nappy rash. London: RCGP; 1996.
  2. Bayer. Nappy rash. Available from URL: http:// www.canesten.co.uk
  3. Medinfo Nappy rash Available from: URL:http://www.medinfo.co.uk/
    conditions/nappyrash.html
  4. NHS Direct.Nappy rash.Available from URL: http://www.healthcareguide.nhsdirect.nhs.uk/
    conditions/npyrsh