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Nappy rash: prevention and cure

Key learning points:

 - Types of nappy rash

 - Advising on appropriate treatment

 - Preventing nappy rash

Many parents and health professionals are unaware that there is more than one type of nappy rash. Awareness needs to be raised of these differences so appropriate treatment and advice can be given.

Research has shown that a baby's skin is between 20-30% thinner than that of an adult's skin.1 A baby's skin continues to mature for at least another year after birth and it is during this time that a baby is most prone to getting nappy rash.2 It is generally the irritants from direct contact with the urine and faeces in the nappies that causes a baby's skin to break down and become sore and sometimes become infected. It is often during teething or weaning that a baby can become more prone to nappy rash, or when a baby is suffering from diarrhoea.3 There is a body of opinion and research that suggests regular use of a barrier cream reduces the chances of normal nappy rash.4 However, it is essential that a distinction is made between normal nappy rash, and when further intervention is required as a result of the nappy rash getting worse.

Types of nappy rash

Mild

'Normal' nappy rash is when the skin looks red and sore and can almost appear shiny, and the baby feels generally well. It occurs when the skin on the bottom has been in contact with a dirty nappy for a prolonged period.5 A bout of diarrhoea can make a baby more prone to nappy rash because the loose faeces is spread over a wider area and are more liquid than usual.5 

It is the combination of urine and faeces which causes the most irritation. Urine contains a chemical called ammonia and it is this that irritates the baby's skin making it inflamed. Mild nappy rash should disappear after a few days of following a good skin care routine of 'clean, dry and apply'. By ensuring the skin is kept clean and dry and then applying a barrier cream, the nappy rash can disappear overnight in some cases, but may take up to three or four days. However, if the rash doesn't go within a week or develops further, it may develop into another form of nappy rash and medical advice should be sought. The health visitor or GP may prescribe hydrocortisone or antifungal cream, or antibiotics, depending on the cause of the nappy rash.6

To protect the red skin, you can use a zinc paste or barrier cream which will form a protective surface over the skin. Weak hydrocortisone creams such as Dermacort can be used for severe cases, but will need to be prescribed by the GP if deemed necessary. This would need to be applied thinly once a day over the sore area and can be discontinued once the rash has disappeared. It is important to note that it must never be used for more than seven days in a row.

Fungal

A fungal nappy rash is a form of thrush, so treatment is often an anti-fungal cream which the GP will need to prescribe such as Miconazole, Clotrimazole or Nystatin creams. This should be applied thinly to the affected area. The fungal rash shows as tiny bright red spots and the genitals can appear swollen, and can sometimes occur if your baby is on antibiotics. It is important that, if the nappy rash is fungal, you avoid barrier creams, as this can make the condition worse.6 Fungal nappy rash may take up to five to seven days to improve after treatment with the antifungal cream.

The usual advice of frequent nappy changes and exposing the area to air is also not enough at this stage, so again the baby will need appropriate referral for the correct treatment.

Bacterial

A bacterial nappy rash shows as infected spots or pimples and the baby is likely to have a fever and be very unsettled and uncomfortable. It can develop from a normal nappy rash when the skin has broken and an infection has developed because of bacteria entering the broken skin. This type of nappy rash may well need antibiotics and should be referred to the GP for treatment advice and monitoring as soon as possible. Bacterial nappy rash can take longer to get better and may take seven to 10 days of antibiotic treatment 

Prevention of nappy rash

To prevent nappy rash from developing in the first place, parents or carers should be advised to always clean the area thoroughly with warm water and dry the area well after each nappy change. A thin layer of barrier cream should then be applied to help avoid nappy rash occurring - 'clean, dry and apply'. 

The baby should also be allowed some 'nappy-free time'. Babies should have as much nappy-free time as possible, as it is wearing a nappy that causes the problem in the first place.

Nappies should also be changed as soon as possible after soiling to limit the amount of contact with the skin.

Treatment of nappy rash 

 - A baby left in a dirty nappy for too long is more likely to develop nappy rash,6 so regular changes as soon as possible after the baby has soiled their nappy is vital, as this will stop the chemicals in the urine and faeces aggravating the skin. However, the condition can also strike the bottoms of babies with particularly sensitive skin, even if they have frequent, fresh nappies. 

 - Nappy-free time is also important for treating active nappy rash, and babies should have as much time as possible out of their nappy.

 - Advise parents of babies with nappy rash to stop using any soaps, detergents or bubble bath that could be irritating your baby's skin.

 - If faeces is stuck on, try a small amount of oil to remove it so as not to damage the skin 

 - Avoid using talcum powder as this can make nappy rash worse, as it blocks the pores in the skin causing friction and irritating the skin.

 - Avoid tight fitting plastic pants over nappies, as this can keep in moisture and encourage a normal rash to develop into a fungal nappy rash.

 - Fasten nappies loosely enough so that there's room for air to circulate round the nappy area.6,7

Types of nappies

Deciding which types of nappy is best for their baby is a dilemma many parents have. The best advice is if using cloth nappies, try changing to disposable nappies as they often absorb more fluid from the baby's skin, so leaving less contact of the urine with the skin. Conversely if using disposable nappies, try switching to cloth nappies. Sometimes changing to another type of nappy will help. 

The main objective however is to change the nappy as soon as possible after the baby has soiled to avoid the contact of the chemicals with the skin that cause nappy rash.

Conclusion 

In summary, prevention of nappy rash is obviously better than cure. Giving advice to parents about how to prevent nappy rash and how it can potentially develop if left untreated enables parents to be empowered with the knowledge of identifying the different types of nappy rash and when to seek medical advice. 

Occasionally, other things can cause nappy rash such as an allergic reaction to a product that the baby's skin has come into contact with that has touched his or her skin. This is called allergic dermatitis, but it is quite rare. Also babies who have eczema are sometimes more prone to developing nappy rash, so nappy rash in these babies should be monitored carefully to avoid it developing into a bacterial nappy rash through breaks in the skin.

Finally always remember to inform parents and carers to wash their hands before and after changing the nappy, to avoid introducing any new infection to the nappy area, and also to ensure that any infection is not passed to others.

References

1. Stamatas GN, Nikolovski J, Luedtke MA, et al. Infant skin microstructure assessed in vivo differs from adult skin in organization and at a cellular level. Paediatric Dermatology 2010;27(2):125-31.

2.  Nikolovski J, et al. Barrier function and water holding and transport properties of infant stratum corneumare different from adult and continue to develop through the first year of life. J Invest Dermatol 2008;1728-1736.

3.  Benjamin L. Clinical correlates with diaper dermatitis. Paediatrician 1987;14(suppl 1):21-6.

4.  Cork M, Vernon P, Protecting the infant skin barrier: advantages an insights. Paediatric News. Sept 2010.

5.  Dib R, Kazzi AA. Diaper rash. 2012. eMedicine. Available at: emedicine.medscape.com. 

6.  NICE. Clinical Knowledge Summaries. Nappy rash. Available at:. www.cks.nhs.uk. 

7. NHS. Nappies. NHS Choices, Health A-Z. 2011. Available at: www.nhs.uk.