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References
Atherton DJ. Understanding irritant napkin dermatitis. International Journal of Dermatology. 2016; 55:(1)7-9
Baer EL, Davies MW, Easterbrook KJ. Disposable nappies for preventing napkin dermatitis in infants. Cochrane Database Systematic Review. 2006; (3) https://doi.org/10.1002/14651858.CD004262.pub2
Burdall O, Willgress L, Goad N. Neonatal skin care: developments in care to maintain neonatal barrier function and prevention of diaper dermatitis. Pediatric Dermatology. 2019; 36:(1)31-35 https://doi.org/10.1111/pde.13714
Lavender T, Furber C, Campbell M, Victor S, Roberts I, Bedwell C, Cork M. Effect on skin hydration of using baby wipes to clean the napkin area of newborn babies: assessor-blinded randomised controlled equivalence trial. BMC Paediatrics. 2012; 12:(59)12-59 https://doi.org/10.1186/1471-2431-12-59
Lawton S. Nappy rash: diagnosis and treatment. Journal of Family Health Care. 2014; 24:(5)36-40
Merrill L. Prevention, treatment and parent education for diaper dermatitis. Nursing for Women's Health. 2015; 19:(4)324-336 https://doi.org/10.1111/1751-486X.12218
Odio MR, O'Connor RJ, Sarbaugh F, Baldwin S. Continuous topical administration of a petrolatum formulation by a novel disposable diaper. Dermatology. 2000; 200:(3)238-243 https://doi.org/10.1159/000018365
Ravanfar P, Wallace JS, Pace NC. Diaper dermatitis: a review and update. Current Opinion in Pediatrics. 2012; 24:(4)472-479
Rowe J, McCall E, Kent B. Clinical effectiveness of barrier preparations in the prevention and treatment of nappy dermatitis in infants and preschool children of nappy age. International Journal Evidence Based Healthcare. 2008; 6:(1)3-23 https://doi.org/10.1111/j.1744-1609.2007.00095.x
Nappy rash affects up to 25% of nappy wearing infants and can be distressing for the infant, their family and carers. This paper focuses on the cause, prevention, diagnosis and management of nappy rash based on current evidence and guidance to provide optimum care and advice antenatally and postnatally. The aim is to shed light on assessment, diagnosis, self-management and therapeutic options to prevent, manage and treat nappy rash. Although common, nappy rash can provide diagnostic challenges. Thus, the paper will highlight further potential causes of nappy rash and when to seek further advice and guidance.
Nappy rash, also known as diaper rash, nappy dermatitis, diaper dermatitis or irritant diaper dermatitis, is one of the most common skin conditions found in infants and is an acute inflammatory reaction of the skin in the nappy area most commonly caused by an irritant contact dermatitis. There are no differences between boys, girls or ethnic groups (Merrill, 2015) and prevalence varies geographically, depending on cultural differences in the use of nappies, toilet training and skincare practices (National Institute for Health and Care Excellence [NICE] CKS, 2018). It affects up to 25% of nappy wearing infants within the first four weeks of life to as much as 100% at some point in infancy (Ravanfar et al 2012, Burdall et al 2019) with the highest prevalence between 9–12 months of age (Cohen, 2017).
Causes of nappy rash
Nappy rash can affect the lower abdomen and back, buttocks, genitalia, and inner aspects of the thighs, especially the skin in closest contact with the nappy (Rowe et al, 2008). The wearing of nappies causes an increase in skin wetness and alkalinity. The skin barrier function may be compromised by skin maceration (excessive hydration), friction between the skin and nappy, and prolonged contact with urine and faeces which increases the skin's pH. Breastfed infants have a lower stool pH than formula-fed infants which may help to prevent nappy rash (Merrill, 2015), although the evidence is limited within the UK literature and may be a potential area for future research. As infants start to eat solid foods, the stool frequency and pH start to increase, and napkin rash occurs more often (DermNetNZ, 2017).
These factors increase skin permeability and activate faecal enzymes (proteases and lipases) which further act as skin irritants. Skin irritation and alteration of the skin's pH predisposes it to colonisation and possible secondary infection with candida albicans and bacteria (most commonly staphylococcus aureus and streptococci). Other risk factors, which may aggravate or worsen the rash, include (NICE CKS, 2018):
Skincare practices: repetitive skin cleansing, inadequate skin care, and how often the area is cleaned and the nappy changed
Type of nappy used: disposable or reusable cotton
Exposure to chemical irritants: soaps, detergents and alcohol-based baby wipes
Skin trauma: friction from nappies or over-vigorous cleaning
Medications: antibiotics predispose to candida, increased stool frequency
Gestational age: preterm infants have an increased risk due to a reduced barrier function of immature skin
Underlying medical condition affecting the gut or urinary tract.
Making a diagnosis
The diagnosis should be made from the history and clinical examination. Parents should be asked questions about the location, description, duration, previous occurrences of the rash and what remedies they have tried. Following the history, the infant should be examined. If the rash is itchy or painful (usually in severe cases), the infant may be upset and agitated. The rash should typically present as well-defined areas of confluent erythema (redness) and scattered papules over convex surfaces in contact with the nappy (the buttocks, genitalia, suprapubic area and upper thighs), with sparing of the inguinal skin creases and gluteal cleft. It may have a glazed appearance if acute or fine scaling if more long-standing.
There may be skin erosions, oedema and ulceration if there is severe involvement. Investigations, such as taking skin swabs, are not normally needed to make a diagnosis of uncomplicated nappy rash but if infection is suspected, they should be taken (NICE CKS, 2018). Signs of infection should also be excluded including oral candidiasis which, if present and untreated, increases the risk of the candidal nappy rash thus presenting sharply marginated, bright red patches or plaques involving the perineum, genitalia, thighs and abdomen.
Confluent zones of papules (spots) and pustules (small blisters filled with pus) typically spread into the skin folds and there may be ‘collarettes’ of scale and satellite lesions. Bacterial infections may present with acute redness, exuding skin and papules, pustules and vesicles (blisters), folliculitis (inflamed hair follicles) and abscesses in extreme cases (NICE CKS, 2018). Viral infections may also present with a vesicular rash and viral swabs should be taken. Following the assessment, if the nappy rash is severe (see Box 1) or persistent despite treatment, there are safeguarding concerns or there is uncertainty about the diagnosis (see Box 2), the infant/child should be referred to a dermatologist (see Box 3).
Severity and symptoms
Mild nappy rash
Faint-to-definite pink rash of less than 10% of the area covered by the nappy
With or without a few scattered papules
With or without slight scaling and dryness
Unlikely to distress the infant
Moderate to-severe nappy rash
Moderate-to-severe redness covering an area greater than 10% of the area covered by the nappy
With or without papules, oedema or ulceration
More likely to be distressing
Secondarily infected with candida albicans (candidiasis)
First-line management should focus on providing practical self-management strategies (nappy use, skin care and use of barrier products) for parents and carers, and supplemented with written information and support. Within this section, the evidence to support current practice will be discussed, although many of the recommendations on self-management advice are based on expert opinion.
Nappy (diaper) use
Nappy choice is important and parents/carers should be given information to make an informed choice regarding which nappy to use. Choice will depend on issues such as convenience, cost and environmental impact. The nappy should fit properly; if too tight, it will increase skin occlusion and if too loose, it will minimise the absorption of fluids. Nappy choice is primarily based on expert opinion; disposable nappies aim to prevent over-hydration of the skin and maintain the skins pH levels (Merrill, 2015). Nappy design has improved with outer breathable backsheets which reduce the occlusive effect of the nappy (Atherton, 2016). A previous Cochrane review (Baer et al, 2006) looking specifically at the types of nappy used and their impact on the incidence of nappy rash found increased nappy rash in infants using cloth diapers versus disposable, absorbent diapers. However, the 28 studies identified were heterogeneous, methodologically flawed, with small sample sizes. Although the data within the review was indicative of the benefits of the higher absorbency products, the authors were unable to categorically conclude benefit (Baer et al, 2006). Several studies, including those reviewed in the Cochrane process, do, however, indicate that super-absorbent diapers reduce the moisture at skin level and so reduce diaper rash when compared to cloth alternatives (Burdall, 2019).
Nappy free time allows the skin to dry and nappies should be left off for as long as possible. Exposing the skin usually covered by the nappy to air reduces the time in contact with urine, faeces, moisture and other irritants. It also decreases frictional damage of the skin in contact with the nappy (Merrill, 2015).
Skin cleansing and care
Baby wipes: the skin should be cleaned using water or fragrance-free and alcohol-free baby wipes, and nappies changed every 3–4 hours, or as soon as possible after wetting or soiling, to reduce skin exposure to urine and faeces. Baby wipes have an acidic pH which may buffer alkaline urine and restore normal skin pH, reducing the irritant effect of urine on the skin (Atherton, 2016). The skin should be dried gently after cleaning and not rubbed vigorously. Studies have shown that using alcohol- and fragrance-free baby wipes in healthy infants results in less erythema and surface roughness compared with using water with a cotton washcloth or cotton wool balls (Visscher, 2009). A further study concluded that wipes had an equivalent effect on skin hydration when compared to cotton wool and water (Lavender et al, 2012). To date, there is a lack of data supporting the superiority of wipes over water or vice versa but neither method seems to be associated with a higher incidence of nappy rash (Burdall, 2019)
Bathing and products used on the skin: infants can be bathed daily, although 2–3 times a week is generally recommended as excessive bathing may dry the skin excessively (Scanlan, 2018). Soap, bubble bath, lotions and talcum powder should not be used as they can irritate the skin. Soap and detergents may raise the skin pH in infants which can compromise the barrier function of the epidermis and should not contain sodium lauryl sulphate (Scanlan, 2018). Talcum powder may cause irritant contact dermatitis and worsen the nappy rash (Ness, 2013)
Barrier preparations: should be used to protect the skin if there is mild erythema and the infant is asymptomatic. They are readily available to buy over-the-counter and should be applied thinly at each nappy change. Examples include zinc and castor oil ointment BP, Metanium ointment, and white, soft paraffin BP ointment. Barrier preparations provide a protective lipid film that reduces skin contact with faeces and urine, reduces humidity and minimises transepidermal water loss which reduces potential skin irritation and maceration. There is no evidence that one product is better than the other (Merrill, 2015) although one review article noted that preservative-free zinc oxide ointment and petroleum-based ointments are safe and inexpensive options. Ointments are generally more effective than creams and lotions as they provide a better moisture barrier (Ness, 2013). The recommendation to apply the barrier preparation as a thin layer is based on the fact that applying a moist layer too thickly may cause water retention and worsen any skin maceration (NICE CKS, 2018).
Topical corticosteroids: this can be used if the rash is inflamed and causing discomfort for children over one month of age. One percent hydrocortisone cream can be applied daily until symptoms settle and for a maximum of seven days as the occlusive effect of nappies may increase the risk of skin penetration and potency of corticosteroids, and increase the risk of adverse effects such as skin atrophy (Merrill, 2015).
Midwives need to be aware of the causes of nappy rash in order to better advise on treatment methods
Treating infections
Candidal infection: expert opinion within the NICE guidelines (2018) states that if the rash fails to respond to standard treatment, persists for more than three days or a candidal infection is suspected, or confirmed from a swab, it should be treated with a prescribed topical imidazole cream: clotrimazole, econazole or miconazole. Further information on the frequency and duration of treatment is available within the NICE guidelines (2018) and there is no evidence comparing the effectiveness of different topical imidazole preparations for the management of nappy rash (NICE CKS, 2018). Parents/carers should be advised not to use barrier preparations until the infection has settled. This is based on limited evidence and expert advice which suggests that the nappy rash may deteriorate if barrier products are used before the candida infection is treated (NICE CKS, 2018)
Bacterial infection: if the rash persists and a bacterial infection is suspected or confirmed from a swab, oral flucloxacillin should be prescribed for seven days. If the infant is allergic to penicillin, oral clarithromycin should be prescribed for seven days. Antibiotic choice may be adjusted if indicated from swab results. Topical antibiotics are not recommended as they may cause irritant contact dermatitis and worsen the rash (Merrill, 2015).
Review
Following the initiation of a management plan, a review should be undertaken to assess the response to treatment with the time interval based on clinical judgment. If symptoms are not settling, consider and, if possible, manage any underlying cause of treatment failure which may include looking at non-adherence to the self-care advice or treatment regimen.
Consider an alternative cause for the rash (see Box 2), such as an immunocompromised host. Also consider taking skin swabs if an infection is being treated or suspected for sensitivity and manage accordingly. If the rash persists following treatment for secondary infection, adjust the choice of topical imidazole or oral antibiotic if indicated and advice might be needed from a microbiologist. Finally, consider referral to a paediatric dermatologist if the rash persists despite optimal treatment in primary care (see Box 3).
Conclusion
Nappy rash can be distressing for infants and their families, and can provide challenges for midwives and healthcare professionals if the nappy rash is severe and complex. Midwives and healthcare professionals should be aware of rare causes of nappy rash, intervening and referring on if simple measures fail to improve outcomes. However, midwives are in a privileged position to provide advice and answer questions relating to skin and nappy care antenatally and postnatally, especially with the ever-increasing array of products available.
Key points
Nappy rash is one of the most common skin conditions found in infants
Skincare practices and products, such as soap, bubble bath, lotions and talcum powder, used in the nappy area have the potential to cause skin damage
Midwives should be aware of the self-management strategies in order to practically advise families and carers
Midwives and other healthcare professionals need to be knowledgeable about the identification of and treatment options for nappy rash and differential diagnosis
