Nappy rash

Question 1

What is nappy rash?
Cause?

Answer 1

Nappy rash is contact dermatitis in the nappy area. It is usually caused by friction between the skin and nappy and contact with urine and faeces in a dirty nappy. Most babies will get nappy rash at some point, and it is most common between 9 and 12 months of age. Additionally, the breakdown in skin and the warm moist environment in the nappy can lead to added infection with candida (fungus) or bacteria, usually staphylococcus or streptococcus.

Question 2

Risk factors?

Answer 2

Delayed changing of nappies
Irritant soap products and vigorous cleaning
Certain types of nappies (poorly absorbent ones)
Diarrhoea
Oral antibiotics predispose to candida infection
Pre-term infants

Question 3

Presentation?

Answer 3

Nappy rash present with sore, red, inflamed skin in the nappy area. The rash appears in individual patches on exposure areas of the skin that come in contact with the nappy. It tends to spare the skin creases, meaning the creases in the groin are healthy. There may be a few red papules beside the affected areas of skin. Nappy rash is uncomfortable, may be itchy and the infant may be distressed. Severe and longstanding nappy rash can lead to erosions and ulceration.

Question 4

Nappy rash vs candida

Answer 4

Candida in the nappy area (thrush) is a common finding. Signs that would point to a candidal infection rather than simple nappy rash are:

Rash extending into the skin folds
Larger red macules
Well demarcated scaly border
Circular pattern to the rash spreading outwards, similar to ringworm
Satellite lesions, which are small similar patches of rash or pustules near the main rash

Check for oral thrush with a white coating on the tongue, as this is likely to indicate a fungal infection in the nappy area.

Question 5

Management?

Answer 5

Simple measures can be taken to improve skin health and treat nappy rash within a few days:

Switching to highly absorbent nappies (disposable gel matrix nappies)
Change the nappy and clean the skin as soon as possible after wetting or soiling
Use water or gentle alcohol free products for cleaning the nappy area
Ensure the nappy area is dry before replacing the nappy
Maximise time not wearing a nappy

Infection with candida or bacteria warrants treatment with an anti-fungal cream (clotrimazole or miconazole) or antibiotic (fusidic acid cream or oral flucloxacillin).

Question 6

Complications?

Answer 6

Candida infection
Cellulitis
Jacquet’s erosive diaper dermatitis
Perianal pseudoverrucous papules and nodules