Skin disease in a child: Nappy rash Flashcards
Define nappy rash.
Nappy rash is inflammation of the skin in the area of the body covered by a nappy. It is primarily an irritant contact dermatitis. The main irritants are urine, faeces, and faecal enzymes, which lead to skin breakdown, typically of the perineum and convex surfaces of the buttocks, with sparing of the skin folds.
Explain the general aetiology of nappy rash.
Most likely due to irritant contact dermatitis. The key irritants are moisture from urine and faeces as well as faecal enzymes (urease, proteases and lipases). Other potential irritants include nappy compotnents, friction produced by nappies themselves, carer’s repeated wiping of the area, or application of baby care products. Components of disposable nappies that have been implicated as potential antigenic triggers include dyes, fragrances, rubber, glue, and other chemicals used in the manufacturing process. Preservatives found in toilet tissues can also be sensitises.
Explain the infectious aetiology of nappy rash.
Infections can exacerbate or cause nappy rash. The main infectious atetiologies include:
- Candida albicans
- Staphylococcus aureus
- Enteric organisms
- Coxsackie virus
- HSV and HIV
- Parasites such as pinworms and scabies
- Fungi leading to tinea corporis
What are other causes of nappy rash?
Underlying dermatological disorders, such as allergic contact dermatitis, seborrheic dermatitis, psoriasis, granuloma gluteale infantum, lichen sclerosis, and infantile granular parakeratosis, are associated with the development of nappy rash.
Unusual aetiologies include nutritional deficiencies, cystic fibrosis, urea cycle defects, immunodeficiencies, and histiocytosis.
Summarise the epidemiology of nappy rash.
The majority of newborns display some skin breakdown in the nappy area by 1 week of age, with increasing severity by 3 weeks. Nappy rash most commonly occurs in first year of life, but can occur up to 2 years of age as this is the most common time for wearing nappies. Approximately half of all children will have rash at some time during years of nappywearing.
What are presenting symptoms of nappy rash?
There will often be a history of poor nappy-changing practice. This can involve the patient being infrequently changed, use of baby care products without checks for minimal additives, excess friction on cleaning, strong detergents used on cleaning, no nappy-free time, and the use of plastic underpants. The patient will often be young (<2 years), as younger children urinate more frequently.
A history of diarrhoea and recent antibiotic exposure may be present (use of antibiotics increases the likelihood of diarrhoea, which in turn means more frequent stools and more time spent in soiled nappies). The patient’s carer may also describe fussiness or irritability in the child with voiding, bowel movements, or nappy changes, due to pain from the nappy rash.
What are signs of nappy rash?
Child’s carer generally reports acute onset of erythema and skin breakdown in the area of the body covered by a nappy. Examination typically reveals erythema on the convex surfaces of the pubic area and buttocks with sparing of the skin folds.
What are appropriate investigations for nappy rash?
- Postassium hydroxide test of skin scraping: Positive results show pseudohyphae in yeast infection. Not routinely done since yeast infections are typically diagnosed by history and clinical presenation. Consider in treatment failure cases.
- Bacterial culture of skin
- Fungal culture of skin
- FBC
- Serum Zinc level
What is the management for nappy rash?
Topical barrier and good nappy practice
Topical antifungal therapy
Low-potency topical corticosteroids
Referral to dermatologist
What are complications associated with nappy rash?
Prone to infections.
What is the prognosis of nappy rash?
Irritant contact nappy dermatitis typically resolves within 1 week.
May take 10 days to 3 weeks to resolve.
