Nappy rash

Summary

• Parental neglect may be contributory.
• It can usually be treated successfully at home.
• The best prevention is to let the baby go without a nappy as much as possible.

Definition

Nappy rash is a type of dermatitis that affects the buttocks, genitals and thighs of babies. Although this may cause the baby discomfort and pain, it is seldom serious. The condition usually lasts only a few days, but may develop into a persistent rash, which indicates a secondary skin condition or infection. The folds of the skin are usually unaffected.

When babies wear nappies constantly, this creates a hot, humid environment that may encourage continuous irritation of the skin in the groin area.

Causes

Nappy rash can be caused by anything that irritates the baby’s skin.

The following can cause irritation:

• Urine and stools left for too long in contact with the skin (the most common cause)
• Inadequate drying of the baby’s skin after a bath
• Allergic reaction to the lotions or soaps used to wash the baby’s skin
• Allergic reaction to the chemicals in the laundry detergent used to clean fabric nappies
• Thrush, a yeast (candida), may cause superinfection
• Bacterial infection, for example staph and strep, may complicate napkin dermatitis
• Antibiotics prescribed for other illnesses, because they may allow fungal growth
• Vaginal fungal infection of the mother or caregiver transmitted to the baby
• Other causes of a rash in the nappy area include atopic dermatitis (uncommon), psoriasis (uncommon) and seborrhoeic dermatitis (common)

Symptoms

The following symptoms may be present:

• Red and/or raw skin on the buttocks, genitals and thighs, but not on the abdomen
• Tight papery skin, or skin that looks shiny and bright red
• Skin that looks as if it has been burned or scalded
• Slight bleeding of the affected areas
• Strong smell of ammonia
• In boys, an inflamed penis
• Fiery red skin with scalloped borders and sharply outlined edges, appearing mainly in the folds of the skin with tiny pus-filled pimples or tiny rashes outside the red area – this may indicate a fungal nappy rash.

Prevalence

Almost all babies get nappy rash at some point.

When to see a doctor

In certain cases medical attention is needed:

• If the condition gets worse after two days of home treatment or if there is no improvement after four days of home treatment
• If there are white patches inside the mouth that appear red after being wiped with a clean cloth (an indication of thrush or candidiasis)
• If the rash is scaly, yellowing and appears not only in the diaper area, but elsewhere, such as behind the ears or under the arms (an indication of seborrhoeic dermatitis)
• If the skin in the nappy area is covered with blisters that leave shallow red sores (an indication of bacterial infection, e.g. impetigo)
• If a boy’s penis is swollen and red, if you cannot retract the foreskin, or if there is a greenish discharge from the penis (an indication of balanitis, an inflammation between the tip of the glans penis and the foreskin)
• If there is an unexplained fever (an indication of an infection)
• If redness, swelling or streaks spread beyond the area of the rash
• If there are blisters filled with yellowish fluid that break open, leaving large red areas (an indication of bacterial infection)

Preparation for a visit to the doctor

Bring the answers to the following questions along to the doctor:

• Has the baby had diarrhoea recently?
• Has the baby’s diet been changed recently?
• Have you recently changed the brand of nappy that you use?
• Have you recently changed the brand of soap that you use for washing the baby?
• Have you recently changed the brand of detergent that you use for washing the baby’s laundry?
• Is the baby currently receiving medication (prescription or non-prescription)?
• Does the baby’s family have a history of skin disorders?
• Do you or the baby’s caregiver currently have a fungal infection of the vagina?

Diagnosis

Diagnosis will be based on a medical history and a physical examination of the baby.

Treatment

Home

Nappy rash may be caused by the parents’ neglect, but home treatment will help clear up the condition:

• Change nappies frequently.
• Rinse and dry the skin in the nappy area every time the nappy is changed, using a facecloth with water and allowing air to dry the area, if possible.
• Wash the skin with a mild soap once a day.
• Protect the skin with an ointment of zinc oxide or petroleum jelly, especially if the baby has diarrhoea. Apply the ointment only to dry, unbroken skin. Do not use zinc on raw or oozing skin. Zinc oxide should be left to dry on the skin before a new nappy is put on the baby.
• Do not use baby powder or cornstarch. It may build up in the skin folds and hold moisture, providing an ideal environment for bacterial growth.
• Avoid baby wipes, because they may contain alcohol, which could burn the skin. Wipes could also spread an infection.
• Let the baby go without a nappy for as long as possible.
• A warm bath for 10 minutes, three times a day, may relieve a very raw bottom. Twenty millilitres of baking soda can be added to the water. However, do not bathe the baby before the umbilical cord has fallen off.
• Change your brand of disposable nappies, soap and detergent.
• Fold the plastic of disposable nappies away from the baby’s body and do not fasten the nappy too tightly.
• Switch to disposable nappies if you suspect that cloth nappies are the cause. Disposable nappies may be more absorbent.
• Rinse cloth nappies twice, using 10 ml of vinegar to a litre of water for the final rinse.
• Avoid using bulky or multi-layered nappies.
• Use waterproof pants only when really necessary while the baby has a rash.
• Give the baby more fluids (water or cranberry juice) to drink than you usually do, to dilute the urine.
• To prevent food allergies that might cause diarrhoea, do not add new foods to the baby’s diet until the rash has gone.

Medication

If the baby has developed a bacterial infection, the doctor may prescribe a topical or oral antibiotic. An anti-fungal cream and an oral anti-fungal liquid will be prescribed for thrush. In certain cases the doctor may prescribe a low-concentration hydrocortisone cream for seborrhoeic or atopic dermatitis. This should be used with care because it may have side effects.

Prevention

• Change nappies as soon as possible after the baby has wet or soiled them.
• If you have a fungal infection of the vagina, you must wash your hands thoroughly before handling the baby.
• Leave the nappy off as often as possible.
• Wash cloth nappies with a mild detergent and rinse twice. Do not use bleach or fabric softener.
• Avoid using waterproof pants whenever possible.
• Use zinc oxide or creams that contain zinc oxide or another ointment, such as vaseline, to protect the skin when the baby has diarrhoea.

(Reviewed by Prof H.F. Jordaan)