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Nappy Rash

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Overview

Also known as ‘napkin rash’, ‘napkin dermatitis’, ‘diaper rash’, and ‘diaper dermatitis’, nappy rash is an acute inflammatory reaction of the skin in the nappy area. It is generally considered to be a form of irritant contact dermatitis.

Skin barrier compromise can occur due to maceration (exposure of the skin to moisture for a prolonged time leading to softness and breakdown) friction, prolonged skin contact with faeces and urine, and changes in skin pH.

Secondary infection with Candida, Staphylococcus aureus, and Streptococci species may occur.

Epidemiology

  • Nappy rash is estimated to affect 1 in 4 nappy-wearing infants at any given time
  • Prevalence is highest between 9-12 months of age

Risk Factors

  • Infrequent nappy changing/skin cleaning – prolonged skin contact with urine and faeces
  • Type of nappy used – disposable/reusable cotton nappies
  • Chemical irritants – such as soaps, detergents, and some baby wipes
  • Skin trauma – such as friction due to over-vigorous cleaning
  • Medication – recent broad-spectrum antibiotics can predispose to Candida colonisation
  • Prematurity – due to immature skin
  • Cause of diarrhoea

Differential Diagnoses

Overview

Nappy rash can have multiple underlying causes. The appearance, timeframe, and presence of any triggers can help with identifying the underlying cause. Rashes can be due to:

Irritant contact dermatitis is the most common cause:

  • Due to prolonged exposure to faeces and urine
  • Well-defined erythema with or without papules over surfaces in contact with the nappy (buttocks, genitalia, suprapubic area, and upper thighs)
  • The skin creases and gluteal cleft are characteristically spared

Secondary infection may be likely if the rash is persisting with skincare measures. Examples include:

  • Candida infection:
    • Erythematous patches or plaques around the perianal skin with sharp edges
    • The rash tends to affect skin folds
    • There may be scale and satellite lesions (which appear as small isolated dots)
    • Oral candidiasis may also be present
  • Bacterial infection:
    • Marked erythematous rash with exudate
    • There may be papules, pustules, blisters, and folliculitis
    • Abscesses may be present if severe

Underlying dermatological disorders may be likely:

  • Allergic contact dermatitis:
    • May present similarly to irritant contact dermatitis
    • Specific brands of nappy or skincare products may lead to symptoms that usually emerge 24-72 hours after exposure. However, this may be hard to identify without skin patch testing in secondary care.
  • Atopic dermatitis (atopic eczema):
    • There is associated itchiness and other areas of the skin are usually affected
    • There may be a family history of atopy (e.g. atopic eczema, hayfever, allergic asthma)
  • Psoriasis:
    • Silvery, scaly rashes are usually seen and are typically present elsewhere on the skin
  • Seborrhoeic dermatitis:
    • The rash is erythematous and has yellow scales with flaking
    • There may be an associated scalp rash ‘cradle cap’ 

Diagnosis

The diagnosis of uncomplicated nappy rash is clinical. Consider skin swabs for culture and sensitivity if a secondary bacterial infection is suspected, especially if the nappy rash is severe.

Management

Overview

Management involves:

  • Advising parents on using nappies with high absorbency, changing nappies as soon as possible after soiling, using disposable nappies instead of towel nappies, using baby wipes that are free from perfumes, alcohol etc., and avoiding irritants such as soaps etc.
  • Prescribing:
    • Topical hydrocortisone if the rash is inflamed and causing discomfort
    • Topical imidazole if the rash persists and Candida infection is suspected
    • Oral antibiotics if the rash persists and bacterial infection is suspected/confirmed on swab (flucloxacillin or clarithromycin if penicillin-allergic)

Referral

Refer to a paediatric dermatologist if any of the following apply:

  • Diagnostic uncertainty
  • The rash persists despite optimal treatment in primary care
  • Recurrent, severe, unexplained episodes 

Complications

  • Secondary Candida infection
  • Secondary bacterial infection – usually Staphylococcus aureus or Streptococcus species (e.g. Streptococcus pyogenes)
  • Jacquet’s erosive diaper dermatitis – punched-out ulcers/erosions with elevated borders
  • Granuloma gluteale infantum – 0.5 – 4cm asymptomatic cherry-red plaques and nodules:
    • Rare and usually resolve within 1-2 months and may leave a scar

Prognosis

  • Uncomplicated nappy rash usually settles within around 3 days

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