What is diaper rash?

Diaper rash is a generalized term indicating any skin irritation (regardless of cause) that develops in the diaper-covered region. Synonyms include diaper dermatitis (dermatitis = inflammation of the skin), napkin (or "nappy") dermatitis and ammonia dermatitis. While there are a several broad categories of causes of diaper rash, contact irritation is the most common culprit. While diaper rash is generally thought to affect infants and toddlers, any individual wearing a diaper (for example, an incontinent adult) is a candidate to develop this dermatitis.

Is diaper rash a sign of neglectful care?

No, not at all. Parents often incorrectly feel that the rash is a visual representation of poor caretaking skills. However, parents need to understand that the basic causes for this common kind of skin irritation are still under active debate in the field of dermatology and that neglectful parenting is not among the possible factors. In the United States, diaper dermatitis represents about 10%-20% of all skin disorders managed by a general pediatrician. While the rash may develop as early as the first week of life, the most frequent time period is between 9 and 12 months of age. Studies have indicated that, at any point in time, between 7%-35% of children in this age range are experiencing such a skin rash.

What causes diaper rash?

There are several categories of causes for this dermatitis. First and foremost is "irritant" or "contact" dermatitis. Skin involvement may vary from mild redness (similar in character to a sunburn) to erosion of the top layers of skin. A characteristic differential point of contract diaper dermatitis from other causes of diaper rash is that it rarely involves the skin fold regions -- therefore, it spares areas not in contact with urine/stool.

Skin infections compose the next most common category of diaper rash. Bacteria (Staph and Strep) and yeast/fungal (Candida) are common causes of diaper rash. Generally both of these types of infections tend to result from a disruption of skin integrity and overwhelming the natural defense mechanisms of skin in this diaper region. Staph and Strep bacterial infections are commonly termed impetigo. Classic descriptions of impetigo include small (1-2 mm) tiny blisters (vesicles) and pustules that tend to easily rupture leaving multiple erosions in a sea of generalized skin irritation. Candida diaper dermatitis also has several distinguishing patterns. The rash is characterized by zones of bright red skin with a series of discrete 2-4 mm "satellite" lesions at the borders of the confluent irritated skin. In contrast to contact dermatitis, Candida is generally only found in the skin folds creases and often around the anal region. Infectious causes of diaper dermatitis can generally be diagnosed by visual inspection alone. If confusion exists, laboratory studies of swabs of the involved areas may be obtained.

Allergic reactions are a less common cause of diaper rash. Commonly proposed allergens are fragrances and components of the diaper and wipes. These regions often have well-defined zones of redness with superficial vesicles and erosions. If the diagnosis of allergic skin reaction is suspect, skin-patch testing may be done to identify the offending agent. This is rarely necessary.

There are very rare causes of diaper rash. Unusual infections, metabolic and nutritional deficiency states, and immunodeficiency states and malignancies can all be implicated. Unfortunately, child abuse (hot-water immersion, extreme neglect to infant hygiene) can also present as diaper rash.

Less often, allergic reactions to the fragrances or other components found in disposable diapers or wipes can cause diaper rash.

What treatments are recommended for diaper rash?

The best treatment for diaper rash is avoidance of the precipitating agents which led to the contact irritation and to regions becoming secondarily infected by skin bacteria or yeast. Frequent diaper changes limit stool and urine exposure to the area and remain the foundation for prevention and management of diaper dermatitis.

Should a rash develop, simple cleansing with water and soft cloths tends to be less irritating to the injured skin than disposable wipes. Frequent application of one of the many diaper-area ointments containing either petroleum jelly (Vaseline) or zinc oxide (Desitin) provides an effective barrier against skin irritants and lessen friction to irritated skin. If the diaper rash is especially irritated by the rubbing necessary for proper hygiene, then using a non-sticky cream or ointment (such as Vaseline) as a barrier may be an important consideration. If sticky stool hinders hygiene, it may be more easily removed after application of mineral oil to the area. Most pediatricians find no benefit to using cornstarch or talcum power. The risk of possible aspiration of these powders underscores their general lack of significant efficacy. High-concentration baking soda or boric-acid baths are to be avoided due to possibility of toxicity associated with an increased rate of absorption due to skin breakdown.

Weather and/or carpet permitting, open-air exposure of the irritated skin is also extremely effective in helping clear up diaper rash. Many children have a therapeutic response to merely sitting in a warm-water bath twice daily for 15-20 minutes per session. The value of additional agents (including baking soda) is debatable.

Should these measures not provide a solid response within two to three days, the possibility of a secondary bacterial or yeast infection must be considered. The diaper region should be examined by a pediatrician unless the parent is confident in correctly making these diagnoses. Several topical antibiotic ointments are available for therapy in these situations.

How about not using disposable diapers?

Parents often wonder if switching from disposable to cloth diapers will lessen the likelihood of contact type diaper rash. In fact, the opposite seems to be true. The absorbent gel material found in most of today's disposable diapers draws moisture away from the skin area, thus helping to promote a healthy diaper area.

How should an allergic rash be treated?

For an allergic reaction to the fragrances or other components found in disposable diapers or wipes, eliminating the offending agents by using either simple water cleansing of the skin and a switch to another brand of disposable diapers or using cloth diapers instead is usually therapeutic.

How about using cortisone cream?

A minimally concentrated hydrocortisone cream may be recommended in certain cases. However, the excessive usage of minimally concentrated hydrocortisone cream and the use of increased potency hydrocortisone preparations are notorious for causing secondary side effects. They should only be used under the guidance of a pediatrician or another physician who is fully familiar with their application to infants.

How about using Neosporin?

This ointment (and others containing the topical antibiotic neomycin) should be avoided since neomycin is a very common allergen promoting an allergic skin reaction. Instead of helping the situation, such a medication may complicate and confuse the situation.

Diaper Rash At A Glance

• Diaper rash is very common in babies and is not a sign of parental neglect.
• Diaper rash is most commonly a kind of contact dermatitis.
• Diaper rash may become secondarily infected by bacteria or yeast normally present on the skin. In this case, topical antibiotic ointments provide a rapid and effective therapy.
• Avoidance of skin irritants by frequent diaper changing provides the number-one preventative measure.
• Effective treatments include frequent diaper changes, application of topical barriers (for example, petroleum jelly), and rarely topical antibiotic/antifungal ointments, or low-potency hydrocortisone cream. High-potency steroid creams, powders, and concentrated baking-soda/boric-acid baths and neomycin-containing ointments are to be avoided.

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