Diaper rash



Definition

Dermatitis of the buttocks, genitals, lower abdomen, or thigh folds of an infant or toddler is called diaper rash. The outside layer of skin normally forms a protective barrier that prevents infection; when the barrier fails, the child may develop a rash in the area covered by the diaper. Diaper rashes occur equally with cloth diapers and disposable diapers.

Description

Diaper dermatitis results from prolonged contact with irritants such as moisture, chemical substances, and friction. Urine ammonia, formed from the breakdown of urea by fecal bacteria, is irritating to sensitive infant skin. Ammonia by itself does not cause skin breakdown. Only skin damaged by infrequent diaper changes and constant urine and feces contact is prone to damage from ammonia in urine. Inadequate fluid intake, heat, and detergents in diapers aggravate the condition. Bouts of diarrhea can quickly cause rashes in most children. Diaper rash begins with erythema in the perianal region. Left untreated, the area can quickly excoriate and progress to macules and papules, which form erosions and crust. Under certain circumstances (in infants under the age of six months, toddlers who have been on antibiotics , and immune compromised children) diaper dermatitis may become secondarily infected with Candida ablicans. Sometimes severe diaper dermatitis becomes super-infected with bacteria (streptococci or staphylococci).

Demographics

Diaper rashes occur in the diaper-wearing age group (birth to three years of age). Diaper rash occurs in about 10 percent of infants and is most common between the ages of seven and nine months. Some infants seem predisposed to diaper dermatitis. These infants have such sensitive skin that diaper dermatitis is a problem from the first few days of life.

Baby with severe diaper rash. ( Custom Medical Stock Photo, Inc.)
Baby with severe diaper rash.
(© Custom Medical Stock Photo, Inc.)

Causes and symptoms

When parents and caretakers do not change the children's diapers often, feces is in contact with skin and irritation develops in the perianal area. Urine left in diapers too long breaks down into ammonia, a chemical that is irritating to infant skin. Ammonia dermatitis of this type is a problem in the second half of the first year of life when the infant is producing a larger quantity of urine.

When the diaper area has prolonged skin contact with wetness the natural oils are stripped away, the outer layer of skin is damaged, and there is increased susceptibility to infection by bacteria or yeast.

Frequently a flat, red rash resulting from chafing of the diaper against tender skin causes friction rash. This rash is not in the skin folds. It may be more definite around the edges of the diaper, at the waist and leg bands. The baby does not seem to experience much discomfort.

Sometimes chemicals in detergents contribute to contact dermatitis . These rashes should clear up as soon as the chemicals are removed. Ignoring the condition may lead to a secondary infection that is more difficult to resolve.

Another infectious cause of diaper rash is impetigo . This bacterial infection is characterized by blisters that ooze and crust.

When to call the doctor

Parents should call the child's healthcare provider for the following reason:

  • newborn with rash looks or acts sick or has a fever
  • rash looks infected (pimples, blisters, boils, weeping sores, yellow crusts, red streaks)
  • rash is not better in three days after treatment for yeast
  • rash bright red then peeling off in sheets or raw and bleeding
  • rash beyond the diaper area
  • rash painful and not responding to home care

Diagnosis

Diagnosis is made by examining the diaper area and taking the history of the onset and duration of the lesions.

The presence of skin lesions means the baby has diaper rash. However, there are several types of rash that may need specific treatment to heal. It is useful to be able to distinguish them by their appearance and causes.

A baby with a rash that does not clear up within two to three days or a rash with blisters or bleeding should receive an evaluation and care from a healthcare professional.

Treatment

Antibiotics are prescribed for rashes caused by bacteria and impetigo. This may be a topical or oral formula, depending on the size of the area involved and the severity of the infection.

Over-the-counter antifungal creams are often used to treat a rash resulting from yeast. If topical treatment is not effective, an oral antifungal is prescribed. Treatment of diaper candida in young infants should include oral drops to treat any candida in the mouth and gut to avoid re-infection.

Mild steroid creams, such as 0.5 to 1 percent hydrocortisone, may be used to treat seborrheic dermatitis and intertrigo. Prescription strength creams are needed for short-term treatment of stubborn cases. Intertrigo can be treated with a combination of hydrocortisone and anti-fungal creams.

Complication

The main complication is secondary infection by yeast or bacteria.

Home care

Good diaper hygiene prevents or clears up many simple cases of diaper rash. Many rashes can be treated as follows:

  • Change diapers frequently.
  • Keep the area dry and clean. Check the diaper often, every hour if the baby has a rash and change the diaper as soon as it is wet or soiled. Check at least once during the night. Good air circulation is also important for healthy skin. Babies should have some time without wearing a diaper. A cotton pad can protect the bed while the baby is diaper free.
  • Frequent and vigorous washing with soap can strip the baby's tender skin of natural protective barriers. Wash gently but thoroughly, including the skin folds. Plain water may be the best cleaning agent when there is a rash. Using warm water in a spray bottle (or give a quick bath) and then lightly pat the skin dry to avoid irritation.
  • Instead of cleaning the baby's bottom with a moist wipe or washcloth, hold the diaper area over the sink and let warm water wash over the inflamed skin. Then dry the area using a blow-dryer set on cool. Washing with plain water and drying with air is soothing to sore skin; it speeds healing by decreasing friction on the area. Some wipes contain alcohol or chemicals that can be irritating and only make diaper rash worse.
  • Parents can sit the baby in a basin or tub of lukewarm water for several minutes with each diaper change. This helps clean and may also be comforting. Or they can pour warm water from a pitcher or use a squirt bottle. They should not use soap unless there is sticky stool, then a mild liquid soap in a basin of warm water is effective; wash gently and rinse well. Baby oil on a cotton ball can also remove stool from small areas.
  • Leave diaper off for a while.
  • Do not use airtight rubber pants over the diaper area. Some cloth-like disposable diapers promote better air circulation than plastic-type diapers. If disposable diapers are used, it helps to punch holes in them to let in air.
  • Petroleum jelly provides a protective coating, even on sore, redden skin, and is easy to clean. Parents should not use talcum powder because of the risk of pneumonia . However, cornstarch reduces friction and may prevent future rashes.

Nutrition

What the baby eats can make a difference in stool frequency and acidity. Typically, breast-fed babies have fewer problems with rashes. When adding a new food to the diet, the baby should be watched closely to see whether rashes appear around the baby's mouth or anus. If they do, the new food should be avoided temporarily.

Babies who are taking antibiotics are more likely to get rashes because of yeast. To help bring the good bacterial counts back to normal, Lactobacillus bifidus can be added to the diet. It is available in powder form from most health food stores.

Herbal treatment

Some herbal preparations can be useful for diaper rash. Calendula reduces inflammation, tightens tissues, and disinfects. It is recommended for seborrheic dermatitis as well as for general inflammation of the skin. The ointment should be applied at each diaper change. Chickweed ointment can also sooth irritated skin when it is applied once or twice daily.

Prognosis

With proper treatment these rashes are usually better in three days if there is no underlying health problem or skin disease. If the rash does not improve with treatment then the child probably has a yeast infection. In that case, the rash becomes bright red and raw, covers a large area, and is surrounded by red dots. For yeast infection, the child needs a special cream.

Prevention

Changing the diaper immediately and good cleaning are the best action a parent can take to prevent diaper rash. Diaper rashes occur equally with cloth diapers and disposable diapers. Some children will get a rash from certain brands of disposable diapers or from sensitivity to some soaps used in cloth diapers. If cloth diapers are used, always wash them separate from other clothing and add bleach to the soap. After washing, the diapers should be rinsed thoroughly.

Parental concerns

Diapering. There are two choices, cloth or disposable. Parents need to decide what works best for their baby and lifestyle.

In the event of suspected yeast, a tablespoon of cider vinegar in a cup of warm water can serve as a diaper area wash. This is diluted enough that it should not burn, but acidifies the skin pH enough to hamper the yeast growth.

Barrier ointments can be valuable to treat rashes. Those that contain zinc oxide are especially effective. These creams and ointments protect already irritated skin. Cornstarch powder is soothing to rashes that are moist, such as impetigo.

KEY TERMS

Dermatitis —Inflammation of the skin.

Diaper dermatitis (diaper rash) —An inflammatory reaction to irritants in the diaper area.

Impetigo —A bacterial infection of the skin characterized by skin blistering.

Lactobacillus bifidus —A property of breast milk that interferes with the growth of pathogenic bacteria in the gastrointestinal tracts of babies, reducing the incidence of diarrhea. Lactobacillus bifidus can be added to infant formulas to help control diarrhea.

Resources

BOOKS

Middlemiss, Prisca. What's That Rash?: How to Identify and Treat Childhood Rashes. London: Hamlyn, 2002.

WEB SITES

Kazzi, Amin, and Khoa Nguyen. "Pediatrics: Diaper Rash." eMedicine.com , November 1, 2004. Available online at http://www.emedicine.com/emerg/topic374.htm (accessed December 15, 2004).

Aliene S. Linwood, RN, DPA, FACHE



User Contributions:

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Valmiro
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Jun 3, 2012 @ 2:02 am
Olive oil is useful. For one thing you can use it as a spot claener for most stains, also it is chemically inert, unlikely to irritate anything.Very sensitive skins (like mine) usually react to things that are supposed to be gentle . Depending on where you mean to take Baby you could get some Zinc Creme to apply to the nose and ears out of doors, also to the arms and shoulders if exposed. Baby is not too young to get skin cancer from sunlight.You can buy things like Vix Vap r rub (I don't know if they do it in America) you rub the ointment on the chest to deliver essential oils to assist breathing.If you inquire carefully you might get an oxygen pak just a bit to help Baby breathe until the Doctor gets there if need be.Don't smoke near Baby.Don't put Baby on the tummy.A mobile with flashing lights is an excellent way to stimulate baby but make sure baby can't use it to plug into the mains current. Just in case have a supply of Tea Tree Oil handy for cuts and scratches.Dilute hydrogen peroxide (say 3%) is of avail for cuts in the mouth.Put all medication in a cupboard out of reach of baby before you go to bed. Do not doze with baby after you take your heart medication or whatever. Get anything baby can swallow out of reach of baby. That means also be sure the cot cannot be taken apart by baby. Wing nuts and so forth swallowed by baby can be a cause of problems.Try not to use soaps, detergents, bleaches, sanitizing agents, and so forth in any way that can come on the baby. Laundered clothing for baby needs an extra rinse. Water from the tap can contain chlorine. That becomes hydrochloric acid. Avoid using perfumed sprays, talc, anything that can make dust or fumes. If you know what you are doing and I mean it exactly use a blow dryer or a fan to dry the skin on the baby, or wipe with disposable paper towels and you might get hold of rubbing oil, olive oil mixed with Rosemary if I recall. Very cautiously and with help you might learn to use Essential Oils, Rose Oil appears to be of general help, and for a rash Rose Hip oil is expensive but good.Have a Fire Extinguisher handy no matter what and have an evacuation plan for the time you leave the radiator and your newspaper in the room with the baby and answer the phone. You can come back to find the paper and the baby on fire.Eventually for parents it is possible to realize baby doesn't know any better and won't be safe to neglect for two or three years.The first born gets into all the trouble in the world as the parents seem to credit the baby with common sense and themselves with experience which they usually acquire the first or second time baby goes downhill into the traffic because mum forgot to set the brake on the pram.Do not walk the baby's head into doorknobs. That happened an awful lot to me as a baby. You can see the doorknob coming but not make any sense to the one carrying you towards it. Do not leave the baby anywhere near the kitchen. You can expect to find honey broken eggs and so on all over the baby the floor and the walls.Do not think baby can't turn on the power saw and the electric grinder in the toolshed.Do not think baby won't get under the car just before you back out.All new born babies can be called Murphy as in Murphy's Law. You are about to be tested by a little demon kamikaze kid while too tired out to cope. Now it might be possible to attempt mental telepathy with the baby. One way is to hold the palm of your right hand above the head of the baby and think of co-operation and safe uses.Anyway when not fussing with the baby the parents ought to take it in turns to massage each other gently. If the baby sees people massaging each other gentle ideas are learned early.Keep the cooking down and take it as easy as possible. Hot liquids can be kept in Thermos bottles, your tea and coffee, Baby's formula and so on. Make life as easy for each other and for Baby as possible. KEEP THE FUSSING DOWN keep the contact with the baby up. Be with the baby not in th (...)

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