Nappy rash, despite it sounding so trivial, can be painful and unsightly and cause parents untold feelings of anxiety and guilt. By and large, it settles through simple measures without intervention from a health visitor or doctor. It may affect up to one in three children who wear nappies, particularly between nine months and one year of age, whereas nappy rash in young babies is rather unusual and other causes of skin disease should be considered.
So what is it? In simple terms, nappy rash is inflammation of the skin in the area covered by the nappy. Essentially, the skin reacts to prolonged exposure to irritant chemicals within urine and faeces. Nappy rash is more likely, but not exclusively, to occur where nappies are changed infrequently, if non-disposable or poorly absorbent nappies are used, or when the child is exposed to particular soaps or overzealous rubbing and wiping.
When examining a child with nappy rash, the genitals and pubic area, buttocks and upper thighs are noted to be red. The creases within the groin tend not to be red unless there is thrush. It is usually mild but may be moderate or even severe, suggested by multiple bright red spots and skin lesions, broken skin, ulcers and blisters in a child who is unwell or distressed.
MORE SERIOUS CONDITIONS
Fungal (thrush) or viral or bacterial infections may complicate the scenario or indeed, cause nappy rashes in their own right. It is important not to get confused with other, sometimes more serious, conditions such as impetigo, allergic dermatitis, perianal streptococcal dermatitis, seborrhoeic dermatitis, eczema, psoriasis or burns, as well as rarer conditions such as zinc deficiency. All of these conditions may occur in addition to nappy rash or in isolation.
Impetigo is a bacterial skin infection that is highly contagious and is associated with a honeycomb crust-like appearance. Perianal streptococcal dermatitis is a bacterial infection and because the red rash is well defined, it is often misdiagnosed as a fungal infection. However, those affected are often out of nappies and anal pain and itching are often seen.
Bacterial infections are also suggested by the presence of fluid-filled pustules, whereas well-defined areas of redness associated with so-called satellite lesions of inflammation suggest thrush.
Seborrhoeic dermatitis tends to occur between two and 26 weeks of age and causes red scaly skin in various areas around the body.
Eczema is suggested by additional dry and inflamed lesions such as behind the elbows and knees. It is common, unlike psoriasis, which is unusual in this age group.
Burns as a cause of nappy rash are not always easy to prove, but in the context of non-accidental injury, are often found on the buttocks, as if the child was dipped into a hot bath.
Zinc deficiency is most common in premature babies and, in addition to nappy rash, causes rash on the hands and around the mouth.
TREATMENT
It is imperative that parents and carers minimise exposure to urine and faeces when managing common nappy rash. Ideally, high-absorbency, well-fitting, disposable nappies should be used and changed frequently, as soon after toileting as possible. However, these can be expensive. Water or child-friendly wipes that don't contain fragrances or alcohols should be used where possible.
If possible and practical, children should have some nappy-free time on a daily basis, so avoiding contact with irritant substances. Air should be allowed to reach the delicate nappy skin.
Bathing children on a daily basis, followed by gentle drying, should be encouraged. The skin should be patted dry rather than rubbed and it should be completely dry before the nappy is replaced.
Barrier creams, which contain zinc, such as Sudocrem, are ideal for protecting the skin against direct exposure to urine and faeces, and they should be used after each nappy change. The cream should not be applied too liberally, however, in order to allow the skin to breathe.
Talcum powder is not thought to be helpful and may be irritant and harmful. In addition, plastic pants, which are sometimes worn over nappies, will lock moisture into the nappy area and should also be avoided.
REFERRAL
Where simple measures do not work, if the rash occurs in very young children or the child is unwell and distressed, or if non-accidental injury is suspected, the child should be referred to a doctor.
Health visitors also offer a wealth of experience and are often the first port of call.
Bacterial and fungal infections should be treated with appropriate antibiotic therapy. Short courses of topical steroids, such as hydrocortisone cream, may be required in some situations to reduce inflammation. If in doubt, always seek medical advice.
Dr Raj Thakkar BSc(Hons) MBBS MRCGP MRCP(UK) is a full-time GP in Buckinghamshire