Rebecca Turley Irritant Nappy Rash Symptom s and Diagnosis Nappy rash (a form of irritant contact dermatitis) is a common skin condition occurring in roughly one third of infants, the majority of whom are aged between nine and twelve months. The main symptom can be described as a redness that covers the majority of the convex surfaces in the nappy area (namely the buttocks, upper thighs and genitals), which can sometimes appear glazed in acute cases, or drier and more flaky in longer cases. The rash should be sparing in the skin folds (flexures). This can be quite uncomfortable and upsetting for the infant. It is essential in cases of suspected nappy rash that any differential diagnoses can be ruled out. The presence of pustules or crusty yellow scabs could be an indication of impetigo, a staphylococcus aureusor streptococcus pyogenesinfection, which requires referral. Candidiasis infections can sometimes be detected by checking for oral candida, which can be a sign of a systemic infection. Other indicators, such as a high temperature can be an indicator of an infection, such as the commonly misdiagnosed perianal streptococcal dermatitis, which can also be identified by painful defaecation. Pathology Nappy rash is not immunologically mediated (i.e. it is not an allergic reaction). A primary cause of nappy rash is contact with faeces and urine. Faecal proteases can contribute to the breakdown of the softer layers of the epidermis. In addition, the ammonia in both faeces and urine can affect the pH of the skin, causing it to become fragile and over-hydrated, which increases the detrimental effects of the protease enzymes. Individuals with sensitive skin can be more predisposed to nappy rash, which can be caused by the rubbing or chafing of the nappy. However, the causes of nappy rash are not always obvious, for example, nappy rash appears to worsen if the infant is teething; the connection between the two has only been speculated. First Line Therapy There are three main areas concerned with the treatment of irritant nappy rash: 1. Hygiene measures 2. Avoiding irritants 3. Barrier creams It is recommended that young babies have their nappies changed ten to twelve times a day and older infants six to eight times. By changing more frequently, contact between the skin and faeces/urine is reduced, therefore reducing the detrimental effect on the skin. It should be ensured that the nappy area is also cleaned properly at each change with either water or a baby-wipe (although over-zealous scrubbing should be avoided so as not to cause more abrasion to the affected area). To prevent any worsening of the symptoms, avoidance of irritants - such as soaps and fragrances - prevents the dermatitis from becoming more aggravated. This is because the stratum corneum has been compromised, and so can no longer act as a barrier to these irritants. It is also recommended that the infant goes without a nappy for periods of time, as this allows the area to dry thus preventing further over-hydration. Finally, barrier creams can be effective in preventing the abrasion between the nappy and the skin. There are many barrier creams available that are specifically for nappy rash, the most highly recommended of those being Zinc and Castor Oil Ointment, BP. The cream should be applied at each nappy change after gentle cleaning and drying. If Therapy Fails If the irritant nappy rash is persistent and does not clear up with the above measures, it would be appropriate to refer the patient to their doctor, who may decide to prescribe topical hydrocortisone cream 0.5% to treat inflammation, to be applied thinly to the affected area one to two times daily. Clear counselling is essential for this medication, particularly for children as they are more susceptible to the adverse effects. Patients should be advised about using the correct amount of the cream for the area being treated (the concept of one adult finger-tip of cream being enough to cover an area of two adult palms is a common and easily understood method). Treatment should be limited to 5-7 days to reduce the likelihood of adverse effects. Alternatively, the doctor may diagnose an infection, in which case they may prescribe a topical antifungal such as clotrimazole cream, or a topical antibacterial.
