Napkin Rash, Causes, Symptoms, Diagnosis, Treatment

Napkin Rash
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Napkin Rash/Diaper dermatitis is one of the most common dermatoses occurring in infancy. It is an irritant dermatitis, in which a variety of factors act in concert to produce inflammation of the diapered skin. The differential diagnosis includes many common and some uncommon conditions. Successful treatment requires detailed instructions to caregivers regarding simple hygienic procedures and diapering practices.

Types of Napkin Dermatitis

Napkin Rash

Irritant Dermatitis

  • Diapers themselves. This most common type of diaper rash is caused by wet skin (from urine and stool mainly) being in contact with the diaper.
  • Typically, there is redness and swelling of the skin along the top of the diaper, over baby’s bum, and around the legs.
  • Allowing baby to go without a diaper as much as possible keeping the skin clean and dry. My kids ran around naked A LOT, and I swear it helped us escape (and sometimes quickly heal) many a diaper rashes. In addition, my kids have done better when we used wipes without alcohol or perfumes because they can excessively dry out and irritate the skin. Applying thick ointment, like zinc oxide, on completely dry skin can protect from excess moisture while wearing a diaper.

Candida Dermatitis

  • Yeast overgrowth. This is also called a yeast infection. Yeast grows rapidly in a warm, moist environment, making diapers the perfect place for yeast to thrive. Although yeast is a normal part of the microbes living on our skin, the overgrowth happens when there is an imbalance in these microbes. Diarrhea, acid in stools, ammonia from urine, tight diapers, and reactions to soaps and products used to clean cloth diapers can contribute to candida dermatitis. Also, yeast overgrowth on the skin can be indicative of an internal, gastrointestinal microbial imbalance.
  • Candida diaper rash is usually seen as redness and swelling in and around the creases of the legs, bottom, testicles and vulva rather than around the diaper lines like irritant diaper rash. Pimples, blisters, ulcers, large bumps, or sores filled with pus can be present. Candida dermatitis classically has “satellite lesions” where there are small round spots of rash located near the main, large rash.
  • Check with your physician to see if candida may be the cause of your baby’s diaper rash. She may prescribe an antifungal medication like Nystatin as a treatment. Probiotics and a healthy, whole foods diet are good places to start in creating and maintaining a balanced gastrointestinal microflora.

Allergic Dermatitis

  • Allergy or irritant. This type of diaper rash is due to an allergic response caused by contact with something. It could be an allergy to the chemicals and materials in the diaper, wipes, diaper cream, lotion, soaps, shampoos, or laundry detergents. Fragrances and preservatives are the most frequent allergens in baby products; however, every baby is unique so you may have to do some serious investigating to locate the perpetrator on an ingredient list.
  • This type of rash is harder to identify but is red and can have areas where the skin is worn away. At most commonly appears as a red, irritated bottom on young infants. It can occur anywhere the allergen touches the skin.
  • You’ll need to do some detective work and figure out what your baby is allergic to—antifungal creams or zinc oxide may not be as effective for this rash. I always turn to ingredient lists when trying to find the potential cause of an allergy, even though we try to use gentle soaps, lotions and detergents at our house to begin with. In general, I like to limit skin products with added fragrances as a way to maintain healthy skin in my family.

Bacterial Dermatitis

  • Bacteria – The most common culprit of bacterial dermatitis is Staphylococcusaureus (Staph) and Group A Streptococcus (Strep). Bacterial rashes often occur when the skin is already irritated or has small cuts and abrasions either from vigorous wiping or a previous non-bacterial rash.
  • Staph small or large pus-filled blisters that rupture easily and will form a “honey-colored” crust or scab. Strep bright red, well-defined rash around the anus (often seen as a ring) and possibly extending into the perineum (the place between the anus and genitals). You may notice small cuts, or abrasions, in the anus leading to small amounts of blood in the stool. Strep infections can occur in older children as well. It usually itches and will cause pain with stool elimination (often leading to constipation from holding stool).
  • Consulting your child’s physician. Bacterial infections can escalate quickly and getting appropriate treatment can be essential.
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Cause of Napkin Dermatitis

Napkin Rash

Napkin dermatitis follows damage to the normal skin barrier and is primarily a form of irritant contact dermatitis.

  • Irritation from stool and urine – Prolonged exposure to urine or stool can irritate a baby’s sensitive skin. Your baby may be more prone to diaper rash if he or she is experiencing frequent bowel movements or diarrhea because feces are more irritating than urine.
  • Chafing or rubbing – Tightfitting diapers or clothing that rubs against the skin can lead to a rash.
  • Irritation from a new product – Your baby’s skin may react to baby wipes, a new brand of disposable diapers, or a detergent, bleach or fabric softener used to launder cloth diapers. Other substances that can add to the problem include ingredients found in some baby lotions, powders and oils.
  • Bacterial or yeast (fungal) infection – What begins as a simple skin infection may spread to the surrounding region. The area covered by a diaper — buttocks, thighs and genitals — is especially vulnerable because it’s warm and moist, making a perfect breeding ground for bacteria and yeast. These rashes can be found within the creases of the skin, and there may be red dots scattered around the creases.
  • Introduction of new foods – As babies start to eat solid foods, the content of their stool changes. This increases the likelihood of diaper rash. Changes in your baby’s diet can also increase the frequency of stools, which can lead to diaper rash. If your baby is breast-fed, he or she may develop diaper rash in response to something the mother has eaten.
  • Sensitive skin – Babies with skin conditions, such as atopic dermatitis or seborrheic dermatitis (eczema), may be more likely to develop diaper rash. However, the irritated skin of atopic dermatitis and eczema primarily affects areas other than the diaper area.
  • Use of antibiotics – Antibiotics kill bacteria — the good kinds as well as the bad. When a baby takes antibiotics, bacteria that keep yeast growth in check may be depleted, resulting in diaper rash due to yeast infection. Antibiotic use also increases the risk of diarrhea. Breast-fed babies whose mothers take antibiotics are also at increased risk of diaper rash.
  • Candida infection – Candida is a fungus that grows in warm, moist places. The rash it causes, also called a yeast infection, is usually bright red with smaller red spots around the edges.
  • Allergic reaction – Soap, laundry detergent, fabric softener, disposable diapers, baby wipes, or lotions can irritate your baby’s skin. Watch your baby’s skin carefully for reactions. Stop using products that appear to cause a rash.
  • New foods – Changes in your baby’s diet can change the content and frequency of their stools. This can make diaper rash more likely. A breastfed baby could develop a rash in reaction to something the mother has eaten.
  • Antibiotics – Yeast infections are common after a baby has been taking antibiotics, or if the mother is on antibiotics while breastfeeding.
  • Urine and occlusion lead to overhydration and skin maceration.
  • Faecal bile salts and enzymes break down stratum corneum lipids and proteins.
  • A mixture of urine and faeces creates ammonium hydroxide, raising pH.
  • The wet skin is colonised by micro-organisms, particularly candida.
  • Mechanical friction from limb movement may increase discomfort.
  • Pre-existing skin conditions such as atopic dermatitis or seborrheic dermatitis predispose a baby to napkin dermatitis.

Other causes of napkin rashes include

  • Candida albicans
  • Impetigo
  • Infantile seborrhoeic dermatitis
  • Atopic eczema
  • Psoriasis
  • Miliaria
  • Acrodermatitis enteropathica
  • Biotin responsive dermatosis
  • Rare disorders.

Napkin dermatitis is not due to

  • Allergy to the napkins
  • Toxins in the napkins
  • Washing powders (unless these are not thoroughly removed by rinsing)
  • Dermatophyte fungal infections (tinea).

Symptoms of Napkin Dermatitis

Napkin dermatitis presents as erythematous macules and papules in the genital area that can spread to involve the lower abdomen and thighs.

  • Irritant napkin dermatitis well-demarcated variable erythema, oedema, dryness and scaling. Affected skin is in contact with the wet napkin and tends to spare the skin folds.
  • Chafingerythema and erosions where the napkin rubs, usually on waistband or thighs.
  • Granuloma gluteale infantum – red or purple nodules
  • Candida albicans erythematous papules and plaques with small satellite spots or superficial pustules.
  • Impetigo (Staphylococcus aureus and Streptococcus pyogenes) – irregular blisters and pustules.
  • Infantile seborrhoeic dermatitis – cradle cap and bilateral salmon pink patches, often desquamating, in skin folds.
  • Atopic dermatitis bilateral scratched, dry plaques anywhere, but uncommon in the nappy area and a family history is common.
  • Psoriasis – persistent, well-circumscribed, symmetrical, shiny, red, scaly or macerated plaques; other sites may be involved; family history common.
  • Disseminated secondary eczema or autoeczematisationrash in distal sites associated with severe napkin rash.
  • Your baby’s skin is red and raw or broken, and may bleed.
  • The rash includes red bumps, pimples (which may drain pus, sores, blisters or boils.
  • The rash covers a large area, and may have a bright red border or be worse in the creases and folds.
  • The rash is painful to the touch and/or your baby seems sick, unhappy or unable to sleep.
  • Napkin dermatitis may predispose the infant to urinary tract infection and in females, to vaginal infection.

Diagnosis of Napkin Dermatitis

Other rashes that occur in the diaper area include seborrhoeic dermatitis and atopic dermatitis. Both Seborrheic and Atopic dermatitis require individualized treatment; they are not the subject of this article.

  • Seborrheic dermatitis, typified by oily, thick yellowish scales, is most commonly seen on the scalp (cradle cap) but can also appear in the inguinal folds.

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Treatments of Napkin Dermatitis

Possible treatments include minimizing diaper use, barrier creams, mild topical cortisones, and antifungal agents. A variety of other inflammatory and infectious processes can occur in the diaper area and an awareness of these secondary types of diaper dermatitis aids in the accurate diagnosis and treatment of patients.[rx]

  • Antifungals – In persistent or especially bad rashes, an antifungal cream often has to be used. In cases that the rash is more of an irritation, a mild topical corticosteroid preparation, e.g. hydrocortisone cream, is used. As it is often difficult to tell a fungal infection apart from a mere skin irritation, many physicians prefer an corticosteroid-and-antifungal combination cream such as hydrocortisone/miconazole.
  • Diaper changingThe most effective treatment, although not the most practical one, is to discontinue use of diapers, allowing the affected skin to air out.[rx] Another option is simply to increase the frequency of diaper changing.[rx] Thorough drying of the skin before diapering is a good preventive measure because it is the excess moisture, either from urine and feces or from sweating, that sets the conditions for a diaper rash to occur.[rx]
  • Diaper type – Some sources claim that diaper rash is more common with cloth diapers.[rx] Others claim the material of the diaper is relevant insofar as it can wick and keep moisture away from the baby’s skin, and preventing secondary Candida infection.[rx] However, there may not be enough data from good-quality, randomized controlled trials to support or refute disposable diaper use thus far.[rx] Furthermore, the effect of non-biodegradable diapers on the environment is a concerning matter for public policy.[rx]
  • Bathing daily – Until the rash clears up, give your baby a bath each day. Use warm water with mild, fragrance-free soap.
  • Witch hazel (winter bloom), a flowering plant – A study showed that applying an ointment made with witch hazel to diaper rash helped. The study included 309 children.
  • Human breast milk – Results are mixed on whether human breast milk applied to diaper rash is better than other treatments. One study showed that applying breast milk to diaper rash is an effective and safe treatment. Infants with diaper rash were treated with either 1 percent hydrocortisone ointment or breast milk. The study included 141 infants. Treatment with breast milk was as effective as the ointment alone.
  • Calendula and aloe vera – A study comparing aloe vera and calendula in the treatment of diaper rash in children found each to be an effective treatment of diaper rash.
  • Shampoo clay (bentonite) – A study showed that shampoo clay was effective in healing diaper rash and that it worked faster than calendula. The study included 60 infants.
  • Other substances – Other natural remedies have been tried, including evening primrose and a mixture of honey, olive oil, and beeswax. Further study is needed to prove their effectiveness for treating diaper rash. Some of these substances may promote bacterial growth.
  • Creams, ointmentsAnother approach is to block moisture from reaching the skin, and commonly recommended remedies using this approach include oil-based protectants or barrier cream, various over-the-counter “diaper creams”, petroleum jelly, dimethicone and other oils. Such sealants sometimes accomplish the opposite if the skin is not thoroughly dry, in which case they serve to seal the moisture inside the skin rather than outside.
  • Zinc oxide – based ointments such as Pinxav can be quite effective, especially in prevention, because they have both a drying and an astringent effect on the skin, being mildly antiseptic without causing irritation.[rx] A 2005 meta-analysis found no evidence to support the use of topical vitamin A to treat napkin dermatitis (diaper rash).[26]
  • Powder – These products aim to soothe a baby’s sore skin or create a protective barrier — or both. Smooth on cream or ointment to your baby’s clean, dry bottom before putting on a clean diaper. Look for zinc oxide or petrolatum (petroleum jelly) on the ingredients list. If you use baby powder, keep it away from your baby’s face. The talc or cornstarch in the powder can cause breathing problems. Place it in your hand, then apply it to the diaper area. Skip the steroid creams you find in the drug store (hydrocortisone) unless your doctor tells you to use one. They can irritate your baby’s bottom even more if used incorrectly.
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Lifestyle and Home Remedies

Generally, a diaper rash can be treated successfully at home with these practices:

  • Keeping diaper area clean and dry – The best way to keep your baby’s diaper area clean and dry is by changing diapers immediately after they are wet or soiled. Until the rash is better, this may mean getting up during the night to change the diaper.
  • After you’ve gently cleaned and dried the skin – apply a cream, paste or ointment. Certain products, such as zinc oxide and petroleum jelly, work well to protect the skin from moisture. Don’t try to scrub off this protective layer completely at the next diaper change, as that could hurt the skin more. If you do want to remove it, try using mineral oil on a cotton ball.
  • Increasing airflow – To aid the healing of diaper rash, do what you can to increase air exposure to the diaper region. These tips may help:
    • Air out your baby’s skin by letting him or her go without a diaper and ointment for short periods of time, perhaps three times a day for 10 minutes each time, such as during naps.
    • Avoid airtight plastic pants and diaper covers.
    • Use diapers that are larger than usual until the rash goes away.

Prevention of Napkin Dermatitis

Consider these preventive tips

  • Regularly bathe baby in warm water. Clean their diaper area each time you change their diaper.
  • Change diapers often. Avoid leaving baby in a wet diaper.
  • Let baby’s bottom air-dry for as long as possible after every diaper change. Patting baby’s bum with a soft cloth or using a blow dryer on the cool-air setting may help speed up the process.
  • Give baby regular diaper-free time.
  • Don’t use rubber pants or diapers that prevent air flow. These can trap moisture near skin.
  • Consider using a diaper cream to help protect your baby’s skin. Creams provide a barrier from urine and stool, which can irritate skin and make it prone to developing a rash.
  • Avoid baby products that contain fragrances and dyes, such as lotions or soaps. These additives can irritate the skin.
  • Don’t give baby unnecessary antibiotics, as they can cause an imbalance of healthy bacteria and yeasts in the body.

References

Napkin Rash

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