What is napkin dermatitis?
Napkin dermatitis and nappy rash are used to describe various skin conditions that affect the skin under a baby's napkin. The US term is diaper rash. Napkin dermatitis is most often a form of contact dermatitis.
Who gets nappy rash?
Nappy rash most often affects babies aged 3 to 15 months of age, especially those wearing traditional cloth nappies (50%). It is much less prevalent in babies wearing modern breathable and multilayered disposable nappies.
Napkin dermatitis can also affect older children and adults that are incontinent.
What is the cause of napkin dermatitis?
Napkin dermatitis follows damage to the normal skin barrier and is primarily a form of irritant contact dermatitis.
- Urine and occlusion leads 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
Other causes of napkin rashes include:
- Candida albicans
- Infantile seborrhoeic dermatitis
- Atopic eczema
- Rare disorders
Napkin dermatitis is not due to:
- Allergy to the napkins
- Toxins in the napkins
- Washing powders
- Dermatophyte fungal infections (tinea)
What are the clinical features of napkin dermatitis?
One or more forms of napkin rash may be present.
- 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
- Chafing: erythema and erosions where the napkin rubs, usually on waistband or thighs
- Candida albicans: erythematous papules and plaques with small satellite spots or superficial pustules
- Impetigo (Staphylococcus aureus and/or 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 nappy area; family history common
- Psoriasis: persistent, well-circumscribed, symmetrical, shiny, red, scaly or macerated plaques; other sites may be involved; family history common
- Disseminated secondary eczema or autoeczematisation: rash in distal sites associated with severe napkin rash
What tests should be done?
In most cases, no tests are necessary. Skin swabs may be useful to confirm yeast or bacterial infection.
What is the treatment for napkin dermatitis?
The need to keep baby dry and use barrier protection should be emphasised. Napkin dermatitis is much less common with modern disposable napkins compared to cloth varieties.
- Are available in different shapes and sizes depending on age and gender
- Keep the skin dry and clean
- Maintain optimal skin pH
- Should be changed when wet or soiled
- Contain cellulose pulp and superabsorbent polymers
- May include petrolatum-based moisturising lotion to support skin barrier
- Fasteners, backsheets and stretch reduce leakage
- Are non-toxic and biologically inert
- Do not contain allergens such as natural rubber latex or disperse dyes
- Lead to less household exposure to faecal matter
If using cloth nappies, use nappy liners to keep the skin dry. Avoid plastic pants.
At napkin changes:
- Gently clean the baby’s skin with water and a soft cloth
- Wet wipes are convenient but expensive and can lead to contact allergy to preservatives used to stop them going mouldy
- Aqueous cream or other non-soap cleanser can be used if necessary
- Pat dry gently and allow to air dry
- Apply protective emollient ointment containing petrolatum and/or zinc oxide
- Give evening fluids early to reduce wetting at night.
- Observe whether certain foods are related to the rash by increasing stool acidity (eg orange juice) or frequency. If this is the case, discontinue the responsible food, at least temporarily.
- Mild topical steroid such as hydrocortisone cream, applied to inflamed skin once or twice daily for 1–2 weeks
- Topical antifungal cream once or twice a day if suspicious of Candida albicans infection.
- Strong steroid creams should not be applied to a baby's bottom.