Treating Diaper Rash

Diaper rashes are common, and often the medical home clinician can instruct parents on how to treat them at home. The rashes usually affect the area in direct contact with irritants, such as near the anus and on the rounded part of the buttocks and genitals. These diaper rashes look red and puffy and may have small red bumps called papules. Diaper rashes can make infants and children fussy and cry more during diaper changes.

Causes:

• Chafing, vigorous wiping, or rubbing (friction)
• Chemical irritants like diaper materials, baby wipes, bath soaps, laundry detergents or softeners, lotions, or scented diaper ointments
• pH disturbances, which can occur when a child has diarrhea or when the child or breastfeeding mother takes antibiotics
• Moisture build-up and poor air flow
• Prolonged contact with feces or urine
• Infections

1. Gently cleanse the area when soiled. Some infants and children do fine with regular commercial wipes, while others do better with hypoallergenic commercial wipes or water and a soft washcloth when the skin barrier is not intact. Cotton balls soaked with mineral oil can also be used to gently remove feces. Use of alcohol, hydrogen peroxide, and other topical antiseptics may cause a lot of pain and should be avoided. If the area is very raw, using water with added baking soda may decrease the stinging sensation. [Shin: 2014]
2. Leave the diaper area open to air dry for several minutes or use a blow dryer on a low heat setting to ensure dryness.
3. Apply a good barrier ointment to protect the skin from further irritation and allow the underlying skin to heal. Effective barrier ointments tend to be sticky/adherent and have no added fragrance or color that can be irritating. For example, pure petrolatum works to protect and moisturize irritated skin; petrolatum-based ointments usually appear mostly clear in color. Zinc oxide (mineral ointment) also promotes healing and provides increased protection; these ointments are often clear or white. Added vitamin A does not demonstrate a clear benefit. [Shin: 2014] Due to higher water content, creams wipe off more easily than ointments; therefore, creams typically do not provide a barrier that lasts as long as ointments.
4. If pH is a problem, mixing an antacid (e.g., Maalox) with the barrier ointment can provide additional protection.
5. Low-potency topical steroids (class 6 or 7), such as hydrocortisone acetate 0.5, 1, or 2.5% cream or ointment, may be considered twice daily for up to 14 days, but avoid use of halogenated steroids (such as triamcinolone). [Shin: 2014] Generally, it is preferable to limit use of steroids in the diaper area to no more than a week to avoid over-thinning the skin.
6. When friction and moisture are the chief problems, use diaper powders such as corn starch, but prevent inhalation of powders into the infant or child’s lungs. [Shin: 2014]
7. A technique called “crusting” can be used for hard-to-treat diaper rashes with significant skin breakdown. “Crusting” is done by alternating layers of a protective barrier ointment with a powder, such as corn starch, talc, or stoma powder, to create extra protection. Layering on the ointment and powder means that during diaper changes, only the soiled outer layer of the “crust” needs to be removed, ensuring that the underlying skin remains constantly protected. Again, avoid inhalation of powders by the child or caregiver. The whole “crust” should be gently removed during bathing and then reapplied after gently drying the area.
8. For recurrent rashes, consider more frequent diaper changes and/or trying a different type of diaper. Also, consider using hypoallergenic laundry detergents, bath, and skin care products.

Diaper rashes typically improve within a few days. If not, then the child may need to be considered for treatment with prescription medications. Although normal intact skin provides a good barrier against infections caused by common yeast and bacteria, the diaper area is a moist, warm environment hospitable to yeast, fungus, and bacteria to grow and cause skin infections. Secondary skin infections in the diaper area may develop after a simple diaper rash was initially present because the normal skin barrier is compromised. Skin infections in the diaper area tend to look angrier and may affect the skin folds more than typical diaper rashes, and there can be closed or open sores. Diaper-area skin infections often respond to medicated treatments for yeast and fungus, such as topical miconazole or ketoconazole. [Shin: 2014] Topical nystatin is also available by prescription and can be quite effective. Apply these after gentle cleansing and drying, as described above. Be sure to also evaluate for thrush and treat if present. For severe, resistant-to-treatment yeast infections, consider oral fluconazole.

If there is a rash that looks like there is pus inside of it (like a big pimple or abscess), the child should be evaluated in the medical home to sterilize the surrounding skin and then obtain a culture of the fluid in the wound and drain a fluid collection. Squeezing out the fluid at home is not recommended. Over-the-counter topical antibiotics (e.g., bacitracin) may be sufficient for home treatment; however, this depends on local bacterial resistance patterns and if there is a known history of methicillin-resistant Staph. aureus (MRSA) in the child or close household contacts. While not common, any wound or rash that appears to be rapidly spreading, hot, and red or fluid-filled, and any diaper rash with a fever, or a rash that is not improving with the methods listed above, may require prescription of a topical antibiotic like mupirocin or an oral antibiotic such as cephalexin, sulfamethoxazole-trimethoprim, or clindamycin. Large or rapidly spreading infections may need a surgical evaluation or IV antibiotics, as well as pain control.

Consider alternative diagnoses such as viral infections (e.g., herpes or varicella), scabies, acrodermatitis enteropathica from zinc deficiency, granuloma gluteale infantum Langerhans cell histiocytosis, and child maltreatment. [Shin: 2014]

• Herpes simplex virus (HSV) 1 or 2: Painful papules, vesicles, and ulcers on an erythematous base that can umbilicate, rupture, or ulcerate. Consider child sexual abuse.
• Varicella, primary: Small pruritic papules that evolve into clear fluid-filled vesicles, then scab over. Closely resembles HSV.
• Varicella-zoster (shingles): Localized red papules that evolve into vesicles over several days that turn yellow. Shingles can occur on the buttocks (among other places) after a prior varicella infection – rare in children, but increased risk if in an immunocompromised child and should be considered as part of the differential for a vesicular rash that could occur in the diaper.
• Enterovirus (e.g., Hand-Foot-Mouth): Small blisters and red papules, usually in conjunction with a more widespread rash on the body and in the oropharynx
• Scabies: Pruritic, scaly, thick papules and plaques that can be local or generalized and may have nodules or burrow tracks
• Acrodermatitis enteropathica: Pruritic, symmetric, eczematous plaques and pustules, scarlet-red; in association with zinc deficiency, diarrhea, conjunctivitis, alopecia, and/or rash at tips of fingers and toes.
• Granuloma gluteale infantum: Non-tender, cherry, reddish-purple nodules and plaques in the diaper area with surrounding erythema, some with ulceration, develops after resistant irritant diaper dermatitis. See [Ramos: 2018].
• Langerhans cell histiocytosis: Severe, unremitting, erythematous, seborrheic papules and plaques, can be hemorrhagic; it is typically associated with multi-system disease, including hepatosplenomegaly.
• Child maltreatment: Neglect can lead to extensive diaper rash.