See also

Eczema
Vulval and vaginal conditions

Key points

1. Effective treatment of nappy rash involves minimising skin contact with irritants and creating a barrier while skin heals
2. If nappy rash doesn’t heal with simple treatment measures, other causes should be considered

Background

Nappy rash is a term used to describe a group of skin conditions affecting the skin covered by nappies. It is an irritant contact dermatitis and affects more than half of infants by twelve months

Factors contributing to the loss of skin barrier function:

• Exposure to urine and faecal enzymes leads to skin overhydration and maceration. This can be exacerbated by infrequent nappy changes, cloth nappies and the use of plastic pants
• Friction between nappy and skin
• Colonisation with micro-organisms such as Candida albicans
• Irritants such as soaps, chemicals, fragrance, plant or food products (eg vegetable or nut oils) present in some nappy wipes, powders, barrier creams and moisturisers
• Pre-existing skin conditions eg eczema
• Recent antibiotics - increased risk of diarrhoea and secondary Candida infections

Assessment

History

• Duration and evolution of rash
• Frequency of nappy changes and type of nappies used
• Review of growth, feeding, solid intake and stool output
• Treatments previously tried
• Family history of atopy
• History of prematurity, bowel surgery, short gut
• Vegan/vegetarian diet in the mother during third trimester (zinc deficiency)
• Severe nappy rash may result in pain, unsettledness and poor sleep

Examination

Assess rash features

• Whole body including scalp
• Mouth for thrush
• Weight, length and head circumference growth trend over time (see Slow weight gain)

Typical presentation

• Widespread erythematous rash on convex skin surfaces in direct contact with the nappy, usually sparing the groin folds
• Associated scaling, swelling, scattered erythematous papules and ulcers from broken skin
  
  

Typical distribution

Mild nappy rash

Severe nappy rash

Differential diagnosis

Consider other causes when nappy rash is severe, unusual in appearance or not responding to appropriate treatment. More than one condition may occur together 

Infections

• Candida: erythema in skin folds with satellite spots or pustules

      
      Candida infection

• Impetigo: see Cellulitis and skin infections
• Perianal streptococcal cellulitis: localised well-demarcated erythema around the anus with fissuring and macerated skin. Can present with itch, painful defecation and/or constipation
• Threadworm
• Viral infection eg hand foot and mouth, herpes simplex virus 

Primary skin disorders

• Eczema
• Psoriasis: sharply demarcated, non-scaly, bright erythematous plaques
• Seborrhoeic dermatitis: non-itchy salmon pink patches sometimes with greasy scale on top, found on scalp (cradle cap), face, body and skin folds
• Miliaria (heat rash)

Nutritional deficiency and malabsorption

• Malabsorption from any cause (eg lactose overload, cow milk protein intolerance, cystic fibrosis, inflammatory bowel disease) can present with diarrhoea, erosive dermatitis and poor growth. Diarrhoea and secondary nutritional deficiencies may contribute to further progressive intractable nappy rash
• Food allergy
• Zinc deficiency (acrodermatitis enteropathica): sharply defined red, often extensive, anogenital rash. Look for perioral, perinasal and hand/foot dermatitis, alopecia, diarrhoea and failure to thrive

Rarer causes

• Langerhans cell histiocytosis: a chronic inguinal or anogenital rash with brownish/red scale and petechiae, which is often erosive and unresponsive to treatment. Purpura, fever, diarrhoea or hepatosplenomegaly may be present
• Immunodeficiency

Management

Investigations

Generally, no investigations are required

Treatment

General skin care measures

• Use warm water +/- bath oil with a soft cloth to cleanse the area after every change
• Pat gently or air dry, avoid rubbing
• Allow as much nappy free time as possible
• Daily bath using warm water and fragrance-free skin cleanser or bath oil
• Avoid soaps and bubble baths

Topical barrier preparations

• Apply a thick layer of barrier cream at every nappy change. Effective barrier creams contain zinc, white soft paraffin or petrolatum. Nappy rash not responding to a barrier cream with low zinc concentration may improve with switch to a higher zinc concentration eg 40%
• Do not remove barrier cream after each nappy change - remove visible soiling then apply another layer over the top

Specific treatments
Refer to local guidelines as formulary restrictions may apply

1% hydrocortisone ointment (1-2 times daily for 1-2 weeks) can be used in addition to barrier cream for nappy rash not responding to simple treatment

Candida infection

• Single agents:
• Clotrimazole 1% cream twice daily, or
• Miconazole 2% cream twice daily, or
• Combination agents:
• Miconazole 2% + hydrocortisone 1% cream twice daily, or
• Miconazole 2.5 mg + zinc oxide 150 mg/g ointment, apply a thick layer with every nappy change
• NB topical antifungal agent can be used in combination with 1% hydrocortisone

See Cellulitis and skin infections for treatment of bacterial infections

Prevention

• Change nappies as soon as possible after they become wet or soiled
• Wash and rinse all cloth nappies thoroughly
• Avoid using plastic pants
• Maximise nappy free time
• Clean area with good quality baby wipes or warm water and a cloth
• Apply barrier cream with every nappy change
• Avoid powders (eg talcum) and soaps

Consider consultation with local paediatric team when

• Rash is not improving with above treatment measures
• Concern that nappy rash is due to a cause other than irritant contact dermatitis

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

Consider discharge when

Family is aware of treatment plan and follow up is in place 

Parent information

Raising Children Network - Nappy Rash
Raising Children Network - Nappies
RCH Nappy Rash fact sheet, also available in Vietnamese and Mandarin

Last updated August 2024