Diaper Rash

Dear Lisa,

My 9 month old baby has a diaper rash that I can’t get rid of. I tried different diaper crèmes, and they didn’t work. Any suggestions? Could there be something else wrong?

“Diaper rash”

Dear “Diaper rash”,

Most diaper rashes are due to the exposure of the child’s skin to urine and stool in the child’s diaper. This exposure in conjunction with the irritation of the diaper itself is the cause of most diaper rashes. (1) The enzymes found in stool irritate the skin and lead to skin break down.

These enzymes tend to have more of an effect on the skin during teething. In addition, teething is commonly associated with diarrhea and looser stools. (2 ) Any childhood condition that results in frequent stooling puts the child at risk for developing diaper dermatitis. (1) Therefore, whenever a child is teething or experiencing frequent stools it is a good idea to be diligent about diapering and skin care.

The best treatment for diaper dermatitis includes frequent diaper changes and exposing the skin to air and light as much as possible. (1) You can expose your child’s bottom to air by putting him to sleep for a nap on top of a waterproof pad with no diaper on. If you open all the shades in the room and expose your child's bottom to light this will also help. Warm baths are helpful for extensive or painful diaper rashes (3). If you put a tablespoon of baking soda in your baby’s bath water this will help soothe the skin.

Applications of emollients such as A& D ointment or Balmex with each diaper change will provide a barrier, so that stool and urine won't come into contact with the skin. You may also use an over the counter antacid liquid and apply it to the area, let it dry and then cover the area with a diaper crème. (1)

It is important to avoid diaper crèmes containing rosins and dyes as an ingredient because these products can irritate the area and exacerbate the condition. Diaper crèmes with lanolin, mineral oil, wax, and olive oil are particularly effective at protecting the skin. (1)

If you follow all of these measures and the rash does not go away, there may be a Candida (yeast) skin infection. A rash that persists for more than three days, and is accompanied by involvement of the skin folds(creases in the skin) and/or Oral Thrush probably represents a secondary yeast infection. (1) An evaluation by your baby’s Doctor or Nurse Practitioner can verify this diagnosis.

Typically, Candida diaper dermatitis appears as a red dry crusty rash with well circumscribed borders covering the diaper area, including the skin folds. Many times satellite lesions or circular lesions can be found. (3) A Candida yeast infection is commonly found in a child with frequent diarrhea or when a child is on a course of antibiotics. It has been found that infants can experience up to a 14 fold increase in the density of Candida Albicans in their diaper area after 10 days of therapy with amoxicillin. (4)

Over the counter products, such as Lotrimin, treat yeast infections on the skin. When applying Lotrimin to the diaper area, it is easier to mix equal parts of your diaper crème, such as Balmex, with the Lotrimin and keep it in a sealed, labeled plastic container. Diapering your child will go a lot smoother if the diaper crèmes are mixed ahead of time.

If a child’s Candida rash persists despite treatment he should be evaluated by his Doctor or Nurse Practitioner. Other skin infections or conditions may need to be ruled out or a switch in the antifungal medication to a prescription brand such as Nystatin may be necessary. (3) Other infections that may be responsible for a prolonged cass of diaper rash include Staph aureus, group A Streptococci (Strep), Coxsackievirus(Hand, Foot, mouth Disease), human papillomavirus (HPV), Herpesvirus and Sarcoptes scabiei(scabies). (1)

In some cases a persistent diaper rash, non-responsive to treatment and with no other signs of infection may represent Contact Dermatitis. Contact dermatitis in the diaper area presents as a redness that spares the skin folds (does not involve the creases in the skin). It is caused by a sensitivity to a product used in the area.

Some common causes of Contact Dermatitis in the diaper area include the colored dyes found in disposable diapers, additives in diaper crèmes and the preservatives and fragrances included in baby wipes. (5) If your child has a persistent diaper rash that doesn’t involve the skin folds you may be able to determine if it is a reaction to a product that you are using by following a few simple steps. First, eliminate all diaper crèmes. Next change the diaper brand to one without colored dyes. After making these changes wait 1 to 2 weeks to if the rash goes away. (1) If the rash disappears, chances are that the rash was due to a sensitivity to one of the products that you were using.

Any diaper rash this is resistant to treatment should be evaluated by your baby’s Doctor or Nurse Practitioner. In some cases a prolonged diaper rash may be a sign of other health conditions. Conditions such as Psoriasis, Zinc deficiencies or Acrodermatitis can present as a chronic diaper rash. (1) These conditions are rare and are only considered if the rash is chronic or lasting for over 4 weeks and resistant to therapy.

References:
(1)Nield L, Kamat D. Diaper Dermatitis: From “A” to “Pee”. Consultant for Pediatricians. 2006;June:373-380.
(2)Grassia T. Talking Teething: Start good oral hygiene early. Infectious Diseases in Children. 2006. August:44.
(3) Chow M, Durand B, Feldman M, Mills M. Handbook of Pediatric Primary Care. Albany, New York:Delmar Publishers Inc. 1984: 614-615.
(4)Brook I. The effects of amoxicillin therapy on skin flora in infants. Pediatr Dermatol. 2000;17:360-363.
(5)Guin J, Kincannon J, Church F. Baby-wipe dermatitis: preservative-induced hand eczema in parents and persons using moist towelettes. Am J Contact Dermat. 2001;12:189-192.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

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