Understanding and Managing Nappy Rash: A Paediatrician's Guide for Parents
Nappy rash is one of the most common skin conditions in babies and young children. It can be distressing for parents to see their child uncomfortable, but with the right care and preventive measures, nappy rash can be managed effectively. This article covers the causes, symptoms, treatments, and prevention of nappy rash, alongside answers to frequently asked questions.
What Is Nappy Rash?
Nappy rash, also known as diaper rash or diaper dermatitis, occurs when a baby’s skin in the nappy area becomes irritated and inflamed. This can lead to redness, discomfort, and even painful sores.
Why Does Nappy Rash Happen?
Several factors contribute to the development of nappy rash, each playing a role in irritating or damaging the delicate skin in the nappy area:
Prolonged Dampness and Occlusion
Wet nappies overhydrate the skin, making it softer, macerated, and more vulnerable to irritation. Urine and faeces contain ammonia, which raises the skin’s pH and irritates it. Additionally, non-breathable nappies and plastic pants trap moisture and heat, creating a warm, humid environment that significantly increases the risk of nappy rash development.
Friction
Tight nappies can rub against the skin, particularly during movement, causing irritation and contributing to nappy rash.
Chemical Irritants
Some baby care products, such as wipes, powders, barrier creams, and moisturisers, may contain irritants like plant-based oils (e.g., vegetable or nut oils) or chemicals such as methylisothiazolinone. Residues from soaps, detergents, or fragrances left on the skin or in cloth nappies after washing can also irritate sensitive skin.
Secondary Infections
Moist, damaged skin creates an ideal environment for microorganisms like yeast (Candida albicans) or bacteria to thrive. These infections can exacerbate the rash and lead to additional symptoms.
Underlying Skin Conditions
Babies with conditions such as eczema, seborrheic dermatitis, or other skin sensitivities are more likely to develop nappy rash due to their already compromised skin barrier.
Dietary Changes
When babies transition to solid foods, changes in stool consistency and pH can make the skin more prone to irritation. Acidic foods, including tomatoes, pineapple, strawberries, and citrus fruits, can further aggravate nappy rash by altering the chemical composition of stool.
Additional Factors
Nappy rash is less common in breastfed babies because their stool has a lower pH, which is gentler on the skin and less likely to cause irritation. Another factor to consider is the type of nappy used. Cloth nappies are less breathable and absorb less moisture than modern disposable nappies, which may increase the likelihood of nappy rash.
Symptoms of Nappy Rash
• The skin on your child’s bottom and genitals typically looks red, inflamed, and sore. On darker skin tones, the rash might appear brown, purple, or grey.
• Some areas of the skin may be raised or swollen and can sometimes become scaly.
• In severe cases, superficial ulcers may develop.
• Redness and irritation often occur where the nappy rubs against the skin, usually around the waistband or thighs, with friction in these areas sometimes leading to small erosions or breakdown of the skin.
• The rash usually spares the skin folds, as urine doesn’t typically come into contact with these areas.
• The rash can cause discomfort, pain, and itchiness, particularly when the area is wiped, making your baby unsettled and irritable.
• If the rash becomes infected with Candida (yeast), bright red patches may extend to involve the skin folds, abdomen, or back, often accompanied by small red dots known as "satellite lesions."
Diagnosing Nappy Rash
Nappy rash is typically diagnosed based on its appearance. Your doctor will examine the affected area or may review photos of the rash during a Telehealth consultation.
In more severe or persistent cases, your doctor might take a swab from the skin to check for the presence of thrush (Candida albicans) or bacterial infections. However, in most cases, empiric treatment is trialled first before further investigations are considered.
How to Treat Nappy Rash
The aim of treating nappy rash is to heal the damaged and irritated skin while protecting it from further dampness and friction that could worsen the condition.
1. Frequent Nappy Changes
Changing your baby’s nappy as soon as it becomes wet or soiled is essential for reducing prolonged contact with irritants. Frequent changes help the skin heal and prevent the rash from worsening. If the rash is severe, check nappies hourly to ensure your baby stays clean and dry.
2. Gentle Cleaning
Clean your baby’s nappy area gently with lukewarm water and a cotton cloth or cotton wool. After cleaning, pat the area dry instead of rubbing to prevent further irritation to the delicate skin. Avoid using baby wipes that contain fragrances or chemicals, as they can irritate sensitive skin (water wipes are a gentler option and may be used).
3. Apply Barrier Cream
Using a barrier cream at every nappy change helps protect your baby’s skin from further irritation and supports healing. Apply a thick layer of cream to form a protective barrier, ensuring it remains visible at the next nappy change. If the cream wipes off too easily or doesn’t adhere well, consider switching to a different brand for better protection. Some examples of barrier creams available in Australia include Sudocrem, Nappy Goo, Bunjie Baby Nappy & Barrier Cream, Mustela Vitamin Barrier Cream, Weleda Calendula Nappy Change Cream, Amolin Baby Cream, QV Baby Barrier Cream, Bepanthen Nappy Rash Ointment, and Desitin Nappy Rash Barrier Ointment.
4. Nappy-Free Time
Giving your baby’s bottom plenty of time to air out helps promote healing by keeping the area dry and reducing friction. Place a towel under your baby to manage any accidents during nappy-free play or rest time. Alternatively, you can fasten the nappy more loosely or use a larger size to improve airflow.
5. Switch to Disposable Nappies
Disposable nappies are more absorbent than cloth nappies and are a better choice during a nappy rash, as they help keep the nappy area dry. However, if you prefer to continue using cloth nappies, ensure they are thoroughly rinsed to remove any soap residue, especially after using bleach-based products. Adding absorbent inserts can also help minimize moisture. Ensure cloth nappies are completely dry before reuse to prevent further irritation.
6. Monitor Diet
If your baby’s nappy rash flares up, consider limiting their intake of acidic foods such as tomatoes, pineapple, strawberries, and citrus fruits, as these can exacerbate irritation. Reducing evening fluids can also help minimize nighttime wetting, reducing the risk of further irritation.
7. Medications
For severe nappy rash or cases that do not improve with basic measures, your doctor may prescribe corticosteroid creams or ointments, such as Hydrocortisone 1%. If a bacterial or fungal infection is present, your doctor might also recommend other specific creams or ointments to address these secondary infections effectively.
By following these steps, you can help your baby’s skin heal quickly and prevent the rash from worsening. If the rash persists or worsens despite these measures, consult your doctor for further advice.
Complications: Thrush and Other Infections
In some cases, nappy rash may result in secondary fungal or bacterial infections.
Prompt treatment is essential to prevent complications and support healing.
Fungal Infections
Damaged skin from nappy rash can often result in fungal infections, most commonly thrush (Candida albicans). Thrush typically appears as inflamed, bright red patches that may extend into the skin folds. A hallmark of thrush is the presence of satellite lesions—small, red bumps surrounding the main rash. Treatment generally involves the use of an antifungal cream, sometimes combined with hydrocortisone, and may take time to fully resolve.
Bacterial Infections
Nappy rash can also lead to secondary bacterial infections, such as impetigo. This bacterial infection often presents as raised, yellow blisters that rupture, leaving behind honey-coloured crusts. Bacterial infections can further aggravate the skin and may require local or oral antibiotic treatment prescribed by your doctor.
Preventing Nappy Rash
Prevention is always better than treatment. Follow these steps to reduce the risk of nappy rash:
• Change nappies frequently and keep the nappy area clean and dry to prevent prolonged contact with moisture.
• Use barrier creams daily to protect the skin.
• Let your baby enjoy nappy-free time to promote skin healing and airflow.
• If you are using cloth nappies, rinse them thoroughly to remove detergent residue and ensure they are completely dry before reuse.
When to See a Doctor
Consult your GP or paediatrician if your baby:
• Has a rash that hasn’t improved after a week of home care or seems to be worsening.
• Develops blisters, crusts, ulcers, or pustules.
• Is unusually distressed, irritable, or struggling to sleep.
• Shows signs of the rash spreading.
• Develops a fever.
FAQs About Nappy Rash
1. How much barrier cream should I use?
Apply a generous layer of cream to ensure the skin is fully covered and protected. The cream should act as a thick barrier, and you should still see some cream remaining at the next nappy change.
2. My baby’s nappy rash won’t improve. What should I do?
If the rash hasn’t improved after a week of consistent treatment, or if it appears to be worsening, consult your GP or paediatrician. Persistent nappy rash may require specialised treatments, such as antifungal, antibacterial, or corticosteroid creams.
3. Can I use cloth nappies during nappy rash?
While disposable nappies are often better at keeping the area dry, cloth nappies can still be used with proper care. Add absorbent inserts, rinse cloth nappies thoroughly to remove detergent residue, and change them immediately when they become wet to minimise irritation.
4. What foods should my baby avoid if they have nappy rash?
Acidic foods like oranges, pineapples, strawberries, and tomatoes can irritate your baby’s digestive system and worsen nappy rash. Consider reducing or avoiding these foods during flare-ups to help the skin heal.
5. Can I prevent nappy rash?
Yes, you can reduce the likelihood of nappy rash by keeping the nappy area clean and dry, changing nappies frequently, and applying a barrier cream regularly. Allowing your baby some nappy-free time each day can also help prevent irritation.
6. Is nappy rash contagious?
Nappy rash itself isn’t contagious. However, if the rash becomes infected with bacteria or fungi, those infections can sometimes spread. Early treatment and proper hygiene are key to avoiding complications.
7. What does an infected nappy rash look like?
Infected nappy rash may include symptoms such as bright red patches that extend into the skin folds, small red bumps (satellite lesions), blisters, or yellow crusts. If you suspect an infection, consult your doctor for treatment.
8. Can I use talcum powder for nappy rash?
Talcum powder should not be used for treating nappy rash, as it can irritate the skin further and potentially cause complications. Stick to barrier creams and regular cleaning for effective management.
9. Does breastfeeding reduce the risk of nappy rash?
Yes, breastfeeding can reduce the risk of nappy rash. Breastfed babies tend to have stools with a lower pH, which are less irritating to the skin. However, as babies transition to solid foods, the risk of nappy rash may increase due to changes in stool consistency and pH.
10. How often should I change my baby’s nappy to prevent nappy rash?
To prevent nappy rash, change your baby’s nappy as soon as it becomes wet or soiled. For newborns, this may mean changing nappies every 2–3 hours, or even more frequently if needed.
Summary
Nappy rash is a common yet manageable condition. Understanding its causes, maintaining good hygiene, and taking preventive steps can help keep your baby’s skin healthy and irritation-free. If the rash persists or worsens, consult a doctor to ensure appropriate treatment and relief.
By staying proactive, you can help your baby stay happy, comfortable, and rash-free.
Written by Dr Samuel Heitner
Click HERE to book a consultation with Dr Sam.