Nappy Rash
Consultation guide for UK community pharmacy: clinical features, referral criteria, time frame to resolution and management strategy.
Clinical features
- Irritant contact dermatitis around the nappy area, resulting from fragile hydrated skin (as a result of nappy wearing) being in contact with urine or faeces for prolonged periods
- Secondary infection with candida or bacteria can occur. Bacterial: marked redness with exudate, and vesicular and pustular lesions. Candidal infection results in sharply marginated redness around the perianal skin, which may involve the perineum. Confluent zones of papules and pustules involving the skin creases; satellite lesions (secondary lesions away from the main rash) are characteristic of candida infection. Candidal infection is more likely when oral candidiasis is present and can be linked to broad spectrum antibacterial use
Referral criteria
- Signs of bacterial secondary infection (bacterial skin infections may present with clinical features such as weeping, oozing, crusting, pustules, erythema in tandem with systemic symptoms such as fever and malaise)
- Presence of inflammation or severe rash
- Candidal infection of the nappy area with concurrent oral candidiasis
Time frame to resolution
- Improvement should be seen within days of treatment commencement
- If candida, treated with a topical antifungal agent, the manufacturer will stipulate the treatment timeframe which may also include use for a specific timeframe after the symptoms have resolved
Management strategy
Non-pharmacological advice
- Consider advising on the use of nappies with the greatest absorbency (for example, disposable gel matrix nappies) whilst respecting parental choice
- Leave nappies off for as long as is practically possible
- Clean and change the child as soon as possible after wetting or soiling. Use water, or fragrance-free and alcohol-free baby wipes (not soap, bubble bath, or lotions), with gentle drying technique
- The child should be bathed at least once a day but not more than twice a day (as it can cause dryness of the skin)
Pharmacological advice
- Irritant contact nappy rash which is not infected and there is mild erythema only (since inflammation may warrant the addition of topical hydrocortisone, which is POM for this indication): a barrier cream (such as Zinc and Castor Oil ointment BP) can be used as directed at each nappy change
- Irritant contact nappy rash with secondary candidal infection (and no oral involvement): use a topical imidazole cream (an example would be clotrimazole 1% cream). Explain how a thin layer of cream only should be applied to prevent moisture entrapment. The frequency of application and duration of treatment depends on the imidazole used. It is generally advised that a barrier preparation should not be used until after the candidal infection has settled (to avoid moisture entrapment)