Nappy Rash (Napkin Dermatitis)

Occurs under the nappy from exposure to wetness and faeces — a dull red rash, most prominent where the nappy contacts the skin. Can occur in any nappy-wearing baby; will inevitably develop if wet/soiled skin is left long enough.

Differential

• Rash in the skin folds raises the possibility of seborrhoeic dermatitis (see cradle cap — often co-occurs).
• Thrush can coexist — brighter red rash, often with satellite pustules/lesions.
• Secondary bacterial infection (impetigo) — crusting, pustules, irregular blisters; swab if honey-crusting is apparent and treat with antibiotics.
• Resistant or recurrent nappy rash — consider psoriasis or atopic dermatitis.

Management

Non-pharmacological:

• Change wet/soiled nappies promptly; nappy-free time to air the area.
• Highly absorbent disposable nappies.
• Give evening fluids earlier to reduce overnight wetting; change the nappy before parents go to bed.
• Wash gently with warm water, pat dry; avoid excessive bathing/soap and avoid powder.
• Moisturise (e.g. zinc oxide and castor oil cream) to keep skin lubricated.

Pharmacological:

• Barrier cream (e.g. Bepanthen, Sudocrem) with every nappy change.
• Hydrocortisone twice daily + combination miconazole/zinc cream with every other change.
• If more severe: methylprednisolone aceponate 0.1% daily + miconazole/zinc with every other change.
• Never use topical steroid without an antifungal agent — a gluteal granuloma can form.