Introduction
Nappy rash, also known as diaper dermatitis, is an inflammatory skin condition that affects the area covered by a nappy (diaper), including the buttocks, perineum, groin, and lower abdomen. It is one of the most common dermatologic conditions in infants and is usually mild and self-limiting, though in some cases it can become severe or complicated by secondary infection.
It typically results from prolonged contact of the skin with moisture, friction, urine, and feces, leading to breakdown of the skin barrier and subsequent inflammation.
Epidemiology
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Most common in infants aged 9–12 months.
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Can also affect older infants and toddlers who wear nappies.
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More frequent during episodes of diarrhea or when starting solid foods.
Etiology and Risk Factors
Primary Causes
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Prolonged exposure to wetness and irritants (urine and feces).
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Friction between skin and nappy.
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Increased skin pH promoting enzyme activity (lipases and proteases) that damage skin.
Secondary Causes
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Candida albicans overgrowth – common in persistent rashes >3 days.
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Bacterial infections (e.g., Staphylococcus aureus, Streptococcus pyogenes).
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Allergic contact dermatitis (rare, due to fragrances, dyes, preservatives).
Risk Factors
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Frequent loose stools.
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Poor-quality nappies or infrequent changes.
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Use of harsh soaps or wipes.
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Recent antibiotic use (increases Candida risk).
Pathophysiology
Moisture and occlusion soften the stratum corneum, making it more susceptible to damage from friction and irritants.
Enzymes in feces break down skin lipids and proteins, compromising the barrier function. The damaged barrier allows penetration of irritants and microorganisms, triggering an inflammatory response.
Clinical Features
Irritant Diaper Dermatitis
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Erythematous patches with poorly defined margins.
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Affects convex skin surfaces (buttocks, thighs, lower abdomen).
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Skin folds often spared.
Candidal Diaper Dermatitis
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Beefy red plaques with well-defined borders.
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Satellite pustules or papules.
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Involves skin folds.
Bacterial Superinfection
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S. aureus: Honey-colored crusts, pustules.
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S. pyogenes: Bright red rash with sharp margins, possible systemic symptoms.
Diagnosis
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Clinical diagnosis based on appearance and distribution.
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No routine lab testing required.
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Fungal culture or KOH preparation if Candida suspected.
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Bacterial swab if severe infection suspected.
Management
General Measures (first-line for all cases)
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Frequent nappy changes: every 2–3 hours and after each bowel movement.
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Gentle cleansing with lukewarm water or mild fragrance-free wipes.
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Air exposure: allow nappy-free time to reduce moisture.
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Use superabsorbent disposable nappies to reduce skin wetness.
Barrier Protection
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Zinc oxide ointment (20–40%): Apply thickly with each nappy change.
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Petrolatum-based ointments: Protect against irritants.
Pharmacologic Treatment
For Irritant Diaper Dermatitis
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Barrier creams (zinc oxide, petrolatum) applied liberally each change.
For Candida-Associated Diaper Dermatitis
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Topical antifungals:
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Clotrimazole 1% cream: Apply twice daily for 7–10 days.
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Miconazole 2% cream: Apply twice daily for 7–10 days.
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Nystatin cream/ointment: Apply with each nappy change until resolution (usually 7–14 days).
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For Bacterial Superinfection
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Mild localized infection: Topical mupirocin 2% ointment, applied 3 times daily for 5–7 days.
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Severe or widespread infection: Oral antibiotics (e.g., flucloxacillin or cephalexin; doses based on pediatric weight).
For Severe Inflammation (short course only)
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Low-potency topical corticosteroid (e.g., hydrocortisone 0.5–1% cream): Apply thinly once or twice daily for up to 7 days, only under medical supervision.
Complications
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Secondary fungal or bacterial infection.
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Chronic recurrent dermatitis.
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Rare systemic infection in immunocompromised infants.
Prognosis
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With prompt and appropriate care, most cases resolve within 2–4 days.
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Recurrence is common if preventive measures are not maintained.
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