Diaper Rash – Understanding, prevention and parent education

Diaper dermatitis commonly known as diaper rash is a fairly common skin condition characterized by an acute inflammatory eruption of the skin in the diaper area of an infant. It can cause considerable pain and stress for infants and can be troublesome for their caregivers.

It is estimated that the prevalence of diaper dermatitis in the general population is between 10 percent and 40 percent. Diaper dermatitis is found most commonly among children younger than 2 years of age, with the majority of cases found in children under the age of 1 year. It is found equally among male and female infants as well as among infants of all ethnic groups

TYPES OF DIAPER DERMATITIS
The three most common types of diaper dermatitis include chaffing or friction dermatitis, irritant contact dermatitis and diaper candidiasis (fungal infection). Among which irritant contact dermatitis is most commonly seen.

WHY DOES MY BABY HAVE DIAPER RASH?
Human skin consists of several layers and the outermost layer which serves as a barrier to providing protection from physical, chemical and biologic threats is still in developing stage in a newborn and it remains vulnerable to the presence of irritants on the skin, such as moisture from urine and faeces, faecal enzymes, diaper materials and cleansing agents, as well as friction caused by the diaper itself.

The development of irritant contact diaper dermatitis is multifactorial. The presence of urine can lead to overhydration of the skin, making the skin surface more fragile and increasing the permeability of the skin by irritants. The presence of fecal enzymes, specifically protease and lipase, has been identified as a major irritant on the skin, while bile salts increase the damage of fecal enzyme action on the skin itself. The presence of these factors can cause a disruption in the integrity of the skin, leading to a breakdown of the skin barrier, resulting in inflammation and diaper dermatitis develop.

FACTORS TO CONSIDER WHEN ASSESSING FOR DIAPER DERMATITIS
-Duration of the rash Symptoms (pain and itch)
-Hygiene practices and cleansing routine (frequency of diaper changes, type of cleanser, washcloths or wipes, exposure to irritants, such as perfumes and dyes)
-Type of diaper used (cloth or disposable)
-Trauma to the skin (friction from the diaper; a vigorous cleansing)
-Recent antibiotic use or other medications- Frequency of urination and defecation (frequency, consistency)
-Products applied to the skin (barrier creams, powders, home remedies)
-Diet (formula vs. breastfed, introduction of new foods and diet)
-Recent gastrointestinal illnesses

PRACTICAL SOLUTIONS FOR THE PREVENTION AND TREATMENT OF DIAPER DERMATITIS
(“ABCDE”) APPROACH
AIR – Expose the diaper area frequently to air as much as possible; allow diaper-free time. The removal of the diaper allows the skin to air dry and also decreases friction on the skin in contact with the diaper.

BARRIER – As both a preventive measure and as part of a treatment regime for diaper dermatitis, barrier cream (zinc oxide or petrolatum) should be applied at each diaper change for infants at risk of developing diaper dermatitis and whenever diaper dermatitis is present. Barrier cream should be applied in a thick coat to all areas of skin that might be exposed to harmful irritants and should not be wiped off completely during diaper changes. The application of oil is allowed if the baby is kept in cotton cloth nappies.

CLEANSING- Gently cleanse the diaper area with water and a soft cloth or a diaper wipe (hypoallergenic with aloe vera) at every diaper change. Avoid rubbing skin vigorously. Cleansing the skin of the diaper area with wipes has been found to be as effective on skin hydration, pH, erythema and microbial colonization as using cotton and water without any adverse effects. However, water alone may not be as effective as a mild cleanser in removing stool from the diaper area, as the water-insoluble fragments may not be removed completely, more friction is necessary to remove the stool and residue may be left on the skin area

DIAPER- Use a super absorbent diaper. Change diaper as soon as the diaper is soiled, at least every 1 to 3 hours during the day and once during the night. The traditional cotton cloth nappies can also be used, but they need to be changed frequently as cannot absorb the urine at all making the baby wake up with every passage of urine/stool.

EDUCATION- Parents must receive appropriate education from nurses and pediatricians to ensure that the importance of diaper hygiene and good skin practices is understood. Parents should be reminded washing their hands before and after the diaper change.

WHEN TO SEE YOUR DOCTOR
Parents are encouraged to continue “ABCDE” approach until the rash is gone and should seek advice from a health care provider if the diaper dermatitis does not respond to these strategies or becomes worse after a few days.
Your doctor may advise certain pharmacologic measures (topical ointments) to treat diaper rash according to type and severity of the rash.

By Dr. Atul Chopra
Head – Paediatrics & Neonatology
Rosewalk Healthcare
&
By Dr. Rahul Jain
Junior Consultant – Paediatrics & Neonatology
Rosewalk Healthcare

ROSEWALK TEAM