Treating Diaper Rash
Guidance for primary care clinicians treating children with diaper rash
Diaper rashes are usually caused by irritant contact dermatitis due to friction, increased moisture, and exposure to urine and feces. Most rashes can be managed conservatively with barrier creams, gentle cleansing, and frequent diaper changes; however, the clinician should be vigilant for the development of secondary fungal or bacterial infections and maintain a broad differential when rashes fail to respond to standard therapies.
Key Points
Causes
- Mechanical irritation, like chafing, vigorous wiping, or rubbing (friction)
- Chemical irritants like diaper materials, baby wipes, bath soaps, laundry detergents or softeners, lotions, or scented diaper ointments
- pH disturbances, which can occur when a child has diarrhea or when the child or breastfeeding mother takes antibiotics
- Prolonged contact with feces or urine
Management
The medical home clinician often can instruct parents on how to
treat diaper rashes at home with barrier creams, gentle cleansing, frequent
diaper changes, and occasionally topical steroid ointments such as
over-the-counter hydrocortisone 1% ointment. Secondary fungal or bacterial
infections can occur; see Bacterial Infections (below).
Presentation
Diaper rashes affect 25-50% of children. Classic diaper rashes typically occur from irritants in contact with the convex surfaces of the genitourinary region and inner thighs. These diaper rashes look erythematous, papular, and can include scaling in some areas. Diaper rashes can make infants and children fussy or cry more during diaper changes.
Differential Diagnoses
-
Atopic dermatitis is uncommon in the diaper region but may occur in widespread disease.
-
Infantile psoriasis, which may be triggered by group A strep infections, appears as sharply demarcated erythematous plaques involving the skin folds.
-
Seborrheic dermatitis presents as scaling, erythematous plaques on the scalp, behind the ears, and in body folds, including the inguinal folds.
- Granuloma gluteale infantum is a complication of persistent diaper dermatitis. It presents as non-tender, violaceous nodules and plaques in the diaper area with surrounding erythema, sometimes with ulceration.
- Herpes simplex virus (HSV) 1 or 2 infections present as painful papules, vesicles, and ulcers on an erythematous base that can umbilicate, rupture, or ulcerate. Consider child sexual abuse.
- Primary varicella zoster (chickenpox) presents as small pruritic papules that evolve into clear fluid-filled vesicles and then scab over. It closely resembles HSV.
- Secondary varicella-zoster (shingles) has localized red papules that evolve into vesicles over several days and turn yellow. Shingles can occur on the buttocks (among other places) after a prior varicella infection – it is rare in children, but risk is increased in an immunocompromised child, and the diagnosis should be considered for a vesicular rash, including in the diaper region.
- Enterovirus (hand-foot-mouth disease) involves small blisters and red papules that often affect the buttocks, usually in conjunction with a more widespread rash on the palms, soles, and in the oropharynx.
- Sarcoptes scabei (scabies) presents as pruritic, scaly, thick papules, plaques, and nodules (especially on the penis) that can be localized or generalized and may have nodules or burrows. Look for lesions in interdigital spaces.
- Candidiasis may be present alone or in conjunction with irritant contact dermatitis. Dry erythematous patches involving the thigh folds, along with papules, pustules, and satellite lesions beyond the immediate rash. Treatments include topical agents (nystatin, miconazole, econazole, or ketoconazole). Be sure to also evaluate for thrush and treat if present. For severe, resistant-to-treatment yeast infections, consider oral fluconazole.
- Perianal streptococcus presents as a sharply demarcated erythematous plaque localized to the perianal region—though there is also a perivulvar variant. Often, concurrent streptococcal pharyngitis is present in the patient or a family member. This diagnosis requires systemic antibiotic treatment.
- Perianal staphylococcus is difficult to distinguish from perianal streptococcus. Systemic antibiotics are recommended.
Systemic processes
- Acrodermatitis enteropathica: Pruritic, symmetric, eczematous plaques and pustules with scarlet-red erythema. This condition is seen in association with zinc deficiency, diarrhea, conjunctivitis, alopecia, and/or rash at tips of fingers and toes.
- Langerhans cell histiocytosis: Unremitting, erythematous, seborrheic papules and plaques that can be petechial; it can be associated with multi-system disease, including hepatosplenomegaly.
Psychosocial circumstances
- Barriers to care (e.g., inability to pay for diapers) and other social determinants of health.
Child maltreatment
- Neglect can lead to extensive diaper rash.
Treatment and Management
Frequent diaper changes
Change the diaper as frequently as possible to reduce contact time
with urine and feces.
Gentle cleansing
Gently cleanse the area when soiled. Avoid wipes with a lot of
ingredients. Consider water wipes or soft cloths (e.g., you can cut up an old
cotton t-shirt) with plain water. Cotton balls soaked with mineral oil can also
gently remove feces. Alcohol, hydrogen peroxide, and other topical antiseptics
may cause pain and further irritation and should be avoided. If the area is raw,
using water with added baking soda may decrease the stinging sensation. [Shin: 2014]
Barrier ointment
Apply a good barrier ointment or paste to protect the skin from
further irritation and allow the underlying skin to heal. Effective barriers
tend to be sticky/adherent and have no added fragrance or color that can be
irritating. For example, pure petrolatum protects and moisturizes irritated
skin; petrolatum-based ointments usually appear mostly clear in color. Zinc
oxide (mineral ointment) also promotes healing and increases protection; these
ointments are often clear or white. Due to higher water content, creams wipe off
more easily than ointments; therefore, creams typically do not provide a barrier
that lasts as long as ointments. Avoid completely wiping off barrier ointments
between changes, as this increases unnecessary friction.
Crusting
A technique called “crusting” can be used for hard-to-treat
diaper rashes with significant skin breakdown. Crusting is done by alternating
layers of a protective barrier ointment with a powder to create extra
protection. Only the soiled outer layer of the “crust” needs to be removed
during diaper changes, ensuring that the underlying skin remains constantly
protected. A dermatologist-recommended crusting regimen:
- Supplies
- Zinc oxide paste 40% (Desitin Max Strength)
- Stoma powder (available for online purchase)
- 3M Cavilon No Sting Barrier Spray
- Regimen - Avoid inhalation of powders by the child or caregiver. You
will probably need to re-crust a few times daily, but do not
aggressively clean soiled crust. The whole “crust” can be gently removed
during bathing and then reapplied after gently drying the area.
- Apply stoma powder directly onto skin.
- Spray the powdered area.
- Repeat so the powder and spray are each applied 3 times.
- Then, add a barrier paste (put it on the diaper rather than the skin).
Powders
When friction and moisture are the chief problems, use diaper
powders such as corn starch, but be aware that inhalation of powders may
cause respiratory symptoms. [Shin: 2014] Corn starch may be used short-term in
crusting if stoma powder is not available, but stoma powder is
recommended.
Low-potency steroids
Low-potency topical steroids (class 6 or 7), such as
hydrocortisone acetate 0.5%, 1%, or 2.5% cream or ointment, may be considered
twice daily for up to 14 days, but avoid use of halogenated steroids (such as
triamcinolone). [Shin: 2014]
Recurrent rashes
Consider more frequent diaper changes and/or trying a different
type of diaper. Consider using hypoallergenic laundry detergents, bath, and
skincare products. One recommended approach to recurrent diaper rash is to apply
these in the following order with every diaper change: econazole, hydrocortisone
2.5% ointment, then an adherent barrier paste-like Desitin maximum strength.
Lack of evidence
There is lack of evidence to recommend:
- Air time between diaper changes promotes healing
- Mixing an antacid, such as liquid Maalox, with the diaper ointment to improve healing [trc: 2023]
- Adding vitamin A to ointments or creams [Shin: 2014]
There is no evidence that cloth diapers reduce the incidence of diaper rash when compared to disposable diapers, which are designed to be highly absorbent. [Helms: 2021]
Bacterial Infections
Services and Referrals
Pediatric Dermatology
(see RI providers
[3])
Consider referral when recurrent diaper rashes
fail to respond to conservative measures or the patient develops characteristics
concerning for an intrinsic dermatologic etiology such as atopic dermatitis or
psoriasis.
Resources
Information & Support
Related Portal Content
For Professionals
Skin & Soft Tissue Infection in Pediatric Patient Over 3 Months (Intermountain Healthcare) ( 460 KB)
A clinical algorithm for treating pediatric purulent and non-purulent skin and soft tissue infections. Although potentially
useful regardless of location, note that the algorithm is based on Utah and regional antibiotic resistance patterns.
Patient Education
How to Treat Diaper Rash (American Academy of Dermatology Association)
Dermatologists’ tips to prevent and treat diaper rash at home - includes a video.
Diaper Rash and Your Baby: Pediatric Education (AAP)
What to do if your baby gets diaper rash - account required to access; American Academy of Pediatrics.
Let's Talk About... Skin Care After Pull-Through Surgery (Spanish & English)
Printable, patient education about how to care for a child's diaper area after anorectoplasty, also known as pull-through
surgery; Intermountain Healthcare.
Let's Talk About... Diaper Rash (Spanish & English)
Printable, patient education about diaper rash prevention and care; Intermountain Healthcare.
Services for Patients & Families in Rhode Island (RI)
Service Categories | # of providers* in: | RI | NW | Other states (3) (show) | | NM | NV | UT |
---|---|---|---|---|---|---|---|---|
Pediatric Dermatology | 3 | 1 | 3 | 1 | 2 |
For services not listed above, browse our Services categories or search our database.
* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.
Helpful Articles
Helms LE, Burrows HL.
Diaper Dermatitis.
Pediatr Rev.
2021;42(1):48-50.
PubMed abstract
Shin HT.
Diagnosis and management of diaper dermatitis.
Pediatr Clin North Am.
2014;61(2):367-82.
PubMed abstract
This article reviews causes and evidence-based treatment of diaper dermatitis.
Authors & Reviewers
Author: | Claire K Turscak, MD, MS |
Reviewer: | Luke S. Johnson, MD |
2023: update: Claire K Turscak, MD, MSA |
2019: first version: Jennifer Goldman, MD, MRP, FAAPA; Sheryll Vanderhooft, MDR |
Page Bibliography
Helms LE, Burrows HL.
Diaper Dermatitis.
Pediatr Rev.
2021;42(1):48-50.
PubMed abstract
Shin HT.
Diagnosis and management of diaper dermatitis.
Pediatr Clin North Am.
2014;61(2):367-82.
PubMed abstract
This article reviews causes and evidence-based treatment of diaper dermatitis.
trc healthcare.
Pharmacist's Letter.
(2023)
https://pharmacist.therapeuticresearch.com/Content/Articles/PL/2006/De.... Accessed on Oct 2023.