One minute your baby happy and the skin in the diaper area looks great; the next minute, he or she is sad and red…
Diaper rash can come really quickly! And if your baby is crying and you know that they’re not sleepy or hungry, checking the diapers both for their content and your baby’s skin might reveal why your baby is fussy.
In this article, I will explain what diaper rash really is it and what is the best way to prevent and treat it. Obviously, it is something that can make a baby very uncomfortable and you want to get it cleared up as soon as possible.
Diaper Rash (Diaper Dermatitis) Guide
How Common Is Diaper Rash?
Diper rash – or diaper dermatitis, which is the medical term – is a common reason for pediatric doctor visits. 65 percent of infants experience it at least once, especially between nine to 12 months old.
There are several types of diaper rashes.
Most are preventable, and many can be managed simply by changing the baby’s skin care regimen. Other types, however, require medical treatment. Recurrent diaper rashes can be frustrating for parents, and uncomfortable for infants and toddlers.
Why Do Diaper Rashes Occur?
There are a variety of reasons why a baby my develop a diaper rash. Infant skin has some unique features that make it more susceptible to this problem.
Infant Skin Is Immature
Skin consists of three layers: epidermis, dermis, and subcutaneous fat. The epidermis is the top skin layer, and the outermost portion is called the stratum corneum. It is the skin’s first line of defense, and has 10 to 15 layers. However, the stratum corneum is much thinner in infants than in older children and adults which makes it prone to irritation and dryness. Skin that becomes too dry also loses more moisture, causing it to feel rough and uncomfortable.
The skin of the diaper area can become irritated in various ways. The ingredients of some soaps, baby washes, or lotions can irritate sensitive skin. In other cases, the cleaning agents or fragrances in conventional laundry detergents are the problem. Friction on the skin may occur while wiping, or because of certain diaper materials. Here is an example of a rash that most likely is caused by the diaper; Pampers in this case.
Urine and stool are additional skin irritants. Once inside of a diaper, urine forms ammonia which can cause a “burn” type of rash. Diarrheal stools are particularly irritating due to the presence of digestive enzymes.
Food allergens can cause a skin-irritating diarrhea as well as an allergic rash. For example, research has confirmed that cow’s milk allergy as well as lactose intolerance are common causes of recurrent diaper dermatitis. In this situation, however, once the offending food is removed from the diet, the diaper rash improves.
Skin pH Is Too High
Let’s review some acid-base chemistry. The term pH is used to numerically describe whether something is acidic, neutral, or alkaline. Water has a neutral pH , and is given a value of 7. Anything below this number is considered an acid such as citrus fruits or vinegar. Baby washes and laundry detergents are alkaline because their pH is above 7.
A normal skin ranges from 4 to 6. At birth, the skin has a neutral pH, but it becomes more acidic within the first few days of life. This acidity stimulates the activity of enzymes within the dermis that protect the skin. Urine, stool, and some skincare products raise the skin’s pH above 7 which impairs the function of these skin enzymes. Prolonged and repeated skin contact with alkaline irritants results in a diaper rash.
Excessive Moisture On The Skin
While it is important to keep diapered skin well hydrated, too much moisture actually causes a diaper rash. Most disposable diapers are designed to prevent leakage of urine and stool. However, this also creates a very warm, humid diaper environment. Some infants and toddlers also sweat while wearing a diaper, thus creating more trapped moisture.
When wet, soiled diapers are not regularly changed, the risk of diaper dermatitis increases. This often occurs when a baby has multiple caregivers. Each may have a different definition of what “regular diaper changes” means, and the infant may stay in a wet diaper much longer than anticipated. Excessive wetness causes irritation and diaper yeast infections. The latter is caused by the overgrowth of a fungus that is part of the normal skin flora, Candida albicans.
Unbalanced Skin Microbiome
The epidermis has a microscopic layer of healthy bacteria called the microbiome. It begins to develop at birth in infants born vaginally, but later in those born via caesarian section. The skin microbiome of full-term infants is fully functional by ages four to six weeks. An alkaline pH or too much moisture on the skin disrupts the balance of flora, and increases the risk of fungal overgrowth or bacterial infections. Yeast diaper rashes may also occur when infants take oral antibiotics for ear and other infections.
A baby suffering from oral baby thrush can get a nappy rash from this if it spreads from the mouth to the rest of the body.
Types of Diaper Rashes and Their Symptoms
The best advice I can give you about how to spot nappy rash is if the diaper area begins to look red and irritated. Know that not all rashes appear the same; the skin can actually be slightly puffy and warm, or tender to the touch.
The diaper rash can also vary in intensity. It can be mild, where it looks like small little spots in a small area. The diaper rash can also be so extreme that the entire area is red, swollen and tender. It can also be anywhere in between.
Let’s go through different types of diaper rashes and what they usually look like.
Irritant nappy rash
An irritant diaper rash is characterized by red, “raw” looking skin that can progress to open and bleeding areas. It may appear anywhere in the diaper area, extending from the pubic bone to the buttocks. Typically, the skin folds and genitals are unaffected.
Candida albicans
Signs of a yeast infection in the diaper area are redness, skin peeling, and, occasionally, itching. Pimples may form within and around the areas of redness. This rash may spread to the scrotum in boys, but is not associated with vaginal discharge in girls.
Bacterial Infections
Some diaper rashes become secondarily infected with bacteria because irritation has disrupted the skin’s protective barrier. Staphyloccocus aureus is the most common culprit, but E. Coli and Bacteroides are other possible pathogens. Classic signs are red, painful skin with pus-filled pimples. In cases of MRSA, a more severe strain of staphylococcus, some skin areas may become black and necrotic.
Coxsackie Viral Infection
Coxsackie viruses cause what is better known as “hand, foot, mouth disease.” This is a common viral illness among infants and toddlers, and may be associated with fever, mouth ulcers, and loose stools. In addition to the characteristic clear fluid-filled blisters that appear on the palms and soles, infants may develop them in the diaper area. Over time, these blisters become dry and crusty. Despite the sometimes worrisome appearance, this diaper rash is not painful and self-resolves.
Infantile Seborrhea
Seborrhea is an oily rash with yellow flakes, similar to adult-type dandruff. Many parents expect to see “cradle cap” on their infant’s scalp or face, but are unaware that it may appear elsewhere. Some cases spread down the body, and include the diaper area. Unlike other forms of diaper dermatitis, seborrhea is associated with excessive oil gland activity, and an immune response to a skin flora fungus called, Malassezia furfur.
Psoriasis
Infants with this rare condition develop a persistent, clearly demarcated, red diaper rash. It may develop after an infection, or from irritation caused by too vigorous wiping. It is more likely to occur when there is a family history of psoriasis. Because of its severity and chronicity, psoriatic diaper rashes usually require longterm treatment.
Diaper Dermatitis Prevention
Prevention is the primary goal for most diaper rashes. The American Academy of Pediatrics has developed the mnemonic ABCDE for diaper area skincare. Research supports the ABCDE guidelines, concluding that the best prevention is diligent skin hygiene and emollient use. Frequent diaper changes, especially overnight, also reduce the frequency of this problem.
Air
Let your baby kick around bare bottom! Regularly exposing the skin to air can prevent most diaper rashes. Removing the diaper for brief periods gives the skin a reprieve from moisture. After a rash has developed, two to three hours per day of diaper-free time can speed its resolution.
Using a hand-held fan during diaper changes may be helpful to ensure that the skin is as dry as possible.
Barrier
When cleaning the diaper area, patting instead of rubbing the skin reduces friction.
The use of diaper ointments, pastes, or emollients creates a barrier between the skin and irritants or moisture. There are a variety of such products on the market which contain ingredients such as zinc oxide, petroleum, and lanolin. Because the skin quickly absorbs lotions and creams, they are less effective for preventing diaper rashes.
Baby powders should be used with caution, and those that contain talc are not recommended. Talc particles can become aerosolized, inhaled, then irritate an infant’s lungs. In contrast, cornstarch powders are safe to use, and may have a drying effect within the diaper. Fungal diaper rashes, however, may become worse with cornstarch or standard diaper rash products.
Cleaning
Hygiene practices can both prevent and improve diaper dermatitis. Rinsing the diaper area under warm water can effectively clean the skin in a non-irritating way. Wet wipes are also ideal. Most are made of cotton, micellar water, and a surfactant, along with pH buffers to help maintain the skin’s acidic pH. Some studies show more skin protection with the use of wipes than solely a moist washcloth.
Wet wipes with fragrances or potentially harsh ingredients, however, should be avoided. They also contain preservatives, so caution should be used for babies with sensitive skin.
Diapers
Once soiled, diapers should be changed as soon as possible. Disposable diapers contain a gel core that absorbs urine and liquid stool, helping to keep moisture away from the skin. There is a limit, however, to the amount of absorption, so diapers should be changed frequently.
Cloth diapers have become increasingly popular, especially in regards to their lower carbon footprint. Many styles are available, including those with attached leakproof but breathable covers. Because cloth diapers do not separate wetness from the skin, they must be changed frequently. Parents should be mindful of specific laundering recommendations for cloth diapers, and that petroleum-based diaper creams can damage the material.
Education
Good hand washing is important, both before and after changing a diaper. This reduces the transmission of bacterial infections, and the need for antibiotics.
If it can be suspected that the diaper rash is caused by e.g. some food allergy or sensitivity to some laundry detergent, removing these will, of course, prevent the diaper rash from reoccuring.
Nappy Rash Treatment Options
Most diaper rashes can be treated with the same ointments, emollients, or pastes used to prevent them. These ointments together with bare bottom time, frequent diaper change and gentle cleaning will often clear the dipaer rash effectively.
When these measures fail, it is time to see a doctor. Some forms of diaper dermatitis require medication. For example, an anti-fungal cream may be prescribed to treat rash caused by Candida albicans. If the skin of the diaper area is very inflamed, a version that contains a topical steroid can be helpful. Most yeast diaper rashes resolve within a week after beginning treatment.
Bacterial diaper rashes are treated with antibiotic ointments if mild, or oral antibiotics for moderate to severe cases. No treatment is necessary for seborrheic or coxsackie diaper rashes.
Psoriatic diaper dermatitis is typically managed by a dermatologist. A low to mid-potency steroid cream is prescribed for two weeks, often followed by ongoing treatment with a non-steroid anti-inflammatory ointment. Steroid creams should not be used in the genital area longterm because of side effects such as localized skin thinning, and potential adverse effects on growth, weight, and immunity.
Recent studies have evaluated the role of breastmilk in the prevention and treatment of diaper rashes. Breastmilk is naturally fortified with fat-soluble vitamins, calcium, and vitamin B12. These components soften and strengthen skin. Although further research is necessary, positive outcomes have been seen when using breastmilk for diaper rashes.
Frequently Asked Questions
Can Teething Cause A Diaper Rash?
It is possible for infants and toddlers to develop mild irritation in the diaper area when teething. This is due to excessive saliva production. Most of this saliva is seen as drooling, but it is also swallowed. Just as it can irritate the skin of the face, the digestive enzymes of saliva can irritate the diaper area when stool is passed.
Do Baths Help Diaper Rashes?
Baths help keep diaper area skin clean, removing urine and stool more effectively. It is important, however, to dry the skin well after bathing to prevent problematic excess moisture once diapered.
Does Vaseline Heal Or Prevent Diaper Rashes?
Although several baby diaper rash products contain petroleum jelly, this ingredient is combined with others to create product that forms a thick protective layer on the skin. Vaseline itself tends to absorb quickly, and is a less effective barrier against wetness and irritants.
Should I Use A Diaper Cream At Every Diaper Change?
Every baby’s skin is different, and those with sensitive skin may need an application of diaper cream each diaper change. For babies with frequent redness in the diaper area, such products are a helpful prevention measure. When prescription creams are required, however, it is best to ask a doctor if the usual diaper rash products may be used concurrently.
What About Diaper Sprays?
Diaper rash sprays are newer products to the market. So far, there are no clinical studies that have evaluated their efficacy in preventing or treating diaper dermatitis. Similar to spray sunscreens, getting complete skin coverage may be an issue, so parents should be mindful of this when using these products.
Can A Diaper Rash Cause A Fever?
It is possible for an infant to develop a fever in cases of bacterial diaper dermatitis. Because a fever is a sign of a more severe infection, oral antibiotics would be prescribed. Coxsackie infections are often associated with high fevers due to virus itself, and not the diaper rash.
Why Does My Baby Keep Getting A Diaper Rash?
Frequent diaper rashes may be due to one or a combination of issues. Sensitive skin is more prone to irritation. Excessive wetness can cause recurrent irritant or fungal diaper rashes. Speaking to a healthcare provider can help determine the source of the problem, and the best way to manage stubborn diaper rashes.
When Should I Call A Doctor?
Medical care is necessary if the following symptoms develop:
- Pain associated with a diaper rash
- Presence of blisters or pus
- Fever
- A rash that worsens despite using standard diaper rash products
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Research References