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.

Other Names

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).

There are no pediatric care guidelines for diaper rashes.

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.

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.
  1. Apply stoma powder directly onto skin.
  2. Spray the powdered area.
  3. Repeat so the powder and spray are each applied 3 times.
  4. Then, add a barrier paste (put it on the diaper rather than the skin).

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

Pediatric Dermatology (see NW providers [1])
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.