Guidance for primary care clinicians treating children with diaper rash

Diaper rashes are caused by irritant contact dermatitis due to friction, increased moisture, and prolonged exposure to urine and feces. Most rashes can be managed conservatively with air time, 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 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
• Moisture build-up and poor airflow due to infrequent diaper changes
• Prolonged contact with feces or urine

Management
Diaper rashes affect 25-50% of children. The medical home clinician often can instruct parents on how to treat diaper rashes at home with air time, barrier creams, gentle cleansing, and frequent diaper changes. Secondary fungal or bacterial infections can occur, though.

There are no pediatric care guidelines for diaper rashes.

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, and they may cry more during diaper changes.

Differential Diagnoses

• Atopic dermatitis is less common to see than eczema in the diaper region, but it may still occur in widespread disease.
• Infantile psoriasis may be triggered by group A strep infections. Appears as sharply demarcated erythematous plaques involving the skin folds.

• Herpes simplex virus (HSV) 1 or 2 are painful papules, vesicles, and ulcers on an erythematous base that can umbilicate, rupture, or ulcerate. Consider child sexual abuse.
• Primary varicella zoster (chicken pox) are 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 that turn yellow. Shingles can occur on the buttocks (among other places) after a prior varicella infection – rare in children, but increased risk if in an immunocompromised child and should be considered as part of the differential for a vesicular rash that could occur in the diaper.
• Enterovirus (hand-foot-mouth disease) involves small blisters and red papules, usually in conjunction with a more widespread rash on the body and in the oropharynx.
• Sarcoptes scabei (scabies) are pruritic, scaly, thick papules and plaques that can be local or generalized and may have nodules or burrow tracks. 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 and satellite lesions beyond the immediate rash may be involved. Treatments include topical agents (nystatin, miconazole, 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 has sharply demarcated erythematous plaque localized to the perianal region only. Often concurrent with streptococcal pharyngitis in the patient or family member. Requires systemic antibiotic treatment.
• Perianal staphylococcus is difficult to distinguish from perianal streptococcous. Systemic antibiotics are recommended.
  Systemic processes
  • Acrodermatitis enteropathica: Pruritic, symmetric, eczematous plaques and pustules, scarlet-red; in association with zinc deficiency, diarrhea, conjunctivitis, alopecia, and/or rash at tips of fingers and toes.
  • Granuloma gluteale infantum: Non-tender, violaceous nodules and plaques in the diaper area with surrounding erythema, some with ulceration, develops after resistant irritant diaper dermatitis.
  • Langerhans cell histiocytosis: Severe, unremitting, erythematous, seborrheic papules and plaques can be hemorrhagic; it is typically associated with multi-system disease, including hepatosplenomegaly.
  Child maltreatment
  • Neglect can lead to extensive diaper rash.
  Psychosocial circumstances
  • Consider barriers to care (e.g., inability to pay for diapers) and other social determinants of health.

1. Change the diaper as frequently as possible to reduce contact time with urine and feces.
2. Gently cleanse the area when soiled. Some infants and children do fine with regular commercial wipes; others do better with hypoallergenic wipes or water and a soft washcloth when the skin barrier is not intact. Cotton balls soaked with mineral oil can also be used to gently remove feces. Alcohol, hydrogen peroxide, and other topical antiseptics may cause pain and should be avoided. If the area is raw, using water with added baking soda may decrease the stinging sensation. [Shin: 2014]
3. Leave the diaper area open to air dry for several minutes and ensure that the area is completely dry before placing a new diaper. If possible, increase airtime by allowing the infant to nap on a towel without a diaper. This may be more practical with female infants.
4. Apply a good barrier ointment to protect the skin from further irritation and allow the underlying skin to heal. Effective barrier ointments 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. Added vitamin A does not demonstrate a clear benefit. [Shin: 2014] 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.
5. If pH is a problem, such as during diarrheal illness, mixing an antacid (e.g., Maalox) with the barrier ointment can provide additional protection.
6. 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] Generally, limiting use of steroids in the diaper area is preferable to no more than a week to avoid over-thinning the skin.
7. When friction and moisture are the chief problems, use diaper powders such as corn starch, but be aware that inhalation of powders into the infant or child’s lungs may cause respiratory symptoms. [Shin: 2014]
8. 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, such as corn starch, talc, or stoma powder, to create extra protection. Layering on the ointment and powder means that during diaper changes, only the soiled outer layer of the “crust” needs to be removed, ensuring that the underlying skin remains constantly protected. Again, avoid inhalation of powders by the child or caregiver. The whole “crust” should be gently removed during bathing and then reapplied after gently drying the area.
9. For recurrent rashes, consider more frequent diaper changes and/or trying a different type of diaper. There is no evidence that cloth diapers reduce the incidence of diaper rash compared to disposable diapers, which are designed to be highly absorbent. [Helms: 2021] Consider using hypoallergenic laundry detergents, bath, and skincare products.

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.