nappy rash

Baby with nappy rash

Baby without nappy rash

Which one is your child?   
By Dr. Marlo Swanepoel

The topic of this month’s article was a complete surprise.  After a consultation room full of crying babies and desperate mommies, I decided to share some knowledge I gained while conducting and writing my thesis as a student.  The topic TREATMENT OF NAPPY RASH.

Why Nappy rash you may ask. Well I am proud to say that I conducted a pilot (first) study on alternative, more specific homeopathic, treatment for Nappy Rash (NR).  My study yielded positive results and was published in the Journal Health SA Gesondheid (Read: Health).  Follow the link should you wish to read it http://www.hsag.co.za/index.php/HSAG/article/view/680. 

In the past few months I was bombarded by mommies desperate to find some solution to this common daily problem their baby had to face.

What is Nappy Rash?

The medical word for NR is known as Diaper Dermatitis.  Diaper meaning Nappy and “derma” skin and “-itis” inflammation, which is exactly what NR is, inflammation of the skin restricted to area covered by a nappy (1).  Nappy Rash is the most common skin complaint in babies and toddlers, estimated at 7% to 35%.  It is nearly impossible to determine the exact prevalence as many cases are treated at home. Others however are so severe that medical intervention is required (2,3).

What does Nappy Rash look like?

There are many different presentations of a Nappy Rash. The most common description is a red, flat, itchy and painful rash restricted to only the area covered by the nappy (diaper).  In some cases the rash may be more severe presenting with pimples and pus like eruptions.  It can become so severe that the skin may be broken forming an ulcer (2,3,4).  In many cases this rash may become infected with bacteria such as Staphylococcus spp. or Streptococcus spp., or fungi such as Candida albicans (5). Many studies showed that up to 77% of cases will within the first three days of having a Nappy Rash  be infected by the above mentioned organisms (6).

What causes Nappy Rash?

Nappy Rash is primarily caused due to the prolonged exposure to faeces and urine as well as the environment present within the diaper.  Although diaper technology has improved in recent years, resulting in a decrease in both incidence and severity of Nappy Rash, this condition remains a common problem (5). Things like: ammonia levels, friction, skin dampness (influenced by the type of diaper), pH level, enzymes contained in the urine and stool, micro-organisms (bacteria, fungus), diet (which has an effect on the alkaline levels), and skin maturation all affect the permeability of the skin resulting in an immune response which leads to inflammation which is what we will see as a rash (1,7). 

There are mainly three types of Nappy Rash: 

• Primary irritant diaper dermatitis, 
• Allergic contact diaper dermatitis and 
• Candida diaper dermatitis; all of which leads to the red painful rash we all dread (8).
  

What you can do to prevent or treat NR?

Due to the numerous causes of NR one must try to avoid contact with the most common causative agents. The golden rule is prevention is better than cure.

1. Nappies should be changed directly after every stool or urine passed 
2. Time spent out of a nappy should be increased
3. Harsh chemicals or irritants such as: wet wipes, perfumes and soap should be avoided
4. Only tepid water and cotton wool must be used to clean the nappy area 
5. Disposable nappies should be used instead of cotton nappies unless sensitivity or allergies towards the nappies are present (6,9,10). 

Moisture barrier creams, which have been shown to decrease water loss from the skin as well as  improving skin conditions in some patients may be applied . 

Topical creams used for Nappy Rash usually contain one or more of the following ingredients:  zinc oxide, petrolatum or dimethicone (a silicone based polymer) (4,9). Creams containing petrolatum, mineral oil, mineral wax and wool wax (lanolin), have also been shown to decrease loss of water, reduce inflammation and lower skin colonisation (bacterial or fungal growth) (2,4,10). Anti-bacterial, anti-fungal or Corticosteroid creams are prescribed for persistent NR to reduce inflammation and prevent secondary infections. However adverse effects such as thinning of the skin and adrenal axis suppression are risks (8,10) thus these should be avoided as long as possible.

In my experience protecting the skin by creating a barrier with things like lanolin, caster oil with zinc oxide mixture, bees wax, milking cream or Happy Nappy Cream (formulated by me) will be sufficient. Some paediatric nurses recommend using Mazina in a paste or the slimy water from oats (make sure it is cold when applied). I have to say even though I will only be a daddy in January 2015 I have been motivated to do my research due to my brothers and sisters having a total of 9 children and these tips I have witnessed as effective.

TOP 5 take away points

1.      Change the nappy regularly

2.      Keep the skin dry by allowing your baby to spent time without a nappy. Be careful of using baby powder as the fine dust can be inhaled by the baby and cause respiratory issues

3.      Avoid harsh chemicals or irritants such as: perfumed wet wipes, perfumes, soap and creams containing parabens

4.      Use tepid water and a cloth or cotton wool to clean the nappy area

5.      Apply a cream or ointment to create a protective barrier against urine and faeces, but be sure to wash your babies bum.

Referece

1.      Fölster-Holst, Buchner & Proksch 2011

2.      Wolf, R., Wolf, D., Tüzün, B. and Tüzün, Y. (2000). Diaper Dermatitis. Clinics in Dermatology, 18:657-660.

3.      Barkin, M.B. and Rosen, P. (2003). Emergency Pediatrics A Guide to Ambulatory Care. Pennsylvania: Mosby. Pp588-589.

4.      Visscher, M.O., and Hoath, S.B. (2006). Diaper Dermatitis. In Irritant Dermatitis. Edited by Chew, A., Maibach, H.I. New York: Springer, pp 37-51

5.      Fernandes, J.D., Machadoll, M.C.R. and de Oliveirall, Z.N.P. (2009). Clinical Presentation and Treatment of Diaper Dermatitis – Part II. Anais Brasileiros de Dermatologia, 84(1).

6.      Concannon, P., Gisoldi, E., Phillips, S. and Grossman, R. (2001). Diaper dermatitis: A Therapeutic Dilemma. Results of a Double-Blind Placebo Controlled Trial of Miconazole Nitrate 0.25%. Pediatric Dermatology, 18: 149-155.

7.      De wet, P.M., Rode, H., van Dyk, A. and Millar, A.J.W. (1999). Perianal candidos in a comparative study with mupirocin and nystatin. International Journal of Dermatology, 38: 618-622

8.      Wahrman, J.E., and Honig, P.J. (2000). Clinical Features and Differential Diagnosis. In Textbook of Pediatric Dermatology. Volume 1. Edited by Harper, J., Oranje, A., and Prose, N. London: Blackwell Science Ltd, pp 58-

9.      Scheinfeld, N. (2005). Diaper Dermatitis: A Review and Brief Survey of Eruptions of the Diaper Area.  American Journal of Clinical Dermatology, 6(5): 273-281.

10.  Friedlander, S.F., Eichenfield, L.F., Leyden, J., Shu, J. and Spellman, M.C. (2009).  Diaper Dermatitis: Appropriate Evaluation & Optimal Management Strategies. Contemporary Pediatrics, April: 1-13.