Nappy rash prevention

16 November 2018

First published December 2011

What is the best way to protect and prevent babies from nappy rash?

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The science of nappy skin

Up to fifty per cent of babies will suffer from the irritant dermatitis in the nappy area, or inflammatory eruption of the skin, known as nappy rash.1 The NHS estimates that up to one third of all nappy-wearing babies will be affected by the condition at any one time.2

Researchers found that prevalence in the UK was as high as 25 per cent in the first month of life alone.3 A paper published this year, however, suggests that some literature may be under­quoting the true figure, arguing that babies with mild-to-moderate nappy rash are rarely taken to a doctor, leaving these cases unreported.4

While most cases of nappy rash are mild, if not treated promptly the damaged skin can quickly become infected with bacterial or fungal infections such as Candida spp. and Staphylococcus aureus, requiring a visit to the GP.5

Nappy rash, which clinically manifests with erythema (redness), is an important issue, and both health visitors and mothers recognise it as such. A survey found that 64 per cent of mothers raised the subject themselves with their health visitor while 57 per cent of health visitors saw preventing and treating the condition as an essential topic to discuss with mums.6

But what causes nappy rash and why are so many infants affected at some stage during their first months? There are two main reasons. First, babies' skin is particularly vulnerable. It was once thought that a healthy, full-term newborn had a similar skin barrier structure and function to that of adults but recent research has shown that a baby's skin is completely different from that of an older child or an adult.7,8

In one study, researchers compared the differences between infant and adult skin in 20 mothers and their children aged between three and 24 months. They found that the infants' stratum corneum (SC), or outer skin layer, was 30 per cent thinner than that of the mothers, while their epidermis (the whole upper skin layer, of which the SC is the outermost) was 20 per cent thinner.9

Another study looked at the waythat water interacted with the SC in 124 babies aged between three and 12 months compared with that of 104 adults. The researchers found that while the babies' SC appeared intact shortly after birth, the way in which their skin stored and transported water only became adult-like after the first year of life.In particular, the rate at which infant skin lost water - known as transepidermal water loss (TEWL) - was higher than for adults. This is significant because the skin acts as a barrier, preventing the body from losing too much of its water and also preventing harmful chemicals and micro-organisms from entering. TEWL is established for evaluating the effectiveness of that skin barrier10- a lower TEWL indicates a better barrier.

The infant SC then is still developing at least during the first year of a child's life and, given that baby skin is already so vulnerable, nappies provide the conditions that can lead to a whole cycle of disruption to the baby's skin barrier in that area.

Nappy rash is the result not of one irritant but of several, acting together. The single most important of these factors is prolonged contact with urine and faeces.11 Nappy-wearing increases the skin's wetness, while urine on covered skin raises its pH; that is, its alkaline level.12,13 An acidic skin surface is essential for the normal microflora that protect the skin against pathogenic bacteria and yeasts.8,14,15

Wetness leads to a softening of the SC, weakening the skin's physical integrity and leaving it more susceptible to damage both from rubbing from the nappy itself, and from salts and enzymes in the faeces that are exacerbated by the high alkaline levels. 16,17,18 Even where there is no clinical nappy rash present, new research shows that the pH and TEWL of the skin under the nappy are higher than for the skin on the infant's thigh. 4

Some circumstances put the infant at higher risk of developing nappy rash. It is widely accepted that the irritant salts in the faeces, along with bacteria and fungi, can all increase during certain phases of development, such as teething or moving from a liquid to solid or semi-solid diet. And the activity of these salts is also greatly increased by acceleration of gastrointestinal transit: one study found a three-to-four-fold increase in nappy rash if the child had diarrhoea during the previous 48 hours.19 Nappy rash is of course treatable but clearly, as with any medical condition, prevention is by far the better option. A body of evidence is now emerging about how this might be achieved.

 

The importance of cleansing

By Sandra Hempel

Skin cleansers have been developing over centuries, from the harsh soaps of ancient Babylon made from animal fats and alkaline solutions, through Lever's Sunlight soap in the 19th century, based on glycerin and vegetable oil, to the sophisticated cleansers of today. 1

New data show that the bacteria on nappy skin is very site-specific, which has important implications for cleansing. 

In the modern world, cleansers aim not simply to clean the skin but to achieve a fine balance between effective cleansing and protecting the integrity of the skin barrier. This is particularly important for the delicate infant outer skin, or stratum corneum (SC), especially in the nappy area.

Nappy-area skin is vulnerable to irritant dermatitis because of the environment within the nappy. A combination of factors work together to set up a specific, damaging cycle that can lead to nappy rash but the most important of these is prolonged contact with urine and faeces. 2

Faeces contain salts and enzymes that damage the skin barrier, while urine produces ammonia that raises the skin pH, in turn increasing the activity of the enzymes. 3 Raised skin pH, or alkaline levels, also disrupt the skin's natural rnicroflora that protect the skin against pathogenic bacteria and yeasts. 4,5,6


At birth, skin pH is near neutral, reaching adult level after a few weeks. Soap, detergents and pure water are known to have the effect of temporarily raising the skin pH in infants. A recent study showed that bathing newborns with a pH of about 4 to 5.5 wash gel significantly reduced pH on four body sites, including the buttock, compared with bathing with water alone.9

It is vital then to cleanse the nappy skin effectively, removing faeces as soon as possible after the nappy has been soiled,2 and also reducing the pH of the skin surface by removing urine if nappy rash is to be prevented.3

However, the skin barrier of a newborn is more vulnerable than that of an adult, so the cleansers must be the mildest possible in order not to damage the skin.National Institute for Health and Clinical Excellence (NICE) guidance on postnatal care advises that "cleansing agents should not be added to a baby's bath water nor should lotions or medicated wipes be used. The only cleansing agent suggested, where it is needed, is a mild non-perfumed soap''. 1 It should be noted that, as stated by Blume-Peytavi et al, this guidance is based on expert opinion rather than evidence. (11). An expert review of the factors involved in nappy rash and its prevention and treatment, states that because soap removes lipids from the SC, it seems logical to use water alone but that modern fragrance and alcohol-free baby wipes were "highly satisfactory for the purpose''.(Lipids are a group of fatty acids naturally present in the skin that play a major role in maintaining the skin's barrier function). The author recommends a nappy area skin care routine that begins with gentle cleansing.

New data show that the bacteria on nappy skin is very site-specific, which has important implications for cleansing. 12 The researchers took skin swabs from the arm, forehead and buttocks of 31 infants, dividing them into three age groups: one to three, four to six and seven to 12 months. An analysis of more than 800 species of bacteria found revealed that a different type (firmicutes) predominated on baby skin from that on adult skin (actinobacteria), and that while streptococci, staphylococci and propionibacteria were most prevalent on the infant forehead; streptococci, staphylococci, and corynebacteria predominated on the arms; and clostridia, streptococci, and ruminococci on the buttocks. The study also found that the infant biome continues to develop for at least the first year of life and that the diversity of the species of bacteria increases with age.

The discovery of firmicutes as the normal flora in young children is important because maintaining this normal flora is essential in protecting an infant's skin and preventing the proliferation of disease-causing micro-organisms. 3This finding may also be useful in the future development of cleansers, one expert suggests, adding that the presence of clostridia - a group that includes some particularly toxic pathogens - on the infants' buttocks highlights the importance of good skin hygiene.3

Regular, effective cleansing that respects the delicate infant SC then is an important first step in preventing nappy rash. It should remove impurities including fat-soluble residues such as faeces that can damage the SC; maintain the natural internal hydration and pH levels that protect the infant skin against pathogens and respect the specific microbial flora of the nappy area, again to protect against pathogenic microbes. Appropriate cleansing, in turn, leads on to the next step: providing the infant SC barrier some extra protection. 

Protection of the nappy area & prevention of nappy rash

Nappy rash is a common condition among infantsand one that resonates with both health visitors and mothers alike.

Nevertheless, many mothers appear not to be receiving the most up-to-date advice about how to help prevent their baby from developing the condition. Most health visitors (57 per cent) recommend that mothers use nappy cream only when signs of nappy rash appear, while over three-quarters (78 per cent) do not recommend using any product for prevention, according to a survey. Yet new evidence shows that regular use of a cream improves skin barrier function. This can help to stop the cycle of factors that lead to nappy rash becoming established. See article 1: The science of nappy skin.

The main function of the outer skin layer, or stratum corneum (SC) is to keep the loss of water from the cells (transepidermal water loss or TEWL) to a minimum while at the same time acting as a barrier, preventing toxic substances and organisms from entering the body. Any damage to the SC risks compromising these two vital functions, which makes protection esssential. Nappy creams provide a lipid film over the surface of the skin and/or supply lipids that can penetrate the SC, mimicking the effects of the normal intercellular lipids. Lipids are a group of fatty acids or their derivatives, insoluble in water, that include oil and wax. They are naturally present in the skin and play a major role in maintaining the skin's function as a barrier.

Ideally, a nappy cream contains lipids similar to those naturally present in the SC, such as cholesterol, free fatty acids and ceramides,5 forming a strong, long-lasting lipid shield that protects the skin while preventing excessive TEWL.1

A review by a leading paediatric dermatologist at Great Ormond Street Hospital concluded that positive action was needed in order to prevent nappy rash.This should comprise of gentle cleansing, the careful selection of nappies, changing the nappy as soon as possible after defaecation, and the application of a suitable barrier preparation at every change.

A barrier preparation could be used either to reinforce normal skin whose SC was under stress from outside and was, therefore, at risk of damage - i.e. the prevention of nappy rash - or in an attempt to restore the function of an already damaged SC, as a treatment. But if healthcare professionals and parents followed the routine of changing the baby as soon as possible after the nappy was soiled, gentle cleansing and then following up with a suitable barrier preparation then the result would be a decrease in the incidence and severity of the condition, the author concluded.1

At the same time the specialist called for controlled clinical trials to evaluate the use of barrier preparations on baby skin. Now a relevant study has been published. The research team responsible for the new evidence say that while full-term healthy newborns have an anatomically well-developed skin, their epidermal barrier function is distinctly different from that of adults and is prone to dermatitis and infection, adding that appropriate skin care is of particular interest in newborns to maintain the natural adaptation of the skin barrier. While skin care regimens varied and were based on tradition in many countries, the influence of commercially available topical baby products on skin barrier function had not been scientifically investigated during the neonate period, the team say.

They therefore compared the results of three skin care regimens with water alone on the skin barrier function of 64 infants. The babies, all under 48 hours old, were randomly assigned to receive twice-weekly bathing with wash gel; bathing and cream; bathing with wash gel and cream, or bathing with water over a period of eight weeks. The researchers measured several skin parameters including TEWL, SC hydration, skin pH and sebum (the fluid that lubricates the skin) on day two and at weeks two, four and eight of life on the front (uncovered skin), abdomen, thigh and buttocks.3

TEWL is a key indication of skin barrier function - a lower TEWL indicates a more effective skin barrier. After eight weeks, TEWL was lower at all the skin sites tested in babies treated with twice-weekly bathing and the application of cream compared with bathing with water, indicating that applying cream helps to keep skin more hydrated and healthy than using water alone.3

Clearly more research is required in this important area. To best advise mothers, health visitors need hard evidence about the skincare regimen that will best protect the particularly vulnerable skin in the nappy area and help to prevent a distressing condition that can lead to infection. Researchers now do appear to be turning their attention to this topic. More work is currently underway that will add to the body of knowledge and translate into evidence-based practice to help ensure infant nappy skin stays healthy and intact. In particular a randomised, assessor-blinded, controlled study comparing the effectiveness of infant skin-cleansing products with that of water is soon to be published. 

 

New evidence shows that regular use of a cream improves skin barrier function. This can help stop the cycle of factors that lead to nappy rash becoming established. 

Learn more about NMC revalidation here.
 

References

The science of nappy skin

  1. Atherton D et al. What can be done to keep babies' skin healthy? RCM Midwives 2004;7(7):288-90 https://www.rcm.org.uk/news-views-and-analysis/analysis/what-can-be-done-to-keep-babies-skin-healthy
  2. https://www.nhs.uk/conditions/pregnancy-and-baby/nappy-rash/
  3. Philipp R, Hughes A, Golding J. Getting to the bottom of nappy rash. ALSPAC Survey Team. Avon longitudinal study of pregnancy and childhood. Br J Gen Pract 1997; 47:493-497.
  4. Stamatas, G.N, Zerweck, et al. Documentation oflmpaired Epidermal Barrier in Mild and Moderate Diaper Dermatitis In Vivo Using Noninvasive Methods. Pediatric Dermatology Vol. 28 No. 2 99-107, 2011.
  5. Brook I. Microbiology of secondari.ly infected diaper dermatitis. Int J Dermatol l 992;31:700-702.
  6. Healthcare Professional Audit, Durdle Davis, November 2009.
  7. Nikolovski Jet al. Barrier function and water-holding and transport properties of infant stratum corneum are different from adult and continue to develop through the first year of lite. J Invest Dermatol. 2008; 128: 1728-1736.
  8. Lund C et al. Neonatal skin care: the scientific basis for practice. Neonatal Netw. 1999; 28:24 l -254
  9. Stamatas Get al. Infant skin microstructure assessed in vivo differs from adult skin in organization and at the cellular level. Pediatric Dermatology 2009;27(2): 125-3 I.
  10. Pinnagoda J, Tupker RA, Agner TA et al. Guidelines for transepidermal water loss (TEWL)measurements: a report from the Standardization Group of the European Society of Contact Dermatitis. Contact Dermatitis 1990;22:164-178.
  11. Atherton DJ. A review of the pathophysiology, prevention and treatment of irritant diaper dermatitis. Current Medical Research and Opinion 2004;20(5 ):645-9.
  12. Berg RW, Milligan MC, Sarbaugh FC. Association of skin wetness and pH with diaper dermatitis. Pediatr Dermatol 1994;1 l (8):18-20.
  13. Andersen PH et al. Faecal enzymes: in vivo human skin irritation. Contact Dermatitis 1994;30( 3 ): 152-8.
  14. Zimmerer RE et al. The effects of wearing diapers on skin. Pediatric Dermatology 1986;3(2):95-101.
  15. Fluhr JW, Elias PM. Stratum corneum pH: formdtion and function of the 'dcid mantle'. Exog Dermatol 2002;1: 163-75
  16. Warner RR, Stone KJ, Boissy YL. Hydration disrupts stratum corneum ultrastructure. J Invest Dermatol 2003; 120(2):275-84
  17. Shin HT. Diaper dermatitis tl1at does not quit. Dermatology Therapy 2005;18(2):124-35
  18. Berg RW, Buckingham KW, Stewart RL. Etiologic factors in diaper dermatitis: the role of urine. Pediatr Dermatol 1986;3(2):102-6.
  19. Benjamin L. Clinical correlates with diaper dermatitis. Pediatrician 1987;14(Suppl 1):21-6

THE IMPORTANCE OF CLEANSING

  1. Walters R, Tierney N, et al. Technological advances in cleansers for infants: A historical review and look towardsthe future. Poster presented at: 26th International Pediatric Association. Congress of Pediatrics 201 O; August 4- 9, 201 O; Johannesburg, South Africa.
  2. Atherton DJ. A review of the pathophysiology, prevention and treatment of irritant diaper dermatitis. Current Medical Research and Opinion 2004;20( 5) :645-9.
  3. Cork M, Vernon, P. Protecting the infant skin barrier: advances and insights. Pediatric News. Sept, 20 I 0
  4. Zimmerer RE et al. The effects of wearing diapers on skin. Pediatric Dermatology 1986;3(2):95-101.
  5. Lund C, Kuller J,et al.. Neonatal skin care: the scientific basis for practice. J Obstet Gynecol Neonatal Nurs 1999;28(3):241- 54.
  6. Fluhr JW, Elias PM. Stratum corneum pH: formation and function of the 'acid mantle'. Exog Dermatol 2002; I: l 63-75
  7. Visscher MO, Chatterjee R, Ebel JP et al. Biomedical assessment and instrumental evaluation of healthy infant skin. Pediatr Dermatol 2002; l 9:473-481.
  8. Gfatter R, Hackl P, Braun F. Effect of soap and detergents on skin surface pH, stratum corneum hydration and fat content in infants. Dermatology l997;195:258-262.
  9. Bartels, N.C, Scheufele, R. et. al. Effect of Standardized Skin Care Regimens on Neonatal Skin Barrier Function in Different Body Areas. Pediatric Dermatology Vol. 27 No. I 1-8, 2010.
  10. National Institute for Health and Clinical Excellence (NICE). Postnatal care: Routine postnatal care of women and their babies. London: NICE; 2006.
  11. Blurne-Peytdvi U, Cork MJ, Faergernann J et al. Bathing and cleansing in newborns from day I to first year of life: recommendations from a European round table meeting. J Eur Acad Dermatol Venereol 2009;23:751-59.
  12. Capone KA et al, Diversity of the human skin microbiome early in life, J Invest Dermatol 2011;131(10):92-102

 

PROTECTION OF THE NAPPY AREA/ PREVENTION OF NAPPY RASH

  1. Atherton DJ. A review of the pathophysiology, prevention and treatment of irritant diaper dermatitis. Current Medical Research and Opinion 2004;20(5):645-9. 
  2. Healthcare Professional Audit, [)urdlc Davis, November 2009.
  3. Bartels, N.C, Scheufele, R. et. al. Effect of Standardized Skin Care Regimens on Neonatal Skin Barrier Function in Different Body Areas. Pediatric Dermatology Vol. 27 No. 1 1-8, 2010.
  4. Clark C, Hoare C. Making the most of emollients. Pharm J 2001;266:227-9
  5. Darmstadt GL, Dinulos JG. Neonatal skin care. Pediatr Clin North Am 2000;47(4):757-82
  6. Pinnagoda J, Tupker RA, Agner TA et al. Guidelines for transepidermal water loss (TEWL)measurements: a report from the Standardization Group of the European Society of Contact Dermatitis. Contact Dermatitis1990;22: 164-I 78.

 

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