Features

The rough with the smooth: managing nappy rash

05 May 2015

Establishing a skin care routine that keeps an infant’s skin healthy can be a challenge for parents, says Sylvia Woolley, and it is the role of the community practitioner to educate parents on the management of nappy rash and the importance of preventative skincare routines.

Nappy rash

Sylvia Woolley MSc SCPHN, PG Cert Higher Professional Education RGN RMN FiHV Health Visitor

‘Smooth as a baby’s bottom’ is a commonly heard adage highlighting the belief that infant skin is perfect. Yet it is estimated that up to 50% of infants at some point will suffer from some degree of nappy rash with the peak incidence being in infants between 9-12 months (Baer et al, 2006; Atherton, 2004). Establishing a skin care routine that keeps an infant’s skin healthy can be a challenge for parents and they can experience feelings of self-blame and guilt if their infant develops nappy rash, particularly if the child displays signs of distress and discomfort (Baer et al, 2006). Therefore it is essential that health professionals are able to identify, treat and advise parents on management of nappy rash along with educating them on the importance of maintaining skin integrity through good, preventative skincare routines (Jones, 2013).

Nappy rash is a non- specific term used to describe a range of geographical inflammatory skin conditions which occur in an otherwise healthy infant (Fischer, 2002). Anecdotal and clinical evidence suggests that nappy rash can occur during certain ‘trigger times’ - for instance during teething, weaning, following an episode of diarrhoea, antibiotic use and changing from breast to formula milk (Morris, 2012). It is recognised that all infants will develop at least one episode of nappy rash during infancy and it equally affects both genders and infants of all racial groups (Gupta and Skinner, 2004). Most cases of nappy rash will resolve without specific treatment.

Nappy rash or contact irritant dermatitis is caused by the interaction of several factors, predominately the prolonged and increased contact with urine, faeces particularly faecal enzymes, moisture and friction from the nappy which subsequently disrupts and damages the physical integrity of the skin (Neild and Kamat, 2007; Atherton, 2004).

 

Symptoms, diagnosis and assesment 

Diagnosis of nappy rash is based on the distinctive appearance and location of an erythematous rash which may include the buttocks, genitals, pubic area and upper thighs but tends not to affect the skin creases (NICE, 2013). With the exception of severe cases there are usually no systemic symptoms and a skin swab is not necessary to form a diagnosis (NICE, 2013). In the acute phase, symptoms of nappy rash may range from mild to severe and include: generalised erythema, red spots which have a glossy appearance, and dry, cracked or broken skin. If left untreated, the increased pH, prolonged contact with faecal enzymes and over hydration of the skin and frictional damage leads to increased maceration and ulceration of the skin which makes the area more vulnerable to secondary skin infection, particularly from Candida Albicans.

Studies have shown Candida Albicans is present in 41-80% of infants with nappy rash which persists for more than 72 hours (Rowe et al, 2008). In a secondary candidal infection there will be defined redness round the perianal skin which may involve the perineum. There will also be erythematous papules and pustules involving the skin creases and satellite lesions of a similar rash nearby are characteristic of candida infections (NICE, 2013). The current guidance on candidal nappy rash recommends treatment with imidazole cream (clotrimazole, econazole or miconazole) and that no barrier preparation is used until the infection has resolved (NICE, 2013).

In a secondary bacterial infection there will be noticeable redness with exudate and vesicular and pustular lesions and parents should be advised to seek further advice from a GP. A skin swab should be considered if a secondary bacterial infection is suspected particularly when nappy rash is severe or persists regardless of treatment to determine appropriate oral antibiotic treatment (NICE, 2013). A differential diagnosis should be considered if there is no response to standard nappy rash treatment as conditions such as atopic eczema, impetigo and infantile seborrhoiec dermatitis can be misdiagnosed as nappy rash (Stevenson, 2011).

NICE (2013) recommends health professionals should consider the following areas when assessing nappy rash:

  • Hygiene practices – how often is the nappy changed, frequency of cleansing
  • Type of nappy used – disposable or reusable
  • Exposure to irritants – soaps, alcohol based wipes, detergents, skin products... 
  • Trauma – from vigorous over cleansing, friction from nappy Recent antibiotic use
  • Oral candidiasis – increases the likelihood of nappy thrush
  • Clinical features of a secondary infection

 

Skin care advice

Good skincare advice is fundamental in both the treatment and prevention of nappy rash. It can be helpful for health professionals to give parents a brief description of skin composition and function in order to help them understand the importance of maintaining a good skin care regime to prevent nappy rash. In particular explaining to parents that although structurally similar both the epidermis and, the stratum corneum, are 20% and 30% thinner than that of an adult, which makes infant skin more susceptible to skin problems (Stamatas et al, 2010). When discussing with parents how the protective barrier functions considering the strateum corneum as a brick wall with the corneocytes as bricks and the lipids as cement can be a useful analogy to illustrate how the decreased barrier function of the corneum stratum makes an infant’s skin more permeable and inclined to dryness (Elias, 1996). Another important feature of skin barrier function is the pH of the skin, which in an infant reduces to 5.5-5.9 in the first few days following delivery to produce an ‘acid mantle’. This helps to stabilise skin hydration and control microbial colonisation, which is important when considering skin cleansing options (Ness et al, 2013). Consequently any products used on an infant’s skin should be pH neutral or slightly acidic to preserve the skin pH and protective function.

Current postnatal care guidelines (NICE, 2006) recommend the use of water and a mild non-perfumed soap if required for cleansing an infant’s skin. However water can raise the pH of the skin from 5.5 to 7.5 and is not suitable for removing oil-soluble skin surface contaminants additionally traditional soaps as well as being alkaline tend to contain Sodium Laurel Sulphate (SLS) which is also present in aqueous cream and is known to have a detrimental effect on the skin barrier function (Mohammed et al, 2011) This suggests that using water alone or in conjunction with alkaline based products containing SLS can affect the skin barrier function leading to increased dryness and irritation (Lawton, 2013). Recent studies have demonstrated that emollients cleanse and hydrate the skin drawing moisture into the stratum corneum which promotes formation of a healthy, functional epidermis suggesting that cleansers with emollient properties may be more suitable for cleansing the nappy area (Ness et al, 2013). A recent randomised controlled trial has demonstrated that using either cotton wool and water or fragrance and alcoholfree baby wipes had a comparable effect on skin hydration, and that the wipes caused no harmful effects (Lavender et al, 2012). As current opinion on skincare products is mixed and can be subject to commercial bias it is essential that health visitors keep up-to-date in this area of practice.

Regular application of a protective skin barrier ointment is considered a valuable component of a preventative skin care regime and there are multiple over the counter products available for parents to purchase. Current guidance from NICE (2013) recommends applying a thin layer of one of the following: zinc or castor oil ointment BP, Metanium, white soft paraffin BP ointment or Bepanthen (dexpanthenol 5% ointment).

The diversity and quantity of products available on the market for infant skin care can be overwhelming for parents. Combined with the frequently conflicting advice given by family members and health professionals and the lack of evidence about the correct way to cleanse infant skin makes this a confusing a confusing area for parents. Consequently health visitors should be able to provide a holistic, non-judgmental and evidence-based assessment taking into account parental preference when providing education on the prevention and treatment of nappy rash which will include the importance of good preventative skincare regimes. Therefore discussion on with parents on preventative skincare regimes should include the following advice:

  • Nappies should be left off for as long as is practical to reduce exposure to skin irritants
  • Nappies should be changed and skin cleansed as soon as possible after soiling. If parents are using cloth nappies then advice should be given on the importance of using a nappy liner to reduce skin friction and to act as a barrier reducing skin contact with urine and faeces. Cloth nappies should be washed on a high temperature, 60°C or above, to destroy biological enzymes and well rinsed to remove potentially skin irritant detergents
  • Use warm water and/or a water soluble emollient or pH neutral, fragrance and alcohol free wipes for cleansing the nappy area
  • Wipe area from front to back
  • Dry skin by gently patting after cleansing
  • Avoid bathing more than twice a day
  • Avoid the use of soap, bubble bath, talcum powder particularly products containing sodium laurel sulphates (SLS) or perfumes
  • Apply a thin layer of a suitable barrier preparation at each nappy change, ointments are more effective than creams as they provide a better moisture barrier
  • Good hygiene should also be discussed including hand washing advice and cleansing of nappy change areas (NICE, 2013)

 

Conclusion

Nappy rash is a common condition affecting most infants at some point while they are wearing nappies. In practice it is important that health visitors are able to identify, treat and advise parents on management of nappy rash along with educating them on the importance of maintaining skin integrity through good, preventative skincare routines. An essential component of this is keeping up-to-date with changes in evidence and clinical practice guidance.

 

References

Atherton D. And Mills, K.(2004) What can be done to keep babies’ skin healthy. RCM Midwives: the Official Journal for the Royal College of Midwives 7 (7): 288-290

Baer, E., Davies, M. and Easterbrook, K. (2006) Disposable Nappies for Preventing Napkin Dermatitis in Infants (Cochrane Review). The Cochrane Library. [online] Available from: www.thecochranelibrary.com

Elias, P. (1996) The stratum corneum revisited. Journal of Dermatology 23: 756-758

Fischer, G. (2002) Nappy Rash Medicine Today 3 (6): 37-49

Gupta, A.K and Skinner, A.R. (2004) Management of diaper dermatitis. International Journal of Dermatology 43(11): 830-840

Jones, K. (2013) Advice to promote healthy neonatal skin and treat common skin disorders. The Journal of Health Visiting 1(3): 158-161

Lavender, T., Furber, C., Campbell, M., Victor, S., Roberts, I., Bedwell, C. And Cork, M.J. (2012) Effect on skin hydration using baby wipes to clean napkin area of newborn babies: assessor blinded randomised controlled equivalence trial. [online] Available from: http://www.biomedcentral. com/1471-2431/12/59. Accessed 20/03/2015

Lawton, S. (2013) Understanding skin care and skin barrier function in infants. Nursing Children and Young People. 25(7): 28-33

Mohammed, D., Matts, P.J., Hadgraft, J and Lane, M.E. (2011) Influence of aqueous cream on corneocyte size, maturity, skin protease activity, protein content and transepidermal water loss. British Journal of Dermatology. 164(6):1304-1310

Morris, H. (2012) The bottom line on nappy rash. British Journal of Midwifery. 20(9): 623-626

Ness, M.J., Davis, D.M. and Carey, W.A. (2013) Neonatal skin care: a consise review. International Journal of Dermatology. 52(1): 14-22.

National Institute for Health and Care Excellence (NICE) (2006) Post natal care of women and their babies. Clinical Guidline No. 37. [online] Available from http://www.nicw.org.uk/nicemedia/live/10988/30144/30144.pdf (accessed 20/03/2015)

National Institute for Health and Care Excellence (NICE) (2013) Clinical Knowledge Summary Nappy rash [online] Available from: http://cks.nice.org.uk/nappy-rash (accessed 19/03/2015)

Rowe, J.M.N., McCall, E. And Kent, B. ( 2008) Clinical effectiveness of barrier preparationsin the prevention and treatment of nappy dermatitis in infants and preschool children of nappy age. International Journal of Evidence Based Healthcare. 6:3-23.

Stamatas, G., Nicolovski, J., Luedtke, M.A., Kolias, N. and Weigand, B.C. (2010) Infant skin microstructure in vivo differs from adult skin in organisation and at the cellular level. Paediatric Dermatology. 27(20: 125-131

Stevenson, J. (2011) Getting to the bottom of nappy rash: skincare advice and treatment. Nurse Prescribing. 9(1): 25-27

 

Picture credit: iStock

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