Approach
Diagnosis is made clinically, based on history and physical examination. Some cases of rashes in the nappy area are caused by non-nappy-related causes, so a complete physical examination may be necessary to avoid misdiagnosis.[14]
In the unusual case when the diagnosis is in doubt or initial treatments have failed, bacterial and/or fungal cultures or potassium hydroxide testing of skin scrapings should be performed.
History
There will often be a history of poor nappy-changing practice. This can involve the infant being infrequently changed, use of baby care products without checks for minimal additives, excess friction on cleaning, strong detergents used on cleaning, no nappy-free time, and the use of plastic underpants. The patient will often be young (<2 years), as younger children urinate more frequently. A history of diarrhoea and recent antibiotic exposure may be present (use of antibiotics increases the likelihood of diarrhoea, which in turn means more frequent stools and more time spent in soiled nappies).[5][12] The patient's carer may also describe fussiness or irritability in the child with voiding, bowel movements, or nappy changes, due to pain from the nappy rash.
Examination
Child's carer generally reports acute onset of erythema and skin breakdown in the area of the body covered by a nappy. Examination typically reveals erythema on the convex surfaces of the pubic area and buttocks with sparing of the skin folds.[15]
Infection testing
Underlying skin infections can be a cause of nappy rash and increase the risk of it being recalcitrant. Testing for infection is not routinely performed because infections are typically diagnosed by history and clinical presentation. However, in cases of treatment failure, cultures should be taken to assess for the presence of bacterial or fungal organisms. Potassium hydroxide testing of a skin scraping is performed when fungal Candida infection (candidiasis) is suspected.[16]
For persistent/recalcitrant cases
An FBC to rule out cyclic neutropenia, and serum zinc levels to rule out zinc deficiency, may need to be considered for severe or persistent disease and recalcitrant cases.[14][17]
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