History and exam
Key diagnostic factors
common
presence of risk factors
Key risk factors include young age (<2 years), history of diarrhoea, underlying dermatological disorder, infrequent nappy changes, excess use of baby care products, plastic underpants, and no nappy-free time.
acute onset of rash in nappy area
Classic finding in irritant contact dermatitis.
erythema of convex surfaces in nappy area
Classic finding in irritant contact dermatitis.
sparing of skin folds
Classic finding in irritant contact dermatitis.
Other diagnostic factors
common
features of candidiasis
Shiny erythematous patches with satellite lesions in nappy area, folds of groin, neck, and axilla, and presence of oral candidiasis.
Nappy rash persisting for >3 days is frequently associated with presence of Candida albicans.[1]
features of Staphylococcus aureus infection
Pustules, vesicles, bullae, denuded skin, and honey-coloured crusting.
features of group A Streptococcus infection
Erythematous patch around vaginal and anal orifices.
uncommon
fussiness
Carer may describe fussiness or irritability with voiding, bowel movements, or nappy changes, due to pain from the nappy rash.
Risk factors
strong
young age (<2 years)
Younger children urinate more frequently and raise fewer objections when wearing a soiled nappy. Therefore, irritants are allowed longer contact with the occluded skin.
One study of hospitalised patients found that skin breakdown was more likely in younger than older children.[5]
diarrhoea
Hospitalised children with more episodes of diarrhoea were more likely to experience skin breakdown. More frequent stools and time spent in a soiled nappy leads to nappy rash.[5]
underlying dermatological disorder
Children with skin problems (e.g. dry skin, eczema, nappy dermatitis) on admission were significantly more likely to experience skin breakdown.[5]
infrequent nappy changes
Increased time in nappies will increase the time exposed to urine and faecal enzymes. Increased exposure to these elements leads to skin breakdown.
excess use of baby care products
Baby care products may expose the baby to potential irritants. Products with minimal additives should be used.
excess detergent
Detergents found in body soaps and laundry soap may irritate the skin. Products with minimal additives should be used, such as those described as fragrance-free or detergent-free.
excess wiping
Friction from carer's repeated wiping is a potential irritant.
plastic underpants
Occlusion of the nappy area by plastic will increase the moisture within the nappy, exacerbating the process that can lead to skin breakdown.
no nappy-free time
Time without nappies minimises the time exposed to irritants used in nappy manufacturing and friction with the nappies themselves. There is also less time in contact with urine and fecal enzymes.
underlying skin infections
Underlying skin infections can be a cause of nappy rash and increase the risk of it being recalcitrant. These can be bacterial infections (S aureus or group A Streptococcus infections) and/or fungal infections (Candida infections).
weak
oral antibiotics
Oral antibiotics may lead to diarrhoea and may also increase the risk of secondary fungal infection.[12]
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