Approach
The child's carer should be educated about the causes of nappy rash and measures that will aid in preventing further skin breakdown. A step-wise approach for treatment is recommended; however, on a case-by-case basis it may be decided to use several interventions simultaneously if the rash has been long-standing and the exact aetiology is unknown, or a secondary infection is suspected. This management approach is evidence-based to a limited degree, as high-quality studies are lacking.[18]
Initial approach
With each nappy change, a barrier should be applied to protect the skin from irritants such as urine and faeces. A barrier with minimal ingredients is preferred, to avoid potential skin sensitisation. A barrier in a paste formulation (such as zinc oxide) is preferred if diarrhoea is present.[16]
Good nappy-changing hygiene practices should be ensured.[13] No matter which type of nappy is used, it should be changed every 2 hours (or inspected for soiling every 2 hours). Nappies should be changed even more frequently in newborns or in a child with diarrhoea. Rash frequency and severity have been noted to be significantly lower when the mean number of reported nappy changes was >8 nappies per day.[3] As environmental and financial costs are likely to be substantial, parents should be advised to consider these potential costs in the risk versus benefit assessment.[18]
Potential irritants at each nappy change should be eliminated by cleansing the nappy area with commercial cleansing wipes or water on cotton cloth. Products with minimal additives should be used, and excess friction and detergents should be avoided.[19]
Rash persisting for ≥3 days
Barrier creams and good nappy practice should be continued together with a topical antifungal if the rash persists for ≥3 days.
If symptoms are severe or if pain is suspected, a topical corticosteroid should be prescribed judiciously. The smallest quantity needed should be applied thinly, twice daily, for 3 days and for no longer than 2 weeks. Low-potency corticosteroids, such as 1% hydrocortisone or desonide, are preferred.[16]
A topical antibacterial agent, such as mupirocin, should be applied if a secondary bacterial infection is suspected.[16]
Skin sensitisation
Skin sensitisation should be suspected at any stage. It may be appropriate to stop all previously prescribed medication, avoid all potential skin sensitisers (including cleansing wipes, any type of skin cleanser, or disposable nappies with potential dyes or fragrances), and re-introduce medication slowly (one product at a time) to identify and eliminate the sensitising ingredient.
Rash persisting for >14 days
Recalcitrant cases should be referred to a dermatologist for possible biopsy or patch testing if they persist for >14 days.[13]
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