Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

all patients

1st line – topical barrier and good nappy practice

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ONGOING
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all patients
1st line – 

topical barrier and good nappy practice

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. 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.

If the child is prone to frequent nappy rash, empirically apply a topical barrier containing zinc oxide, white soft paraffin, glycerin, lanolin, sucralfate, or mineral oil at each nappy change.[20]​ Zinc oxide is the preferred barrier for children with diarrhoea. Topical preparations containing sucralfate as an active ingredient may need to be compounded by a pharmacist.

Allow for nappy-free time whenever practical. Avoid use of plastic underpants over the nappy.

2nd line – topical antifungal therapy

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2nd line – 

topical antifungal therapy

Topical antifungal creams can be used for rashes that persist beyond 3 days.

A topical barrier should be applied after the topical antimicrobial.

Primary options

nystatin topical: (100,000 units/g) apply to the affected area(s) three times daily, continue use for 3 days after rash clears

OR

miconazole topical: (0.25%) apply to the affected area(s) at each nappy change, continue use for 7 days (even if rash has already cleared)

OR

econazole topical: (1%) apply to the affected area(s) twice daily, continue use for 3 days after rash clears

Consider – low-potency topical corticosteroids

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Consider – 

low-potency topical corticosteroids

Additional treatment recommended for SOME patients in selected patient group

Use if symptoms are severe, such as suspected pain and fussiness.

Use low potency, for 3 to 14 days only.[16]​ Misuse of topical corticosteroids in an occluded nappy may lead to increased systemic absorption, so should be used sparingly.

A topical barrier should be applied after treatment with a topical corticosteroid is completed, to avoid further skin damage.

Primary options

hydrocortisone topical: (1%) apply sparingly to the affected area(s) twice daily for 3-14 days

OR

desonide topical: (0.05%) apply sparingly to the affected area(s) twice daily for 3-14 days

Consider – topical antibacterial therapy

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all patients
Consider – 

topical antibacterial therapy

Additional treatment recommended for SOME patients in selected patient group

A topical antibacterial agent, such as mupirocin, should be applied if a secondary bacterial infection is suspected.[16]​

Primary options

mupirocin topical: (2%) apply to the affected area(s) three times daily for up to 10 days

3rd line – referral to a dermatologist

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3rd line – 

referral to a dermatologist

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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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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