Approach
The child's caregiver should be educated about the causes of diaper rash and measures that will aid in preventing further skin breakdown. A stepwise 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 etiology 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 diaper change, a barrier should be applied to protect the skin from irritants such as urine and feces. A barrier with minimal ingredients is preferred to avoid potential skin sensitization. A barrier in a paste formulation (such as zinc oxide) is preferred if diarrhea is present.[16]
Good diapering hygiene practices should be ensured.[13] No matter which type of diaper is used, it should be changed every 2 hours (or inspected for soiling every 2 hours). Diapers should be changed even more frequently in newborns or in a child with diarrhea. Rash frequency and severity have been noted to be significantly lower when the mean number of reported diaper changes was >8 diapers 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 diaper change should be eliminated by cleansing the diaper 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 diaper 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 sensitization
Skin sensitization should be suspected at any stage. It may be appropriate to stop all previously prescribed medication, avoid all potential skin sensitizers (including cleansing wipes, any type of skin cleanser, or disposable diapers with potential dyes or fragrances), and reintroduce medication slowly (one product at a time) to identify and eliminate the sensitizing 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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