Case Reports: Treatment of nappy rash in a four-month-old

This case study demonstrates the importance of patient education for parents. By Dr Nigel Stollery

Nappy rash: red spots on a background of erythema (Photograph: Dr Nigel Stollery)
Nappy rash: red spots on a background of erythema (Photograph: Dr Nigel Stollery)
This four-month-old baby girl presented with nappy rash. She had been successfully breastfed and had a normal six-week check. The baby was immunised in line with the recommended protocols. There was no significant family history of skin problems in her parents and her older sister. A few days before the appointment, she had been cared for by her grandparents, while her parents took a short break. In their absence, she had been fed on expressed breast milk with no need for formula top-ups. On her parents' return, they noted that she had developed nappy rash.

The baby's mother reported that her daughter seemed a little upset and off her feeds, but she was not sure whether this was due to her being away for two nights.

Closer inspection of the baby's nappy area revealed a number of red spots on a background of mild erythema. It was a Friday evening and the local surgery was closed for the weekend, so her mother bathed her as usual and applied a liberal coating of zinc oxide barrier cream. This was repeated regularly over the weekend with each nappy change.

The background erythema settled quickly, but the number of papules increased over the following three days, at which point the baby was brought to the surgery.

A full history was taken and inspection of the nappy area revealed multiple bright red papules extending out from the vulva. The papules affected all of the skin, including the creases. When assessing nappy rash, sparing of the creases usually suggests an irritant contact dermatitis from prolonged skin contact with urine, or an allergic reaction to the contents of the nappy liner.

The use of a barrier cream such as zinc oxide paste, and more frequent nappy changes or, if this does not work, a change of nappy type, will usually settle this down.

Spread of the rash into the creases and areas not in contact with the nappy usually suggests an alternative cause, such as infection (bacterial, fungal or yeast) or a localised occurrence of a generalised skin condition such as psoriasis, atopic eczema or seborrhoeic dermatitis.

The appearance in this case was typical of candida albicans or thrush, with satellite lesions extending outwards. A topical antifungal cream (clotrimazole 1%) was prescribed, to be applied three times a day for five days, with advice to use a barrier preparation such as zinc oxide paste with other nappy changes.

The parents were also advised that candida likes warm moist conditions, so frequent nappy changes and spells without a nappy at all would be helpful.

Causes of nappy rash
Nappy rash is a generic term to describe a number of inflammatory conditions that occur within the nappy area. Nappy rashes are not all the same and careful history-taking and examination are important at the first presentation, so a correct diagnosis is made, allowing for the correct treatment. Failure to do this can cause delay in resolving the rash, leading to prolonged discomfort and upset for the child.

Two studies1,2 investigated the use of baby wipes compared to simple bathing with warm water when changing nappies and came to the conclusion that baby wipes were superior, because water has a polar nature that limits its ability to remove lipophilic substances from the skin and because water is incapable of pH buffering action.

The baby's parents were advised of these findings. They were also told to avoid the use of bubble baths, which can also increase the risk of developing thrush. Alternative bath emollients do not usually have this effect, but sitting in water containing shampoo can have a similar effect to fragrant bath additives and this should also be avoided.

This advice was followed and the rash resolved completely after four days. Although in this case a swab was not taken before treatment, this can be used to confirm the diagnosis, especially if the rash does not respond as expected.

  • Dr Nigel Stollery is a GP in Kibworth, Leicestershire, and clinical assistant in dermatology at Leicester Royal Infirmary

Competing interests: None declared

1. Adam R. Skin care of the diaper area. Pediatr Dermatol 2008; 25(4): 427-33.
2. Ehretsmann C, Schaefer P, Adam R. Cutaneous tolerance of baby wipes by infants with atopic eczema and comparison of the mildness of baby wipe and water in infant skin. J Eur Acad Dermatol Venereol 2001; 15 Suppl 1: 16-21.

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