Guideline for the Management

of Nappy Rash

Title of Guideline (must include the word Guideline Guideline for the Management of Nappy
(not protocol, policy, procedure etc) Rash

Contact Name and Job Title (author) Sandra Lawton, Nurse Consultant
Dermatology
Barbara Howard, PDM Neonates
Directorate & Speciality Dermatology

Date of submission November 2013

Date on which guideline must be reviewed (this November 2018

should be one to three years)
Explicit definition of patient group to which it applies
(e.g. inclusion and exclusion criteria, diagnosis) Infants and children

Abstract This guideline describes the

management of nappy rash

Key Words diaper rash, nappy rash, diaper

dermatitis or irritant diaper dermatitis
Statement of the evidence base of the guideline
Evidence base: (1-6)
1 NICE Guidance, Royal College Guideline, SIGN NICE: NHS Clinical Knowledge
(please state which source). Summaries; Nappy rash management.
2a meta analysis of randomised controlled trials
2b at least one randomised controlled trial Cochrane Database of Systematic
3a at least one well-designed controlled study Reviews. Disposable nappies for
without randomisation preventing napkin dermatitis in infants.
3b at least one other type of well-designed quasi-
experimental study Recommended best practice based on
4 well designed non-experimental descriptive clinical experience of the dermatology
studies (ie comparative / correlation and case team
studies)
5 expert committee reports or opinions and / or
clinical experiences of respected authorities
6 recommended best practice based on the
clinical experience of the guideline developer
Consultation Process Children's Hospital Dermatology,
Pharmacy, Microbiology, TV

Target audience Nursing and medical teams caring for

infants and children.

This guideline has been registered with the trust. However, clinical guidelines are guidelines
only. The interpretation and application of clinical guidelines will remain the responsibility of
the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised
when using guidelines after the review date.

Sandra Lawton Page 1 of 13 October 2013

 CONTENTS Page

INTRODUCTION 3
ASSESSMENT 4
DIFFERENTIAL DIAGNOSIS 4-5
PRINCIPLES OF NAPPY CARE 6-7
TREATMENT UNCOMPLICATED 8
TREATMENT COMPLICATED 8-9
REFERRAL 9-10
AUDIT 10
REFERENCES 11
APPENDIX 1 FLOW CHART 12

Key Points for Guidelines for the Management of Nappy Rash

Priority Action Rationale

1 Signs & Symptoms
2 Differential Diagnosis
3 Principals of Good Nappy Care
4 Treatments
5 Referral pathway
6 Audit
Staff knowledge base
Staff knowledge base, safe practice
Patient/staff protection, safe practice
Patient/staff protection
Staff knowledge base, safe practice
Quality of service

Sandra Lawton Page 2 of 13 October 2013

 Guidelines for the Management
of Nappy Rash
1) INTRODUCTION
Nappy dermatitis (also known as diaper rash, nappy rash, diaper dermatitis or irritant diaper
dermatitis) is a general term used to describe an irritant inflammatory skin reaction in the
nappy area, as a result of one or more factors: urine, faeces, moisture or friction. For the
purpose of this guideline, the term nappy dermatitis and nappy as opposed to diaper will be
used. Nappy dermatitis is one of the most common disorders in neonates and infants, with the
prevalence of nappy dermatitis is estimated to be between 7% and 35% and a peak in
incidence between 9 and 12 months of age (Rowe et al 2008). There are no differences in the
prevalence between boys and girls or ethnic groups (Atherton 2001). Although nappy
dermatitis is often considered to be seen exclusively in babies, a similar rash can occur in
older children and adults who are incontinent of urine. Nappy dermatitis can affect
anatomically the lower abdomen, lower lumbar region, gluteal area, genitalia and inner
aspects of the thighs, especially those convexities of the skin in closest contact with the nappy
(Rowe et al 2008). The wearing of nappies causes a significant increase in skin wetness and
alkalinity. If the wetness is prolonged, this can lead to maceration of the skin, weaken the
physical integrity of the stratum corneum (outer most layer of the epidermis), making it more
susceptible to friction from the surface of the nappy. It also increases the risk of further skin
damage and other problems caused by exposure to irritants, especially faecal proteases and
lipases as well as ammonia in urine. In addition, repetitive skin cleansing increases the rate at
which the epidermal cells and surface lipids are removed, disrupting the skins protective acid
coating, which compromises the skin barrier (Rowe et al 2008). Other factors may aggravate
or lead to worsening of the rash; these include inadequate skin care, micro- organisms,
antibiotics, diarrhoea and abnormalities of the gut or urinary tract (Atherton 2001). Infants and
children undergoing bowel surgery, ostomy takedown or who have diarrhoea have an
accelerated gastrointestinal transit, which results in an increased activity of faecal protease
and lipase, and makes them more susceptible to severe nappy dermatitis (Rowe et al 2008).

2) EVIDENCE BASE

Further information is available from Clinical Knowledge Summaries, a service provided by the
National Institute for Health and Care Excellence (NICE):

http://www.cks.library.nhs.uk/nappy_rash/view_whole_guidance

3) INDICATIONS AND CONTRA-INDICATIONS

Indications

This guidance is for use when an individual is being treated for nappy rash or it is suspected.
It aims to provide information about what nappy rash is and how it is treated effectively.

Contraindications

Nappy rash treatment requires the prescriber to be aware of the contraindications when
considering treatments, ensuring that the correct products are then prescribed.

4) HAZARDS
See under contraindications

5) EQUIPMENT LIST
Prescribed medication please refer to applying treatment section.

Sandra Lawton Page 3 of 13 October 2013

6) DESCRIBING THE CARE

Assessing a child with nappy rash and making the diagnosis?

Ask about factors which predispose a child to nappy rash:

Hygiene practices (for example how often the area is cleaned and the nappy changed) - lack
of hygiene and prolonged contact with urine / faeces predisposes to irritant dermatitis.
Type of nappy used- disposable nappies or reusable cotton nappies.
Exposure to irritants when cleaning - such as soaps, detergents, or alcohol/ perfume based
baby wipes.
Trauma - for example, friction from nappies or over-vigorous cleaning.
Recent antibiotic use antibiotics predispose to candida colonization and diarrhoea

Nappy rash is diagnosed from the characteristic appearance of the rash and by excluding other
diagnoses of rash in the nappy area (especially in neonates, as nappy rash is uncommon in this age
group). Typically there is redness over convex surfaces closest to the nappy (buttocks, genitals, pubic
area, and upper thighs) with sparing (no redness) in the deeper skin creases. The rash has a glazed
appearance if acute, or fine scaling if more long-standing and hypopigmentation in some dark-skinned
infants (Atherton 2004). There are usually no symptoms (scratching or systemic upset) however, if the
nappy rash is severe or painful, the child may be distressed or uncomfortable. A skin swab is not
necessary to make a diagnosis and is only indicated if bacterial infection (marked redness with
exudate, and vesicular and pustular lesions) is suspected particularly when the nappy rash is severe,
or persists despite treatment (Brook 1992, NHS CKS 2009).

Assessing the severity of nappy rash.

Although there is no universally recommended or validated method for assessing severity, the
following classification may be a useful guide and will influence the management (Odio et al, 2000):

Mild nappy rash faint to definite pink rash of less than 10% of the area covered by the
nappy, with or without a few scattered papules, with or without slight scaling and dryness. Mild
nappy rash is unlikely to distress the infant and can usually be managed with simple nappy
skin care measures.

Moderate to severe nappy rash moderate to severe redness covering an area greater
than 10% of the area covered by the nappy, with or without papules, oedema, or ulceration.
Moderate to severe nappy rash is more likely to be distressing and secondarily infected with
Candida albicans.

Differential Diagnosis (Atherton 2001, 2004, NHS CKS 2009, DermNet NZ 2012)

There is a wide variety of disorders to consider in an infant presenting with an inflamed rash in the
nappy area. Other diagnosis should be considered when a nappy rash fails to respond to what is
regarded as adequate therapy, this may include infections, primary skin conditions, rare conditions
affecting the nappy area and issues of neglect and abuse:

Infections (Yeast, bacterial and viral):

Candida albicans: The clinical features of nappy rash predominantly caused by Candida
albicans (candidiasis) most commonly include, erythema initially developing around the
perianal skin and later, erythema spreading to involve the perineum and sometimes the upper
thighs. It develops into sharply marginated confluent zones with papules, pustules involving
the skin creases of the nappy area. Satellite lesions, papules and small pustules or erosions

Sandra Lawton Page 4 of 13 October 2013

 are characteristic of candida infection (Scheinfeld, 2005). Oral thrush may be present, the
mouth should always be examined and co-existing oral thrush treated (Adalat et al 2007).

Impetigo: Is an infection of the superficial layers of the skin, usually caused by

Staphylococcus aureus, and less commonly by Streptococcus pyogenes. Typically, thin-
walled vesicles or pustules are present which rupture; the overlying exudate dries to form
thick, yellowbrown or golden crusts.

Perianal streptococcal dermatitis: Presents as a bright red, sharply demarcated rash that is
commonly misdiagnosed and treated as a fungal infection. It occurs most commonly in
children 34 years of age. It remains unresponsive to treatment with topical steroids and
antifungal creams. Perianal pain and itching are common and blood-streaked stools occur in
up to a third of cases.

Eczema herpeticum: Disseminated herpes simplex virus infection (eczema herpeticum)

presents with widespread lesions that may coalesce into large, denuded, bleeding areas that
can extend over the entire body.

Skin Conditions

Infantile seborrhoeic dermatitis: usually affects the scalp, ears, eyebrows, neck, and axillae,
but may also affect the nappy area. It presents as well-defined areas of redness and scaling,
which do not seem to disturb the child. It most commonly starts between the second week and
sixth month of life; it usually clears within a few weeks and does not recur. Unlike nappy
dermatitis which spares the deeper skin creases, all of the skin is involved in seborrhoeic
dermatitis.

Atopic eczema: a tendency to dry skin, a positive family history of atopic eczema, and rash
affecting other skin areas help to distinguish it from a primary nappy rash (often the nappy
area is spared as this area is so well hydrated and not accessible to excoriation).

Psoriasis: Infantile psoriasis is uncommon, and when it occurs it most typically affects the
nappy area. The rash may have a well-demarcated edge and characteristic adherent scales,
although in the nappy area this typical appearance is usually significantly modified by
occlusion and friction. Psoriasis may start as early as the second month of life. Affected
infants have a greater chance of developing psoriasis in adulthood.

Allergic contact dermatitis: Other types of contact dermatitis are uncommon causes of
nappy rash. They are distinguished by their characteristic patterns of distribution following
exposure to potential irritants or allergens such as nappy dyes, detergents, drug reactions
(such as antibiotics), and baby wipes with perfumes and fragrances added.

Scabies- is an itchy rash caused by a little mite that burrows in the skin surface. Scabies
burrows appear as tiny grey irregular tracks between the fingers and on the wrists. They may
also be found in armpits, buttocks, on the penis, insteps and backs of the heels. Scabies rash
appears as tiny red intensely itchy bumps on the limbs and trunk. It can easily be confused
with dermatitis or hives (and may be accompanied by these). Blisters and pustules on the
palms and soles are characteristic of scabies in infants (DermNet NZ 2012)

Rare causes of nappy rash

Zinc deficiency (Acrodermatitis enteropathica): is a rare genetic disorder characterised by

diarrhoea, an inflammatory rash around the mouth and/or anus, and hair loss may present
with nappy rash that fails to respond to normal treatments (DermNet NZ 2012).

Langerhans' cell histiocytosis: commonly presents in the third month of life with persistent
intertrigo. Initially small, yellow papules develop which become confluent and subsequently
ulcerate.

Sandra Lawton Page 5 of 13 October 2013

 Principles of Good Nappy care

ACTION RATIONALE
Good nappy care will generally prevent nappy rash. There is little available evidence on which aspects
of skin care can improve or prevent nappy rash. Advice is based on consensus and common sense
measures to reduce the time that urine and faeces are in contact with the skin. Parental preference,
practical issues and cost should be considered (NHS CKS 2009). The principles of good nappy care
include:

Reduce interval between nappy changes.
Reduces skin exposure time to urine / faeces.
(Occurrence of nappy rash demonstrated to be
significantly lower in one study (n=1089) when
mean number of nappy changes was above
average (i.e. >8 changes per day) irrespective of
nappy type (Jordan et al 1986).

The required frequency of nappy changes varies

Frequency of nappy changes will normally be with the age of the child. Neonates may pass urine
dictated by the age of the child but should more than 20 times in a day whereas this reduces
generally take place as soon after soiling as to an average of 6.5 times a day at 1 year (Holden
possible. 1998).

Children who receive overnight feeds via a

(Frequency of passing urine may vary in gastrostomy may pass more urine overnight than
children on artificial feeding regimes) during the day and therefore require overnight
nappy changes or a nappy of greater absorbency.

Use, and frequent changing of, a disposable
gel-core nappy. (The use of other types of
nappy is not prohibited and parents/ carers may
prefer to use alternatives. Given the variety of
products available the appropriateness of the
nappy would need to be assessed on a case to
case basis depending on the childs
circumstances)
The gel-core of modern disposable nappies
absorbs and retains fluid, keeping it away from the
skin and preventing mixing with faeces. There is
however not enough evidence from good quality
randomised controlled trials to support or refute the
use and type of disposable napkins for the
prevention of napkin dermatitis in infants (Baer et al
2006).

Thorough cleansing of the nappy area with
warm water and / or a water-soluble emollient
(see emollient formulary) or fragrance-free and
alcohol-free baby wipes after soiling.
Baby wipes had an equivalent effect on skin
hydration when compared with cotton wool and
water and showed no evidence of any adverse
effects of using these wipes. (Lavender et al 2012).
Use fragrance- free and alcohol- free wipes (NHS
CKS 2009).

Do not use soap, bubble bath, or lotions (NHS CKS

2009). Soap products can lead to drying of the skin
and may affect the skin pH, further facilitating the
action of faecal enzymes (Gfatter et al 1997)

Sandra Lawton Page 6 of 13 October 2013

Apply a water-repellent emollient or barrier
preparation with each nappy change to reduce
irritant contact with urine and faeces.
Parents who wish to use alternative barrier
creams may do so freely in cases where bowel
function is normal.
Talcum powder or equivalent should not be
used
Exposing the skin to the air for periods of time
may be beneficial in the prevention of nappy
rash
If exposing the nappy area to air, do not lay the
child on incontinence pads. Use a gel core
nappy laid flat under the child
If a child is embarking on a treatment regimen
(e.g. antibiotic or chemo-therapy) that is
expected to alter bowel habit (e.g. causing
changes to frequency, consistency, enzyme or
acid content of faeces) then Cavilon barrier
film should be introduced before damage
occurs.
Sandra Lawton Page 7 of 13
Any agent used should be applied thinly to ensure
that it is well absorbed. Any excess barrier cream/
ointment may transfer to the nappy preventing it
from absorbing faeces/ urine (NHS CKS 2009).
There is no evidence that any barrier cream is more
effective than simple water-repellent ointments
(white or yellow) soft paraffin in the treatment of
uncomplicated nappy rash (Atherton 2001, Rowe et
al 2008).
Talcum powder forms a paste when wet which
causes friction and irritation (Atherton 2004). This
paste can also clog nappies limiting absorption. In
infants and neonates inhalation of powder residue
in the air may lead to respiratory complications
(Pfenninger and DApuzzo 1977, Mofenson et al
1981, Cotton and Davidson 1985).
Air exposure allows the skin to dry and reduces
persistent exposure to urine/ faeces (NHS CKS
2009).
Incontinence pads have a paper pulp core, which is
less absorbent than gel core nappies and is unable
to retain fluid potentially leading to greater
exposure to urine/ faeces.
Timely prophylactic intervention should avoid the
onset of tissue damage.
Cavilon barrier film single use applicators
should be used to apply the film.
October 2013
 Treatment Products for uncomplicated nappy rash

Please refer to Specific Product Characteristics and BNF when prescribing the
products listed below
Barrier Products
Barrier preparations are offered to provide a protective layer between the skin and urine/faeces.
There is no evidence to support the use of branded preparations containing water-repellent
substances (dimeticone). Many contain antiseptics, fragrances, and perfumes which may exacerbate
irritant dermatitis (NHS CKS 2009). Suitable preparations from the local formularies include ointment
based emollients and the products listed below:

Zinc and castor oil ointment BP contains pharmaceutical grade arachis (peanut) oil. This is
highly refined, and therefore, effectively, the peanut oil should have been removed. As a
precaution, however the Committee on the Safety of Medicines advises that people with a
known allergy to peanuts or soya (possible cross-sensitivity) should not use medicines
containing peanut oil (NHS CKS 2009).(for prevention)
Cavilon Durable Barrier Cream
Metanium Ointment
Cavilon Barrier Film (Applicators)

Emollients
Suitable choices from Emollient Formulary:
http://www.nottsapc.nhs.uk/attachments/article/8/emollient%20formulary.pdf
Liquid Paraffin and White Soft Paraffin Ointment (50:50)
Cetraben Emollient Cream
Hydromol Ointment
and
Yellow Soft Paraffin 15 g
White Soft Paraffin 15 g

Treatment Products for Complicated nappy rash

Topical antifungals (NHS CKS 2009)

Topical imidazole preparations (clotrimazole, ketoconazole and miconazole) are recommended, as

they are effective against Candida albicans. There is little evidence of difference between these
preparations, and they are all licensed to treat candidal skin infections in people of all ages. Topical
nystatin preparations are also effective against C albicans. They are licensed for use in all ages
(BNFC 2012).

Clotrimazole 1% 20g cream

Ketoconazole 2% 30g cream (Nizoral)
Miconazole nitrate 2% 30g cream (Daktarin)
Nystatin 100 000 units/g,chlorhexidine hyrdocholride 1% 30g cream (Nystaform)

Topical corticosteroids (NHS CKS 2009)

Hydrocortisone 0.51% is recommended if a topical corticosteroid is required. It is rarely necessary to

use a more potent corticosteroid than 1% hydrocortisone unless advised by dermatology. Topical
corticosteroids need only be applied once a day, whereas topical anti fungals need to be applied two
to three times a day.

Sandra Lawton Page 8 of 13 October 2013

Topical corticosteroids should be stopped as soon as the rash clears, whereas it is recommended that
antifungals are continued for 710 days after the rash has cleared to ensure complete mycological
eradication. Topical corticosteroids should not be used for more than 7 days because of enhanced
absorption in the occluded area which could give rise to skin thinning or adrenal suppression if used in
large quantities over a long time. If not responding consider diagnosis.

Combination Therapies

It is best to prescribe a topical corticosteroid and topical anti-candidal separately rather than as a
combined preparation, as this minimises exposure to topical corticosteroids and their potential adverse
effect (NHS CKS 2009):

Topical corticosteroids need only be applied once a day, whereas topical antifungals need to
be applied two to three times a day.
Topical corticosteroids should be stopped as soon as the rash clears, whereas it is
recommended that antifungals are continued for 710 days after the rash has cleared to
ensure complete mycological eradication.

Antibiotics (NHS CKS 2009,BNFC 2012)

Topical antibacterial preparations can be used for very minor bacterial infections. Polyfax ointment is
the preferred choice, fusidic acid cream can be used, but only a short course is recommended
because of the potential for resistance. Mupirocin should be reserved for MRSA positive patients only
(Nottingham Microbiology Policy).

Treat with oral antibiotics if there are features of severe or recurrent secondary bacterial infection. Oral
antibiotics should be used cautiously in nappy rash, as broad-spectrum antibiotics may cause
worsening of candidal infection (NHS CKS 2009).

Flucloxacillin is a good empirical first-line antibiotic as it will cover both staphylococcal and
streptococcal species.
Erythromycin as an alternative if known to be allergic to penicillin.

http://nuhnet/diagnostics_clinical_support/antibiotics/Pages/Home.aspx

Further Management
Follow-up advice

For all children with persistent nappy rash (NHS CKS 2009):

Review after 710 days of treatment if the rash has not resolved, or sooner if there is
deterioration. Daily if inpatient.
Review skin care of the nappy area and effective use of treatments.
If the child has persistent moderate to severe nappy rash despite 710 days of anti-
candidal treatment, consider changing to a different anti-candidal treatment, e.g. from an
imidazole to nystatin (or vice versa).
Fungal Infections unresponsive to topical antifungals. Swab and request fungal as well as
routine culture on microbiology request card.

Referral

Consider seeking advice from a dermatologist for:

Nappy rash which remains moderate to severe or distressing despite treatment.

Nappy rash which requires frequently repeated courses of topical corticosteroids, which
risks localized or systemic adverse effects Investigate?
Sandra Lawton Page 9 of 13 October 2013
 Extension of rash onto areas of skin not in contact with faeces /urine
The presence of epidermal loss or ulceration into dermis
If nappy rash has features of secondary bacterial infection that have not responded to a
first-line oral antibiotics.
Cellulitis
Presence of skin disease elsewhere
Diagnostic doubt

REFER TO SPECIALIST SERVICES

(See flow chart)

7) PLANS FOR TRAINING

Dissemination through clinical leads responsible for specialist teams.

8) IMPLEMENTATION AND DISSEMINATION

This guideline will be placed on the Trusts Intranet Site.

9) SUPPORTING RESOURCES FOR IMPLEMENTATION & DISSEMINATION

Further information is available from:

http://www.cks.library.nhs.uk/nappy_rash/view_whole_guidance

http://www.dermnetnz.org/dermatitis/napkin-dermatitis-imgs.html
(Skin disease information and photographs)

10) UPDATING

This guidance will be reviewed every three years earlier if evidence indicates an earlier review.

11) MEASUREMENT

Audit Methods Evidence source

Structure Checklist
Process Staff Survey
Outcome Checklist Observation

SUGGESTED AUDIT POINTS

Component Yes No
1. Was appropriate treatment prescribed?
2. Were emollient creams used to cleanse the skin?
3. Was treatment kept on the skin for the appropriate length of time?
4. Were the rashes reviewed 7-10 days following treatment?
5. Was the referral appropriate?
6. What investigations were undertaken if any?

Sandra Lawton Page 10 of 13 October 2013

12) REFERENCES

Adalat, S, Wall, D and Goodyear, H (2007) Diaper Dermatitis- Frequency and Contributory Factors in
Hospital Attending Children. Pediatric Dermatology.Vol.24:No.5: 483-488

Atherton, DJ. (2001) The aetiology and management of irritant diaper dermatitis. European Academy
of Dermatology and Venereology. 15. Supp 1:1-4.

Atherton DJ. (2004) A review of the pathophysiology, prevention and treatment of irritant diaper
dermatitis. Current Medical Research and Opinion. 20. 5:645-9.

Baer EL, Davies MW, Easterbrook KJ (2006). Disposable nappies for preventing napkin dermatitis in
infants. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004262. DOI:
10.1002/14651858.CD004262.pub2

British National Formulary for Children 2012-2013 (2012) British London, British Medical Association
and Royal Pharmaceutical Society of Great Britain.

Brook, I. (1992) Microbiology of secondarily infected diaper dermatitis. International Journal of

Dermatology 31(10), 700-702.

Cotton WH, Davidson PJ. (1985). Aspiration of baby powder. New England Journal of Medicine.
313.26:1662.

DermNet NZ (2012) http://www.dermnetnz.org/ Dermatology Resource [Accessed 02/10/13]

Gfatter R, Hackl P, Braun F. (1997). Effects of soap and detergents on skin surface pH, stratum
corneum hydration and fat content in infants. Dermatology 195.3:258-62.

Holden C. (1998). Infant napkin dermatitis. Journal of Wound Care. 7.8: 417-418

Jordan, W.E., Lawson, K.D., Berg, R.W. et al (1986) Diaper dermatitis: frequency and severity among
a general infant population. Pediatric Dermatology 3(3), 198-207.

Lavender,T., Furber,C., Campbell,M., Victor,S., Roberts,I., Bedwell,C and Cork,M.J (2012) Effect on
skin hydration of using baby wipes to clean the napkin area of newborn babies: assessor-blinded
randomised controlled equivalence trial. BMC Pediatrics: Jun 1;12:59
http://www.biomedcentral.com/content/pdf/1471-2431-12-59.pdf [Accessed 02/1013]

Mofenson HC, Greensher J, DiTomasso A, Okun S. (1981). Baby powder--a hazard! Pediatrics. 68.
2:265-6.

Odio, M.R., O'Connor, R.J., Sarbaugh, F. and Baldwin, S. (2000) Continuous topical administration of
a petrolatum formulation by a novel disposable diaper. 2. Effect on skin condition. Dermatology
200(3), 238-243.

Pfenninger J, D'Apuzzo V. (1977). Powder aspiration in children. Report of two cases. Archives of
disease in Childhood. 52.2:157-9

NHS Clinical Knowledge Summaries (2009) Nappy rash Management. Available at:
www.cks.nhs.uk/nappy_rash [Accessed 02/10/13]

Rowe, J., McCall, E and Kent, B (2008) Clinical effectiveness of barrier preparations in the prevention
and treatment of nappy dermatitis in infants and preschool children of nappy age. International Journal
Evidence Based Healthcare. 6: 323

Scheinfeld, N. (2005) Diaper dermatitis: a review and brief survey of eruptions of the diaper area.
American Journal of Clinical Dermatology 6(5), 273-281.

Sandra Lawton Page 11 of 13 October 2013

 Nappy Rash Flow Cha

Good Nappy Care (Record care on SSKIN Bundle)

Reduce interval between nappy changes
Nappy Changes should take place ASAP after soiling.
Use of, and frequent changing of, a disposable gel-core nappy
Cleanse nappy area with warm water and emollient or alcohol/ perfume free wipes
Apply a water-repellent emollient or barrier preparation with each nappy change to reduce irritant contact with urine and faeces.
Expose the skin to the air for periods of time after cleansing.

Mild Nappy Rash Moderate to Severe Nappy Rash Candidiasis

Faint to definite pink rash of less than 10% of
the area covered by the nappy,
With or without a few scattered papules,
With or without slight scaling and dryness.
Is unlikely to distress the infant
Moderate to severe redness covering an area greater Erythema extending to areas not in contact
than 10% of the area covered by the nappy, with faeces
With or without papules, oedema, or ulceration. It develops into sharply marginated confluent
Is more likely to be distressing and zones with papules, pustules involving the
Secondarily infected with Candida albicans skin creases of the nappy area.
(candidiasis) Satellite lesions are characteristic
Oral thrush may be present- treat

Topical Antifungal with + / - Topical corticosteroid

Good Nappy Care

Ongoing assessment and education

Referral to Specialist Services Referral to Specialist Services

Nappy rash which remains moderate to severe or distressing despite treatment. Medical Teams

N03 2013 Dermatology

Nappy rash which requires frequently repeated courses of topical corticosteroids

Extension of rash onto areas of skin not in contact with faeces /urine Tissue Viability

The presence of epidermal loss or ulceration into dermis

Author
Sandra Lawton

Written November 2013 Review 2018

Consultation Process: expert panel

Ratified by: Nottingham Childrens Hospital Clinical Educators Group

(comments received from KF, AH)

Signed off by: Angela Horsley, Kerry Webb and Rachel Keay

N03 2013