Generally, management for all forms of nappy rash is the same, even when the rash is very severe. Treatment involves environmental modification and specific medical management. Highly absorbent disposable nappies are preferable to cloth nappies. If cloth nappies are used, parents should be advised to change them every two hours and avoid using plastic overpants and nappy liners. As with any sort of dermatitis, a soap substitute should be used instead of soap and a dispersible bath oil used in every bath. At each nappy change, a damp cloth and bland emollient should be used instead of commercial wipes, and further emollient applied. Zinc and castor oil preparations are popular as a nappy rash treatment, but any greasy emollient is effective.
In many cases, environmental modification alone is inadequate and the medical treatment of choice is 1% hydrocortisone cream used in conjunction with a topical antifungal such as nystatin or an imidazole (clotrimazole or miconazole). There are several combined products, such as clotrimazole plus hydrocortisone, which are convenient and not much more expensive. The treatment should be used three times daily until the rash has resolved. Generally, hydrocortisone 1% is the only corticosteroid that should be used in the nappy area.
Inadequate response to treatment may be due to:
- noncompliance with treatment
- irritancy or allergy from topical therapy
- bacterial or viral infection
- an underlying rare condition.
Pustules, erosions, vesicles, ulcers or areas of weeping may indicate a bacterial or viral infection, particularly in infants in whom there has been an inadequate response to therapy. A bacterial, and possibly a viral, swab should be taken and treatment started according to culture and sensitivity results. C. albicans will grow from a bacterial swab.
In the very rare instance of a herpetic infection, no specific treatment is needed, as the lesions will heal spontaneously within two weeks. If the infection is severe with ulceration or urinary retention, the infant may need to be admitted to hospital for intravenous aciclovir.
Seborrhoeic dermatitis is the term used to describe a clinical presentation that may occur in three common infantile dermatoses: idiopathic seborrhoeic dermatitis, atopic dermatitis and psoriasis. The eruption is seen most often before 2 months of age. Initially, the face, scalp, neck, axillae and nappy areas are involved, but the rash may generalise (Figure 3). The lesions are well defined and have a greasy scale. Characteristically, babies with seborrhoeic dermatitis are well and not itchy.
The rash in classic, idiopathic seborrhoeic dermatitis is self-limiting, clearing spontaneously in a few weeks or sooner if treated. However, both atopic dermatitis and infantile psoriasis may also present in this way, and in these cases, the rash recurs. In about one-third of cases, seborrhoeic dermatitis will remit completely and the babies will have no further problems with their skin; in the other two-thirds, psoriasis or atopic dermatitis will develop. Infection with either C. albicans or Staphylococcus aureus is common; it should be suspected if crusting, weeping or pustulation are present and actively treated.