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Helping Parents To Manage Nappy Rash

7 minutes

27/11/2020

Dr Stephanie Ooi

Overview

Nappy rash is the most common skin condition amongst young infants, affecting 1 in every 4 babies.1 Also known as irritant diaper dermatitis, this is a complex skin condition that is marked by compromised epidermal barrier function occurring on the buttocks, perianal region, inner thighs, and abdomen.2 Expert GP, Dr Stephanie Ooi explores the unique structure of babies’ skin and how it can become susceptible to nappy rash, along with its causes and risk factors. Finally, she provides practical advice to support parents on the specific skin cleaning needs of babies during this time.

Seeing a baby experience nappy rash can cause significant distress among new parents but it’s important to remind them from the outset that this condition is very common amongst young infants. It is estimated that nappy rash affects up to 25% of nappy-wearing infants at any given time,1 and can effect babies of all ages.3 The incidence and severity of nappy rash has decreased since the introduction of super-absorbent disposable nappies and hypoallergenic skin care products.3-5

a mother changing her baby’s nappy.

The unique structure of babies’ skin

The skin of infants and young babies is unique compared to that of older children and adults in terms of structure, composition and function. The epidermis in babies is 20% thinner and the stratum corneum is 30% thinner6 which increases susceptibility to permeability and dryness.7 However, in contrast to adults, infant skin has an increased proliferation rate,9 which supports the maturation of the skin barrier during the first year of life.

Baby skin is less firmly attached than mature skin and has a higher natural tendency to increase loss of water from inside the body through the epidermis, and reduce hydration of the top layer of the epidermis, reflecting a less effective skin barrier function.7,9 As the ratio between baby body surface to baby body weight is higher,7 topical agents are more readily absorbed and can therefore have a more pronounced effect on baby skin.

Anatomically, the skin of the nappy area features several folds and creases, presenting challenges in terms of both efficient cleansing and control of the skin environment, unless proven measures and materials are identified and carefully adapted on a routine basis.10

Did you know?

Skin barrier development in infants can remain incomplete until around 12 months,11 consistent with a ~3.5 X higher transepidermal water loss (TEWL) observed from neonatal skin relative to mature skin.12

Nappy rash – symptoms, causes and risk factors

These can be categorised as mild, moderate or severe, with mild presenting as slightly red irritated skin in the nappy area and severe characterised by raw, bleeding and open sores.13 Nappy rash is usually mild and can be dealt with at home.

Fast facts

  • It is not unusual for every child to have at least one episode of nappy rash by the time he or she is toilet-trained14

  • Nappy rash can range in severity: out of a given pool of patients, reportedly 58% have a slight rash, 34% a moderate rash and 8% a severe rash15,16

  • It is often during teething or weaning that a baby can become more prone to nappy rash17

It is well established in scientific literature that exposure to moisture and occlusion in the nappy area can contribute to local irritation, reduced skin resilience, impeded barrier function and ultimately dermatitis.18 When the skin becomes hydrated, it is especially vulnerable to mechanical damage and chafing due to friction from the nappy, allowing biologic and chemical irritants to penetrate the stratum corneum.10,20 These irritants, namely components of urine and faecal enzymes can lead to the build-up of ammonia from the urinary urea, resulting in an elevation of the baby’s skin pH.19 Consequently, this increased skin pH triggers faecal proteases and lipases, both regarded as the key contributors in the development of nappy rash.20

There are limited studies examining the risk factors associated with nappy rash among infants. One study reported that the prevalence of nappy rash was associated with infant maturity, infant formula feeding, and the presence and level of faecal C. albicans.16 In another study, recurrent nappy rash was shown to be associated with increasing infant age, lack of barrier cream use and frequency of nappy changes, whereas current nappy rash has been shown to be associated with oral thrush (candidiasis), previous episodes of nappy rash and frequency of nappy changes.21

Antibiotic use and diarrhoea are also considered risk factors in the development of nappy rash.19,22,23 Lastly, breastfed infants appear to be less susceptible to nappy rash as faeces have a lower pH. The bile salts in the stools encourage the activity of faecal enzymes, compounding the effect.14

Preparing parents for nappy rash

Gentle and effective cleansing of the nappy area can halt the nappy rash cycle in babies through restoring the skin dryness, eliminating irritants and balancing skin pH levels.

NICE has set out a few key steps in managing nappy rash for parents and caregivers to follow24:

Air

  • Leave nappies off for as long as possible to help skin drying of the nappy area

Change nappies frequently

  • Clean the skin and change the nappy every 3–4 hours, or as soon as possible after wetting or soiling, to reduce skin exposure to urine and faeces

  • Use water, or fragrance-free and alcohol-free baby wipes in order to protect the skin barrier25

  • Apply a barrier cream (type and application depends on the severity of symptoms)

Not necessary to bathe daily

  • Avoid excessive bathing (such as more than twice a day) which may dry the skin excessively. Pat dry after cleaning

  • Avoid soap, bubble bath, lotions, talcum powder, or topical antibiotics which can have an irritant effect and destabilise the skin pH268

If the nappy rash does not resolve after following these steps, a referral to GP should be considered.20

Practicing good hygiene is also important

Parents should be equipped with the necessary education on proper hygiene techniques:

  • Washing hands before and after each nappy change to prevent contamination20

  • Wiping should be done from the front to the back20

  • Keeping babies’ hands clean, relating to their hand-to-mouth behaviours, can help reduce or prevent oral transmission of pathogens. Parents should pay particular attention to skin on the facial area, which may be irritated easily by milk, food and saliva2

The role of wipes in managing and preventing nappy rash

Whilst cloth wipes or cotton wool and water have traditionally been considered the gold standard for cleaning baby’s nappy area, recent studies have consistently demonstrated across a range of clinical settings how some baby wipes provide effective cleaning whilst also being tolerable and mild, supporting their use even on delicate neonatal skin.20,27-31 In fact, it has been shown that baby wipes are associated with no increase in skin irritation where commercially available alcohol- and fragrance-free baby wipes were used, compared with cloth or cotton wool and water.25 Additionally, parents reported that baby wipes were more convenient to use than cotton wool and water.28,32

A mother changing her baby’s nappy whilst  her daughter watches.

Babies cleansed with WaterWipes have a lower incidence and a shorter duration of nappy rash

A new clinical study of 698 mums published in Pediatrics and Neonatology has shown that mums using WaterWipes on their babies’ skin had a lower incidence of nappy rash (19%), compared to those cleansed with brand 1 (25%) or brand 2 (30%). Additionally, for each day of nappy rash experienced by the WaterWipes babies, the rash would have lasted approximately 50% longer had they they used the other brands (1.69 days with brand 2 and 1.48 days with brand 1). The other brands are marketed as mild and gentle enough for newborn skin but contain additional ingredients to WaterWipes. This is the first research of its kind, revealing different formulations of baby wipes can impact the skin integrity of infants.33

WaterWipes are gentle on the most sensitive skin

Containing just two ingredients, 99.9% high purity water and 0.1% Fruit Extract, WaterWipes are so gentle on skin they can be used on premature babies.

WaterWipes are manufactured under clean room conditions using a unique purifying technology. The water in WaterWipes undergoes a 7-stage water purification process which results in an ultra-pure wipe which delivers a soft feel on the skin. This process makes the water purer than cooled boiled water. This purifying technology produces a unique product that effectively cleanses the skin, without the need for additional unnecessary cleansing ingredients.

The Fruit Extract contains naturally occurring polyphenols and vitamin C which act as a gentle skin conditioner and cleanser.34

WaterWipes are purer than cotton wool and water

Based on a review of the scientific literature by its independent team of experts, the Skin Health Alliance concluded that WaterWipes baby wipes are purer than using cotton wool and water.

The difference in purity between WaterWipes and cotton wool and water.

WaterWipes are recommended by midwives and other healthcare professionals worldwide and have become the preferred wipe for many Neonatal Intensive Care Units throughout , Ireland, UK, Portugal, USA, Australia and New Zealand.

*Moderate to severe nappy rash

References
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1. Ravanfar,P., Wallace,J.S. and Pace,N.C. (2012) Diaper dermatitis: a review and update. Current Opinion in Pediatrics. 24(4), 472-479. [Abstract]

2. Telofski LS, Morello AP 3rd, Mack Correa MC, Stamatas GN. (2012) The infant skin barrier: can we preserve, protect, and enhance the barrier?. Dermatol Res Pract. 198789. doi:10.1155/2012/198789

3. Cohen, B. (2017) Differential diagnosis of diaper dermatitis. Clinical Pediatrics 56(5S), 16-22. [Abstract]

4. Visscher, M.O. (2009) Recent advances in diaper dermatitis: etiology and treatment. Pediatric Health 3(1), 81-98.

5. Atherton, D.J. (2016) Understanding irritant napkin dermatitis. International Journal of Dermatology 55(Suppl 1), 7-9. [Abstract]

6. Stamatas, G., Nikolovski, J., Luedtke, M., et al, 2010. Infant skin microstructure assessed in vivo differs from adult skin in organization and at the cellular level. Pediatric Dermatology 27, 125–131 Available at: https://www.ncbi.nlm.nih.gov/pubmed/19804498 Last accessed: 4 September 2018.

7. Cooke, A, Bedwell, C, Campbell, M, et al (2018) Skin care for healthy babies at term: A systematic review of the evidence. Midwifery 56: 29–43 https://www.midwiferyjournal. com/article/S0266-6138(17)30354-6/pdf [last accessed March 2020]

8. Leung, A., Balaji, S., Keswani, S G., 2014. Biology and Function of Fetal and Pediatric Skin: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3654382/

9. Oranges, T., Dini, V., Romanelli, M., Skin Physiology of the Neonate and Infant: Clinical Implications. Advances in Wound Care 2015: 4(10): 587-595. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4593874/. Last accessed 19 October 2019.

10. Adam R. Skin care of the diaper area. Pediatric Dermatology. 2008;25(4):427-433.

11. Nikolovski J, Stamatas G, Kollias N, Wiegand B: Barrier Function and Water-Holding and Transport Properties of Infant Stratum Corneum are different from adults and continue to develop through the first year of life. J Investig Dermatol 2008;128:1728–1736.

12. Cork MJ, Danby SG, Vasilopoulos Y, Hadgraft J, Lane ME, Moustafa M, Guy RH, MacGowan AL, Tazi-Ahnini R, Ward SJ: Epidermal Barrier Dysfunction in Atopic Dermatitis. J Investig Dermatol 2009; 129:1892–1908.

13. Oakley A. (1997) Napkin Dermatitis. DermNet NZ https://www.dermnetnz.org/topics/napkin-dermatitis

14. Argwal, R. 2018. Diaper Dermatitis https://emedicine.medscape.com/article/911985-overview#a5 [last accessed March 2020]

15. Atherton DJ. (2004) A review of the pathophysiology, prevention and treatment of irritant diaper dermatitis. Curr Med Res Opin. 20:645-649

16. Jordan, WE , Lawson, KD , Berg, RW (1986) Diaper dermatitis: frequency and severity among a general infant population. Pediatr Dermatol; 3: 198–207

17. Khan, N. (2014) Nappy rash: prevention and cure. Nursing In Practice https://www.nursinginpractice.com/nappy-rash-prevention-and-cure [last accessed March 2020]

18. Berg RW. (1998) Etiology and pathophysiology of diaper dermatitis. Adv Dermato, 3:75–98

19. Merrill, L. (2015), Prevention, Treatment and Parent Education for Diaper Dermatitis. Nursing for Women's Health, 19: 324-337. doi:10.1111/1751-486X.12218

20. Wesner, E., Vassantachart, J.M., Jacob, S.E. 2019. Art of prevention: The importance of proper diapering practices,

International Journal of Women's Dermatology 5:4, 233-234, http://www.sciencedirect.com/science/article/pii/S2352647519300103 [last accessed March 2020]

21. Adalat, S , Wall, D , Goodyear, H : Diaper dermatitis - frequency and contributory factors in hospital attending children. Pediatr Dermatol 2007; 24: 483–488

22. Li, C & Zhu, Z & Dai, YH. (2012). Diaper Dermatitis: A Survey of Risk Factors for Children Aged 1 – 24 Months in China. The Journal of International Medical Research. 40:1752-60 https://journals.sagepub.com/doi/full/10.1177/030006051204000514

23. Campbell, R.L., Bartlett, A.V., Sarbaugh, F.C. and Pickering, L.K. (1988), Effects of Diaper Types on Diaper Dermatitis Associated with Diarrhea and Antibiotic Use in Children in Day‐Care Centers. Pediatric Dermatology, 5: 83-87. doi:10.1111/j.1525-1470.1988.tb01143.x

24. NICE (2018) Na Campbell, R.L., Bartlett, A.V., Sarbaugh, F.C. and Pickering, L.K. (1988), Effects of Diaper Types on Diaper Dermatitis Associated with Diarrhea and Antibiotic Use in Children in Day‐Care Centers. Pediatric Dermatology, 5: 83-87. doi:10.1111/j.1525-1470.1988.tb01143.xppy rash - Scenario: Management of nappy rash, https://cks.nice.org.uk/nappy-rash#!scenario [last accessed March 2020]

25. Fernandes J.D., Machado, M.C.R., Oliveira, Z.N.P (2011) Children and newborn skin care and prevention. Anais Brasileiros de Dermatologia http://www.scielo.br/scielo.php?pid=S0365-05962011000100014&script=sci_arttext&tlng=en [last accessed March 2020]

26. Van Onselen, J. (2018) Spotlight: tackling nappy rash in infants. British Journal of Family Medicine, https://www.bjfm.co.uk/napkin-dermatitis-in-infants-overview-and-current-treatment-guidance [last accessed March 2020]

27. Visscher, M., Odio, M., Taylor, T., White, T., Sargent, S., Sluder, L., ... & Huebner, A. (2009). Skin care in the NICU patient: effects of wipes versus cloth and water on stratum corneum integrity. Neonatology, 96(4), 226-234.

28. Lavender, T., Furber, C., Campbell, M., Victor, S., Roberts, I., Bedwell, C., & 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, 12(1), 59

29. Garcia B.N, Massoudy L, Scheufele R, Ekkehart D.M, Proquitte H, Wauer R, Bertin C, Serrano J, Blume- Peytavi U (2012) Standardized diaper care regimen: a prospective, randomized pilot study on skin barrier function and epidermal IL-1a in new borns Pediatric Dermatology 29(3):270–276

30. Odio, M., Streicher-Scott, J., & Hansen, R. C. (2001). Disposable baby wipes: efficacy and skin mildness. Dermatology Nursing, 13(2), 107

31. Blume‐Peytavi, U, Kanti, V. Prevention and treatment of diaper dermatitis. Pediatr Dermatol. 2018; 35: s19‐ s23. https://doi.org/10.1111/pde.13495

32. Furber C, Bedwell C, Campbell M, Cork M, Jones C, Rowland L, Lavendar T (2012) The challenges and realities of diaper area cleansing for parents. Journal of Obstetric, Gynecologic and Neonatal Nursing, 00:1-13.

33. Price AD, Lythgoe J, Ackers-Johnson J, Cook PA, Clarke-Cornwell A, MacVane Phipps F (2020) The BaSICS (Baby Skin Integrity Comparison Survey) Study: a prospective experimental study using maternal observation to report the effect of baby wipes on the incidence of irritant diaper dermatitis from birth to eight weeks of age. Pediatrics & Neonatology: doi:10.1016/j.perneo.2020.10.003. [Epub ahead of print]

34. Burnett, C. 2017. Safety Assessment of Citrus Plant- and Seed-Derived Ingredients as Used in Cosmetics. Cosmetic Ingredient Review. http://www.cir-safety.org/sites/default/files/cplant122016rep.pdf, last accessed 12 March 2020

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