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Zoé, 11 months old. Infant’s nappy rash.
Zoé, 11 months old. Infant’s nappy rash.
Reviewed by Dr. Alexandre, dermatologist.
5 min read
Related topics
- Dryness / Atopy / Eczema
Zoé, an 11-month-old infant, has been brought to the doctor by her concerned mum because her bottom is in very “bad condition”.
Since Zoé’s birth, her parents have bathed her 3 or 4 times a week, and “cleaned” her bottom with nappy cream at every nappy change.
Zoé’s bottom became irritated about 2 months ago, and mum has been applying an over-the-counter antifungal cream.
The nappy rash is getting worse. There are no other lesions on the rest of the body.
What diagnosis do you suggest?
True answer!
Wrong answer!
Nappy-area mycosis begins in the folds (intertrigo) and then spreads in a W pattern over the rest of the nappy area, with small peripheral pustules.
This is an irritant/maceration dermatitis, consisting of erythematous lesions (some slightly papular, some pre-erosive) located on the convex parts of the nappy area in contact with the nappy (vulva, buttocks).
In the case of a zinc deficiency (acrodermatitis enteropathica), the nappy area and face are affected, with desquamative lesions.
Langerhans cell histiocytosis manifests itself as small purplish papules and purpuric erythema on the skin folds of the nappy area (inguinal folds), sometimes associated with lesions on the armpits, scalp, or elsewhere.
Nappy-area psoriasis consists of fairly thick, well-defined, erythematosquamous lesions extending beyond the diaper area.
What tests do you suggest?
True answer!
Wrong answer!
The diagnosis of irritant/maceration dermatitis of the nappy area is clinical. If there is no improvement despite proper care, refer to a specialist to rule out rarer diagnoses.
What care should be given? (many possible response)
True answer!
Wrong answer!
Irritant/macerative nappy dermatitis
- is a very common pathology in infants;
- is linked to maceration/irritation of the skin of the nappy area,
- in contact with urine- or stool-soiled nappies;
- the skin’s sensitivity to infection is increased.
- It can be resolved with appropriate hygiene. Provide advice to the parents of the affected child.
- The erythema begins on the convex areas in contact with the soiled nappy (buttocks, vulva, or scrotum), then later spreads to the whole of the nappy area.
- Initially, nappy rash covers the inner thighs, buttocks, and pubic area, but not the skin folds.
- Papules, nodules, or erosions may appear later.
Factors favouring nappy rash :
Prolonged contact between the baby’s bottom and their stool and urine has an irritating effect.
A number of factors can lead to nappy rash:
- Diarrhoea
- The use of unsuitable nappies
- Unsuitable hygiene practices:
- diaper changes that are too infrequent encourage maceration
- the use of irritating care products
- insufficient or incomplete cleaning of the nappy area, poor drying
The progression of nappy rash:
- With appropriate hygiene, nappy rash heals in a few days (from 24 hours to 15 days, depending on the severity)
- Without care, erosions, fissures, and papules may appear
- Irritant dermatitis can also be complicated by fungal infections
Seborrhoeic dermatitis:
It is generally associated with profuse seborrhoeic dermatitis of the scalp and begins at an early age.
Psoiasis of the perineal or "nappy" area:
It appears as a thick erythema over the whole of the nappy area and extending beyond that area.
Contact eczéma:
It manifests itself as a very itchy erythema localised to a specific area (often around the elastic of the nappy).
Perianal streptococcal dermatitis:
It presents as perianal erythema, with small fissures, accompanied by constipation, and is sometimes accompanied by fever.
Acrodermatitis enteropathica:
It presents as a desquamative erythema of the nappy area, associated with lesions on the face (chin, perioral area, cheeks).
Kawasaki disease:
It may include diffuse erythema in the nappy area with peripheral desquamation, but other symptoms (fever, deterioration of general health, adenopathy, etc.) are more characteristic of the disease.
Langerhans cell histiocytosis
It manifests itself as small purpuric papules and erythema on skin folds, in the nappy area, but also on the armpits and scalp, and may be more widespread. If there is any doubt, it is essential to perform a skin biopsy.
Nappy-area mycosis
It begins in the skin folds (inguinal, intergluteal) and then spreads to the rest of the nappy area.
A few small pustules may appear around the periphery of the erythema.
What should you pay special attention to?
- In the case of nappy rash, carefully analyse the onset of lesions (skin folds or convex areas) and the presence or absence of pustules or papules.
- Keep it simple and logical when it comes to nappy area hygiene.
Reduce irritation and maceration:
Stop cleaning with wipes and nappy cream.
Practice appropriate hygiene:
Learn to choose the right products (syndet, cleansing oil): look at the ingredients—the smaller the number of ingredients, the better.
Apply simple, clear instructions:
- cleanse the nappy area in the morning after waking and then after each bowel movement, using water and a gentle cleanser
- rinse
- then dry
Increase the frequency of nappy changes:
At least 8 times a day.
Soothing and protective skin repair cream:
Apply at least once a day (including in the evening at bedtime, to protect the skin from the soiled nappy).
- Avoid products such as antiseptics, bicarbonate of soda, eosin, potassium permanganate, talc, etc.
- Avoid the systematic use of oil and lime-water nappy cream to clean the nappy area: it can be used as an additional product for cleansing the nappy area or to moisturise the nappy area after it has been cleaned with a gentle cleanser and water
- Keep it simple: it’s better to clean with a gentle cleanser and water rather than wipes, lotions, etc.
- Remind parents how to use products
- Water alone does not clean properly
- Beware of amber necklaces to prevent teething pain and diaper rash: they are ineffective and potentially dangerous
Annabel Maruani-Raphael
Pediatric dermatologist
,
France
The majority of nappy rash cases are linked to maceration and irritation.
Keep care simple: clean the nappy area with a gentle syndet and water, then dry thoroughly.
Dr
Samuel Sarfati
General practitioner
,
France
Nappy rash: erythematous lesions in convex parts of the nappy area, versus nappy-area mycosis, which starts in the skin folds and spreads to the rest of the nappy area.
Treatment is essentially based on appropriate hygiene rules.
Watch out : avoid products such as antiseptics, bicarbonate of soda, eosin, potassium permanganate, etc.
Nicolas Dutriaux
Midwife
Education on health and preventive care are critically important for our profession.
Promote the proper usage of the various products, with a focus on simple and limitedingredient formulations.
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