What is the best course of treatment for a 2-year-old with a persistent and worsening nappy rash that started after antibiotic treatment for urinary symptoms?

Treatment for Nappy Rash After Antibiotic Use in a 2-Year-Old

The best treatment for this 2-year-old with a nappy rash that developed after antibiotic use is a mild hydrocortisone cream (1%) applied to the affected area up to 3-4 times daily for 5-7 days, combined with frequent diaper changes and gentle cleansing. 1

Diagnosis and Assessment

This case presents a classic antibiotic-associated diaper dermatitis with the following key features:

• Temporal relationship: Rash developed after starting Augmentin and worsened after discontinuation
• Characteristics: Erythematous, bumpy rash in the nappy area
• Failed treatments: Sorbolin, loratadine, and miconazole have been tried with little effect
• Family pattern: Twin sister has similar but less severe rash

This presentation is consistent with an irritant contact dermatitis likely triggered by antibiotic-associated changes in the skin microbiome or direct irritation from antibiotic metabolites excreted in urine.

Treatment Algorithm

1. Topical corticosteroid therapy:

   • Apply 1% hydrocortisone cream to affected areas 3-4 times daily 1
   • Use for 5-7 days (not exceeding 7 days without reassessment)
   • Apply thinly after gentle cleansing and drying of the area

2. Barrier protection:

   • Apply a zinc oxide-based barrier cream after each diaper change
   • This creates a physical barrier between irritants (urine/stool) and the skin

3. Diaper area care:

   • Frequent diaper changes (every 2-3 hours and after bowel movements)
   • Gentle cleansing with warm water (avoid wipes with alcohol or fragrances)
   • Pat dry or allow air-drying rather than rubbing

4. Air exposure:

   • Allow diaper-free time several times daily (15-20 minutes)
   • This promotes healing by reducing moisture and irritant contact

Evidence and Rationale

The FDA labeling for hydrocortisone specifically addresses its use for diaper rash in children over 2 years of age, recommending application to the affected area no more than 3-4 times daily 1. This child is exactly 2 years old, making this treatment appropriate.

While the evidence provided doesn't specifically address antibiotic-associated diaper rash, topical hydrocortisone is well-established as effective for inflammatory skin conditions. The anti-inflammatory properties help reduce the erythema and discomfort while the skin barrier recovers.

Important Considerations and Precautions

• Duration of treatment: Limit hydrocortisone use to 7 days. If the rash persists beyond this period, reassessment is necessary 1
• Application technique: Apply only to affected areas, avoiding healthy skin
• Potency selection: Use only mild (1%) hydrocortisone for the diaper area in young children
• Monitoring: Watch for signs of skin thinning, though this is unlikely with short-term use of mild preparations 2
• Avoid combination with antifungals: Since miconazole was ineffective, this suggests the rash is primarily inflammatory rather than fungal

When to Seek Further Medical Attention

Parents should seek prompt medical reassessment if:

• The rash worsens despite treatment
• The rash spreads beyond the diaper area
• The child develops fever or appears unwell
• No improvement is seen after 3-4 days of treatment
• Any signs of secondary bacterial infection develop (increased redness, warmth, drainage)

This approach balances effective treatment of the inflammatory component while minimizing potential adverse effects of topical corticosteroids in a young child.