What is the treatment for diaper dermatitis in infants?

Treatment of Diaper Rash in Infants

Clean the diaper area with emollient ointment instead of water or commercial wipes, apply a barrier cream containing zinc oxide or petrolatum, ensure frequent diaper changes, and allow air exposure when possible. 1, 2

First-Line Management Approach

Cleaning and Hygiene

• Use emollient ointment to clean the diaper area rather than water or commercial wipes, as this reduces friction and irritation while maintaining skin barrier function 1, 2
• Avoid commercial wipes containing alcohol or fragrances, which can further irritate the skin 2
• Change diapers frequently to minimize exposure to urine and feces 3

Barrier Protection

• Apply barrier creams containing zinc oxide or petrolatum (with or without vitamin A) to protect the skin from moisture and irritants 1, 2, 4
• After bathing, use zinc oxide powder to thoroughly dry the skin, which reduces rates of skin irritation 2
• Apply wound dressing or barrier cream to bony prominences (heels, elbows) and trauma-exposed sites 2

Diaper Modifications

• Use well-fitted standard diapers and trim off the inner elastic of disposable diapers to reduce friction 1, 2
• Line diapers with soft cloth liners coated with emollient or paraffin-impregnated gauze 1, 2
• Superabsorbent disposable diapers reduce the incidence of diaper dermatitis 3

Treatment for Inflammatory or Moderate Cases

Topical Corticosteroids

• For eczematous inflammation with erythema and desquamation, use low-potency topical corticosteroids such as hydrocortisone 2.5% 2
• However, FDA labeling specifically states "do not use for the treatment of diaper rash" for over-the-counter hydrocortisone products 5
• This creates a clinical dilemma: guidelines suggest low-potency corticosteroids for inflammatory diaper dermatitis 1, 2, but FDA labeling prohibits their use in diaper rash 5
• If corticosteroids are used (under physician supervision), limit duration of exposure due to increased absorption in the diaper area and apply no more than twice daily 1

Alternative Anti-inflammatory Options

• Topical PDE-4 inhibitors (like crisaborole) may be considered for mild to moderate cases as an alternative to corticosteroids 1
• Wet-wrap therapy with topical corticosteroids can be effective short-term for moderate to severe cases 1

Management of Complicated Cases

Bacterial Superinfection

• Look for signs of bacterial infection including crusting or weeping 2
• Add systemic antibiotics such as flucloxacillin or erythromycin if clinical signs of bacterial superinfection are present 1
• Bacterial infection typically requires culture-directed antibiotics, with flucloxacillin for Staphylococcus aureus 2
• Long-term topical antibiotics are not recommended due to increased risk of resistance and skin sensitization 1

Fungal Infection

• Assess for signs of fungal infection in the diaper area 2
• Seek medical evaluation for appropriate antimicrobial treatment if suspected infection occurs 2

Blistered Skin

• For blistered skin in the diaper area, use a hydrogel dressing such as Intrasite Conformable dressing 6, 2

Important Caveats and Pitfalls

What NOT to Use

• Do not use topical antihistamines, as they increase the risk of contact dermatitis 1
• Avoid over-washing with hot water or harsh soaps, which damages the skin barrier 2
• Do not apply topical corticosteroids more than twice daily to minimize systemic effects 1

When to Seek Medical Attention

• Seek medical evaluation if the condition worsens, symptoms persist for more than 7 days, or clear up and recur within a few days 5
• Medical evaluation is needed for appropriate antimicrobial treatment if infection is suspected 2

Special Considerations

• Babies with sensitive skin or atopic tendencies may be more susceptible to diaper rash 2
• Recent antibiotic use or excessive moisture are aggravating factors to consider 2
• Regular use of emollients has both short-term and long-term protective effects in mild to moderate diaper dermatitis 1