Treatment of Diaper Rash in Infants with Diarrhea
Apply a barrier cream containing zinc oxide or petrolatum to the affected area with each diaper change, and focus on managing the underlying diarrhea with oral rehydration and continued feeding to prevent worsening of the rash. 1, 2
Barrier Protection Strategy
The cornerstone of treating diaper rash in the setting of diarrhea is creating a protective barrier between the irritated skin and the caustic stool:
- Apply zinc oxide ointment or petrolatum-based barrier cream at each diaper change to protect the skin from further irritant contact 2, 3
- Zinc oxide combined with dexpanthenol (5%) significantly reduces transepidermal water loss by day 3 of treatment compared to ointment base alone, indicating faster skin barrier repair 2
- Products containing zinc gluconate, zinc oxide, dexpanthenol, and taurine target multiple mechanisms of diaper dermatitis and show clinical improvement within 15-30 days 4, 5
Critical Caveat: Avoid Topical Steroids
Do not use hydrocortisone or other topical corticosteroids for diaper rash. The FDA explicitly contraindicates hydrocortisone for treatment of diaper rash 6. This is a common pitfall—while steroids may seem appropriate for inflammation, they are not indicated for this condition.
Diaper Area Care Protocol
- Cleanse gently with water and a soft washcloth or baby wipes after each stool, as both methods have comparable effects on diapered skin 3
- Pat dry thoroughly before applying barrier cream—moisture trapped under ointment worsens maceration 7
- Change diapers frequently to minimize contact time between stool and skin, particularly important during diarrheal episodes 7
- Allow air exposure when feasible between diaper changes to promote drying 7
Address the Underlying Diarrhea
The rash will not fully resolve until the diarrhea is controlled. Managing the diarrhea is essential to reducing stool frequency and acidity:
Rehydration and Ongoing Loss Replacement
- Replace ongoing fluid losses with 10 mL/kg of oral rehydration solution (ORS) for each liquid stool and 2 mL/kg for each vomiting episode 1, 8
- If the infant shows signs of dehydration (decreased skin turgor, dry mucous membranes, decreased urine output), administer 50 mL/kg ORS over 2-4 hours for mild dehydration or 100 mL/kg over 2-4 hours for moderate dehydration 1
Continue Feeding
- Continue breastfeeding on demand throughout the diarrheal episode without interruption 9, 1
- For formula-fed infants, resume full-strength lactose-free or lactose-reduced formula immediately, as this does not worsen diarrhea and supports nutritional recovery 9
- For older infants on solids, continue age-appropriate foods including starches, cereals, yogurt, fruits, and vegetables; avoid foods high in simple sugars and fats 9, 1
When to Avoid Antibiotics
Do not use antibiotics or antidiarrheal agents routinely for acute watery diarrhea 9, 1. Antibiotics are only indicated if:
- Bloody diarrhea (dysentery) is present 9, 1
- High fever is documented in a medical setting 9
- Watery diarrhea persists for more than 5 days 9, 1
Antidiarrheal medications like loperamide are absolutely contraindicated in all children under 18 years of age due to risks of respiratory depression and cardiac adverse effects 8.
Expected Timeline and Reassessment
- Expect improvement within 3 days if diarrhea is resolving; zinc oxide with dexpanthenol shows significant reduction in transepidermal water loss by day 3 2
- Complete clearance typically occurs within 7 days once diarrhea resolves, with efficacy rates of approximately 58-60% by day 7 2
- Persistent rash beyond 7 days warrants reassessment for secondary candidal infection (look for satellite lesions) or other underlying conditions 1
Red Flags Requiring Medical Evaluation
Instruct caregivers to seek immediate medical attention if: