What is the best approach to manage diaper rash in an infant or toddler?

Diaper Rash Management

Clean the diaper area with emollient instead of water or wipes, apply barrier creams containing zinc oxide or petroleum jelly at every diaper change, and assess for signs of bacterial or fungal infection that require antimicrobial treatment. 1

Initial Assessment

Examine the diaper area for specific features that guide management 1:

• Look for signs of bacterial infection including crusting, weeping, or erosions that require culture-directed antibiotics (typically flucloxacillin for Staphylococcus aureus) 1
• Look for signs of fungal infection (satellite lesions, beefy red appearance with sharp borders) that indicate Candida overgrowth, particularly in infants with recent antibiotic use 1, 2
• Identify aggravating factors such as excessive moisture, recent antibiotic use, or atopic tendencies that increase susceptibility 1

First-Line Treatment Strategy

Cleansing and Barrier Protection

• Use emollient to clean the diaper area instead of water or commercial wipes to avoid disrupting the skin barrier 1
• Avoid commercial wipes containing alcohol or fragrances that can irritate skin 1
• Apply barrier creams containing zinc oxide or petroleum jelly at every diaper change to protect infant skin from moisture and irritants 1, 3
• Allow frequent diaper-free time to reduce moisture and friction exposure 4

Friction Reduction Techniques

• Trim off the inner elastic of disposable diapers to reduce friction on inflamed skin 1
• Use a nappy/diaper liner covered in emollient to reduce movement of diaper on skin 1
• Line diaper with soft cloth liner coated with emollient or paraffin-impregnated gauze for severe cases 1

Management of Specific Complications

Eczematous Inflammation

• For inflammatory eczema with erythema and desquamation, apply low-potency topical corticosteroids such as hydrocortisone 2.5% cream for short-term use (not more than 3-4 times daily) 1, 5
• Note: FDA labeling specifically warns against using hydrocortisone for treatment of diaper rash without consulting a doctor, and it should not be used in children under 2 years without physician guidance 5
• This creates a clinical dilemma—use hydrocortisone only for clear eczematous inflammation under physician supervision, not for simple irritant diaper dermatitis 1, 5

Blistered or Severely Damaged Skin

• Apply hydrogel dressing to blistered skin in the diaper area 1
• Apply wound dressing or barrier cream to bony prominences and trauma-exposed sites 1

Bacterial Infection

• Seek medical evaluation for culture-directed antibiotics if bacterial infection is suspected (crusting, weeping, honey-colored discharge) 1
• Flucloxacillin is typically used for Staphylococcus aureus infection 1

Fungal Infection

• Seek medical evaluation for appropriate antifungal treatment if Candida infection is suspected (satellite lesions, persistent rash beyond 3 days of barrier treatment) 1, 2

Prevention Strategies

• Use zinc oxide powder after bathing to thoroughly dry the skin, which reduces rates of skin irritation 1
• Ensure thorough drying of skin before applying powder to maintain skin dryness 1
• Change diapers frequently to minimize contact time with urine and feces 4, 2
• Consider superabsorbent disposable diapers which reduce incidence of diaper dermatitis by keeping skin drier 4, 6

Common Pitfalls to Avoid

• Never use harsh soaps or over-wash with hot water as this damages the skin barrier 1
• Avoid commercial wipes with alcohol or fragrances that irritate compromised skin 1
• Do not use emollients with fragrances or preservatives as they increase risk of contact sensitization 7
• Do not use hydrocortisone without physician guidance in children under 2 years or for routine diaper rash 5