What is the best treatment approach for an infant or toddler presenting with diaper rash?

Diaper Rash Treatment

For uncomplicated diaper rash, apply barrier creams containing zinc oxide or petrolatum liberally with each diaper change, use emollients instead of commercial wipes for cleaning, and change diapers frequently. 1, 2

Initial Assessment

Examine the diaper area for specific features that determine management:

• Look for bacterial infection signs: crusting, weeping, or honey-colored discharge 1, 2
• Look for fungal infection indicators: satellite lesions, involvement of skin folds, or rash persisting despite standard treatment 1
• Identify aggravating factors: recent antibiotic use, excessive moisture, or exposure to irritants 1
• Check for atopic tendencies: babies with sensitive skin are more susceptible 1

First-Line Treatment Strategy

Cleaning and Barrier Protection

• Use emollients to clean the diaper area instead of water or commercial wipes 1, 2
• Avoid commercial wipes containing alcohol or fragrances that irritate skin 1
• Apply barrier creams liberally with each diaper change—zinc oxide or petrolatum-based products are equally effective 1, 2, 3
• Change diapers frequently to minimize moisture exposure 2
• Allow "diaper-free" time to reduce skin contact with irritants 2

Additional Protective Measures

• Use zinc oxide powder after bathing to thoroughly dry the skin, which reduces irritation rates 1
• Apply a nappy liner covered in emollient to reduce friction from diaper movement 1
• Trim off the inner elastic of disposable diapers to reduce friction 1
• Line diaper with soft cloth coated with emollient or paraffin-impregnated gauze 1

Management of Eczematous Inflammation

If inflammatory eczema develops with erythema and desquamation on dry skin:

• Apply low-potency topical corticosteroids such as hydrocortisone 2.5% or prednicarbate 0.02% cream for eczematous inflammation 1
• Note the FDA warning: hydrocortisone is NOT indicated for treatment of diaper rash in children under 2 years without physician consultation 4
• Avoid over-washing with hot water or harsh soaps which damages the skin barrier 1

Management of Specific Complications

Blistered or Eroded Skin

• Use hydrogel dressing (such as Intrasite Conformable) for blistered skin in the diaper area, particularly if epidermolysis bullosa is suspected 1, 2
• Apply wound dressing or barrier cream to bony prominences and trauma-exposed sites 1

Bacterial Infection

• Suspect bacterial infection if crusting, weeping, or honey-colored discharge is present 2
• Obtain culture and prescribe antibiotics: typically flucloxacillin for Staphylococcus aureus 1
• Seek medical evaluation for appropriate antimicrobial treatment 1

Fungal Infection (Candida)

• Rule out candida infection if rash persists despite appropriate care 5
• Prescribe antifungal agents when fungal infection is confirmed 6

Critical Red Flag

Eczema herpeticum is a medical emergency characterized by multiple uniform "punched-out" erosions or vesiculopustular eruptions—requires immediate systemic acyclovir and empirical antibiotics 2

Common Pitfalls to Avoid

• Do not use commercial wipes with alcohol or fragrances 1
• Do not use hydrocortisone for diaper rash in children under 2 years without physician guidance 4
• Do not over-wash with hot water or harsh soaps 1
• Do not delay antimicrobial treatment when infection is suspected 1, 2