How should diaper dermatitis be managed in an infant?

Diaper Rash Treatment

For uncomplicated diaper dermatitis, apply a thick barrier ointment (zinc oxide or petrolatum) liberally with each diaper change, keep the area clean with emollient rather than wipes, ensure frequent diaper changes, and add a low-potency topical corticosteroid if inflammation persists beyond 2-3 days. 1, 2, 3

Immediate Management Steps

Barrier Protection and Cleansing

• Clean the diaper area with emollient ointment rather than water or commercial wipes to minimize friction and irritation 1, 2
• Apply zinc oxide ointment liberally with each diaper change, especially at bedtime or when exposure to wet diapers may be prolonged 3
• Use petrolatum-based barrier creams (like Aquaphor) on clean, dry skin to create an occlusive moisture barrier and reduce transepidermal water loss 2
• Apply barrier products at least twice daily, though more frequent application (with each diaper change) is needed for active dermatitis 2

Diaper Management

• Change wet and soiled diapers promptly 3
• Use well-fitted diapers and trim off the inner elastic bands around the legs to reduce friction 4, 1
• Line diapers with soft cloth liners coated with emollient or paraffin-impregnated gauze to further reduce friction 1
• Consider superabsorbent disposable diapers, which reduce incidence and severity of diaper dermatitis 5, 6

Anti-Inflammatory Treatment

When to Add Topical Corticosteroids

• Use low to medium potency topical corticosteroids for inflammatory diaper dermatitis that persists despite barrier care 1
• Apply no more than twice daily to affected areas only, limiting duration due to increased absorption in the diaper area 1
• If the eruption lasts more than 3 days despite treatment, consider adding an antifungal agent as Candida superinfection is likely 6

Alternative Anti-Inflammatory Options

• Topical PDE-4 inhibitors (crisaborole) may be considered for mild to moderate cases as a corticosteroid alternative 1
• For moderate to very severe cases unresponsive to standard treatment, wet-wrap therapy with topical corticosteroids can be used as short-term second-line treatment 1

Managing Secondary Infection

Candida Superinfection

• Add antifungal treatment if classic erythematous satellite lesions are present or if dermatitis persists beyond 3 days 6
• Avoid greasy barrier creams during active folliculitis as they may facilitate bacterial overgrowth; switch to water-in-oil emollients temporarily 2

Bacterial Superinfection

• Add systemic antibiotics (flucloxacillin or erythromycin) if clinical signs of bacterial superinfection are present 1
• Long-term topical antibiotics are not recommended due to increased risk of resistance and skin sensitization 1

What to Avoid

Contraindicated Products and Practices

• Do not use topical antihistamines as they increase the risk of contact dermatitis 1
• Avoid emollients containing fragrances, preservatives, or potential contact allergens 2
• Do not use petrolatum in neonates with severe barrier dysfunction as it may increase infection risk and impair sweating 2
• Avoid fluorinated topical corticosteroids in the diaper area 7

Adjunctive Measures

For Severe Cases

• Oral antihistamines may be used for their sedative properties during severe flares to help with sleep disturbance, though large doses may be required in children 1
• Bleach baths may be beneficial in some cases, but benefits and risks should be carefully weighed 1

Red Flags Requiring Further Evaluation

If the rash is recalcitrant or clinically atypical despite appropriate treatment, consider rarer disorders such as psoriasis, Langerhans' cell histiocytosis, Leiner's disease, or acrodermatitis enteropathica, and refer to dermatology 6