rash, diaper

Just about every infant will eventually have some diaper rash problems. It comes with the diaper-wearing territory, although I will say that the incidence of diaper rash has fallen dramatically in my practice over the last few years. I attribute this to the widespread adoption of super-absorbent diapers, which are so clearly superior to cloth diapers in every respect but cost.

All ordinary diaper rashes basically start the same way - moisture.

Moisture stays in contact with the skin, allowing the softening of the hard protective top layer of the skin.
The pH of the skin surface, normally neutral to slightly acidic, may shift to alkaline, caused both by certain chemical substances in stool and urine (digestive enzymes that break down proteins and fats) as well as a byproduct of bacterial growth.
Conditions become ideal for the bacteria present on the skin begin to grow, and white blood cells appear to kill them, releasing in the process chemicals that cause enlargement of the blood vessels in the skin (inflammation or redness).
Yeast spores may start to grow and multiply.
Abrasion from the diaper causes additional damage to the skin.

Thus the treatment of diaper rash involves attacking each of the various aspects of it. First and obviously foremost, restoring dryness. There are certain misconceptions about diapers. In clinical tests, the rank order of diaper types for maximum dryness and minimal rash is (best to worst)

Super-absorbent disposable
Regular absorbency disposable
Cloth, no pants
Cloth with plastic pants

If you aren't using a super-absorbent disposable already, you may consider switching at least temporarily until the rash is better. You may need to change the child in the middle of the night as well. If the problem is really bad, change the diaper very, very frequently - every hour or so during the day, and once or twice at night.

Next, moist, softened skin is less resistant to the abrasive effects of diapers and wet-wipes. For this reason, you may want to try to do less scrubbing of the skin, namely rinse it off rather than scrub it off. This dovetails with the next point, controlling pH.

The normally slightly acidic pH of the skin can be raised significantly (made more alkaline) by two factors:

the production of ammonia in the diaper from the urine by urea digesting bacteria in the stool and on the skin (urea is the nitrogen-containing waste product in urine)
alkaline bile salts in especially loose stools

I have always thought that this last factor contributes heavily to causing some of the worst rashes. Severe diarrhea can produce an appearance of the diaper area best described as scalded. This type of rash is really a chemical burn from the alkali in the stool, and looks it.

Treatment of this type of rash involves dryness, of course. I'm in favor as well of restoration as much as possible of the normal acidic pH of the skin. When rinsing the baby's bottom, try putting a little vinegar in the water in the basin. Dip the baby in the warm water, and gently cleanse the bottom, avoiding scrubbing with a cloth. Allow the vinegar-water to air dry on the worst areas of rash if possible. Use a barrier cream like Acid Mantle®, Flanders Ointment® or Borofax® that also contains some acidity. I learned years ago about Burrough's solution soaks for diaper rash, which seemed to help. Burrough's solution is boric acid - a poison; vinegar is cheap and safe.

Next, we can attack the inflammation by the application of anti-inflammatory medication. 1% hydrocortisone cream is available without a prescription and is usually sufficient (Cortaid®, Cortizone-10® and a host of others). Stronger steroids applied to the skin for too long can cause permanent thinning and reddening of the skin and can be systemically absorbed through the baby's very thin skin; for this reason dermatologists generally recommend staying with hydrocortisone. If you do use 1% hydrocortisone you are very safe in this regard - that's why the FDA allows its over-the-counter sale.

Next we come to the fungal, or yeast infections of the diaper area. These are caused by a fungus called Candida albicans. Spores of this fungus are everywhere on and in the human body. It is found in the mouth, the intestinal tract, the vagina, and all over the skin.

Ordinarily, Candida is held in check by a "balance of nature" - under normal conditions, Candida is inhibited from growing by dry conditions and the prescence of other germs (bacteria) that secrete substances that hold it in check. Thus it can only cause problems when something upsets that balance (for example taking antibiotics) or if the basic environmental conditions change (for example, when dry hard skin becomes moist, soft, injured and invadable).

Classical Candida infections produce a typical appearance. The rash starts in the creases (where it is most moist) and spreads out over the thighs and pubis, scrotal and labial areas. This is in contrast to the typical contact-type rash described above, which starts on the surfaces that touch the diaper.

Treatment of this type of rash involves drying measures and the application of an anti-fungal preparation several times a day. Clotrimazole (Lotrimin-AF®) is now available over the counter. It is a good anti-fungal, actually superior to prescription nystatin.

Thus we come to mixed-type rashes, diaper rashes that start perhaps with a classical contact rash and then become additionally infected with Candida. A short trial of alternating hydrocortisone with clotrimazole may save a trip to the doctor. However, these rashes require just a bit more patience and sometimes need prescription medication.

Then to round out the collection, some of the less common diaper-area rashes.

Blisters that appear suddenly, mimicing a burn, are a skin infection caused by the Staphylococcus germ called bullous impetigo. Contact your doctor. Staph germs can cause serious illness. Prescription medication is needed, either oral or a special antibiotic ointment (mupiricin, Bactroban®)
Psoriasis
Atopic dermatitis (eczema)
Seborrhea
Other weird things

Suffice it to say that while most diaper rashes can be taken care of by the parents with over the counter medications and a bit of common sense care, persistent diaper rash should be examined by your doctor.

As recommended by Dr. Sidney Hurwitz of Yale University, an excellent diaper remedy can be compounded without prescription by your pharmacist:
5 ml of Burrow's solution (1:40)
20 gm of Aquaphor ointment
30 gm zinc oxide ointment
Apply after each diaper change. If yeast infection develops, mix in 30 gm of over the counter clotrimazole cream (Lotrimin-AF®).

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