Diaper dermatitis (diaper rash)

Diaper dermatitis (diaper rash) is an inflammation of the skin in the diaper area. It mainly occurs in infants and small children.

Moisture, urine and feces can irritate the skin and lead to inflammation in the diaper area. As a result, the skin becomes painful and red and is particularly vulnerable to infections and pathogens.

Diaper rash usually heals quickly if certain measures are taken to treat it. A frequent complication is colonization of the irritated skin by the yeast fungus Candida albicans. Doctors refer to this condition as diaper thrush.

Older people who are no longer able to control their bladder or bowel and frequently wear adult diapers or incontinence pads may also suffer from diaper dermatitis.

With diaper dermatitis, redness typically occurs on the areas of the skin that come into direct contact with the diaper – in other words, the bottom, genitals, lower abdomen and thighs. Skin folds generally remain unaffected.

The severity of the symptoms of diaper dermatitis can vary widely:

• If the inflammation is mild, individual patches of redness or tiny, isolated bumps will appear. The skin is only slightly swollen and irritated.
• In the case of moderate diaper dermatitis, the red patches have spread further and the skin affected is swollen or chafed and sore. The patient will experience pain and feel unwell.
• Severe diaper dermatitis causes the appearance of a large area of shiny red skin rash. There are often areas of open skin, as well as nodules and papules (raised bumps).

If treated properly, mild to moderate diaper dermatitis should heal within a few days. If it fails to heal, this could indicate that the skin is also infected with bacteria or yeast.

If the skin is infected with Candida albicans yeast, the diaper area will have thick, flat patches of red skin with papules and puss-filled bumps known as pustules. The skin folds are usually also affected in this case.

There are two factors that cause diaper dermatitis:

• elevated moisture levels under the diaper
• prolonged contact between the skin and urine or feces

In some cases, the skin may be overly sensitive to certain skin products or components used to make diapers, leading to skin irritation.

The environment beneath any diaper is damper than uncovered skin. The uppermost layer of skin is damaged by moisture and rubbing of the diaper against the skin. The by-products of urine and feces also irritate the skin and damage the skin barrier. This weakens the skin’s protective function, making it easier for pathogens to spread.

Candida yeast in particular thrives and multiplies under these conditions. This type of yeast fungus occurs naturally in the mucus membranes of the mouth, genital area and digestive tract. However, bacteria that colonize human skin, such as streptococcal and staphylococcal bacteria, may also multiply on the irritated skin and intensify the inflammation.

A number of factors make diaper dermatitis more likely to occur:

• irregular, infrequent diaper changes
• diarrhea or more frequent bowel movements due to other conditions
• a change in the diet that alters the acidity of feces – for example, the introduction of bottled milk; babies who are breast fed are less likely to suffer with nappy rash
• treatment of bacterial infections with antibiotics that cause diarrhea and promote fungal growth
• use of certain skincare products, such as liquid soap or talcum powder

In principle, anyone who wears diapers or incontinence pads can get diaper dermatitis.

Newborns and infants are particularly susceptible, as their skin is still immature. The condition occurs most commonly between the ages of 9 and 12 months. Around half of all children will experience diaper rash at some stage while wearing diapers.

Diaper dermatitis is a common diagnosis. Around a quarter of all children whose parents consult a pediatrician due to skin problems during the first year of their life are diagnosed with diaper dermatitis.

Diaper dermatitis has become less common since the advent of disposable nappies that are particularly absorbent and hypoallergenic.

The best way to prevent diaper dermatitis is to change diapers frequently, especially after the passage of urine or feces. This minimizes the duration of contact between the skin and urine or feces.

A soft washcloth and warm water are usually sufficient to clean the skin. If soap is required, it should be mild and fragrance-free. No skincare products or diaper creams have been proven to prevent diaper dermatitis.

Caked-on fecal residue can be removed by gentle rubbing with baby oil. The skin should then be patted dry with a soft towel. Wet wipes can also be used, especially when traveling, provided that they are free of fragrances and alcohol.

In general, diaper rash can easily be detected by looking closely at the area affected. If it has an atypical presentation or is not healing well, it may be useful to take a swab from the affected skin areas. This can then be tested in a lab to determine whether the skin is also infected with bacteria, fungi or viruses.

If the skin fails to heal with the usual treatments, a skin biopsy may be necessary. This involves the doctor giving a local anesthetic before using a round knife (called a punch) to remove a tiny piece of skin to examine under the microscope.

The treatment of diaper dermatitis consists of taking measures to care for the skin, selecting the right diaper and applying medicated ointments that are effective against inflammation and certain pathogens.

Skincare measures

• If diapers are changed frequently, this minimizes the duration of contact between the skin and urine or feces. This prevents the area beneath the nappy from becoming irritated.
• It’s good for the child’s skin to go diaper-free some of the time and allow the skin to come into direct contact with the air.
• It helps to clean the diaper area with warm water or with a mild, soap-free cleanser after a bowel movement.
• Wet wipes containing no soap, essential oils, alcohol, fragrances or preservatives can be used when traveling.
• Pastes containing zinc, ointments with petroleum jelly (Vaseline), lanolin or paraffin, or silicone-based oils support the skin’s protective function and prevent moisture from reaching the skin.

Choice of diaper

• Choosing the “right” diaper is essential to successful treatment. Highly absorbent diapers may be beneficial. These disposable diapers absorb moisture and urine more effectively than cloth diapers. 

Medicated ointments

• If the diaper rash fails to improve after taking the measures outlined above, anti-inflammatory cortisone ointments are available without prescription.
• If a yeast or bacterial infection is detected, anti-fungal or anti-bacterial ointments are effective.