These recommendations are based on expert opinion from review articles [Atherton, 2004; Gupta and Skinner, 2004; Scheinfeld, 2005].

Predisposing factors

• There is limited evidence that frequent nappy changes, using disposable nappies, avoiding irritants, and frequent, gentle cleaning with water or fragrance-free and alcohol-free baby wipes reduce the incidence and severity of nappy rash (see Skin care advice).
• A prospective study of 57 children showed that after 10 days of oral amoxicillin treatment, 16% of children developed nappy rash and there was a twofold increase in skin colonization with candida [Honig et al, 1988].

Clinical features of secondary infections

• Expert opinion from review articles suggests that a candidal or bacterial infection can be clinically differentiated from non-infected nappy rash [Brook, 1992; Gupta and Skinner, 2004; Scheinfeld, 2005].
• Case series show oral Candida to be associated with candidal nappy rash due to excretion of Candida in the faeces [Hoppe, 1997].

Skin swabs

• Skin swabs are not generally recommended for the management of nappy rash as the results are difficult to interpret.
• Both Candida and bacteria (such as Staphylococcus aureus) colonize healthy skin and a skin swab may be positive when infection is not present.
• A swab should only be taken when a secondary bacterial infection is suspected, to guide choice of antibiotic [Leyden and Kligman, 1978; Ferrazzini et al, 2003].

These recommendations are based on expert opinion from review articles [Atherton, 2004; Gupta and Skinner, 2004; Scheinfeld, 2005] limited trial evidence, and pragmatic advice to reduce the skin's exposure to irritants which cause nappy rash.

Choice of nappy

• Experts recommend using nappies with the greatest absorbency.
• A series of randomized controlled trials suggest that children wearing breathable, disposable nappies with a gel matrix experienced significantly less nappy rash than children wearing non-breathable, standard nappies [Davis et al, 1989; Philipp et al, 1997; Odio and Friedlander, 2000; Akin et al, 2001; Baldwin et al, 2001].
• However, a Cochrane systematic review concluded that although the studies do favour breathable, gel matrix nappies, the results should be reviewed with caution as all the studies were open to significant bias [Baer et al, 2006].

Leave nappies off

• Wearing a nappy causes nappy rash. The longer the skin is occluded, the greater the risk of peristent dermatitis due to ongoing increases in skin hydration, pH, and frictional damage [Wolf et al, 2000; Borkowski, 2004; Gupta and Skinner, 2004].

Frequent nappy changes

• A US cross-sectional survey of 1089 infants, showed the incidence and severity of nappy rash was significantly lower (p < 0.03) when parents reported more frequent nappy changes [Jordan et al, 1986].

Avoid soaps, bubble bath, or lotions

• Soaps, bubble bath, or lotions can remove fats (lipids) from the skin, making it more vulnerable to irritants and microorganisms.

Avoid bathing more than twice a day

• Expert opinion from review articles suggests that bathing a child more than twice a day may dry out their skin and lead to worsening nappy rash [Atherton, 2004].

Use fragrance-free and alcohol-free baby wipes

• Two clinical trials (n = 163) showed that fragrance-free and alcohol-free baby wipes are suitable for use on nappy rash, and are as good as using water alone. Baby wipes have the advantage of being convenient and soft (which minimizes frictional damage) [Ehretsmann et al, 2001].

Skin care advice

• Expert opinion is that nappy rash which is not causing distress is unlikely to have a secondary candidal infection [Ferrazzini et al, 2003; National Collaborating Centre for Primary Care, 2006], and most children can be managed with skin care advice alone.

Barrier preparations

• The routine use of a barrier preparation at each nappy change is widely recommended by experts [Atherton, 2004; Gupta and Skinner, 2004] to reduce contact between the skin and urine and faeces.
• Barrier preparations containing zinc oxide or titanium dioxide are widely used in the UK. White soft paraffin and dexpanthenol 5% ointment are alternatives. However, there is little evidence to support the use of any barrier preparation in nappy rash.
• The products recommended are preservative-free, and do not contain antiseptics known to cause sensitization, fragrance, or colouring, as such ingredients can exacerbate dermatitis.
• Ointments are generally more effective than creams and lotions, as they provide a better moisture barrier [Atherton, 2004].
• Lipophilic (water-repellent) emollients and pastes (e.g. zinc or titanium ointment, white soft paraffin) should provide a suitable moisture barrier, but they should not be applied too liberally as this may 'clog-up' the skin causing water retention and worsening maceration [Atherton, 2004]. Other products such as dexpanthenol 5% ointment are also recommended to be applied thinly [Bayer Healthcare, 2009].
• Zinc ointment BP and Zinc and Castor Oil ointment BP may be difficult to source.
• Nappy rash with a candidal infection may worsen if a barrier preparation is used before the infection is settled [Lund, 1999]. Therefore, experts advise using an emollient after the candidal infection is treated [Singleton, 1997].

Topical imidazole treatment

• Candidal infection is more common in nappy rash that is causing discomfort [Ferrazzini et al, 2003; National Collaborating Centre for Primary Care, 2006]. Prescribing an imidazole will eliminate the fungal infection and reduce the inflammation causing discomfort [Wolf et al, 2000; Gupta and Skinner, 2004].
• Evidence from a randomized, placebo-controlled trial (n = 202 children) showed that topical miconazole (compared with ointment alone) resulted in a significant improvement in moderate-to-severe nappy rash [Concannon et al, 2001].

Topical hydrocortisone

• CKS found no evidence evaluating topical corticosteroids in nappy rash, however topical hydrocortisone is widely recommended by experts to settle inflammation causing discomfort [Canadian Paediatric Society Statement, 2000; Burns et al, 2004].
• Experts advise that topical corticosteroids should be avoided if the nappy rash is not causing discomfort [Gupta and Skinner, 2004] because infants are much more susceptible to adverse effects from topical corticosteroids (localized effects include skin atrophy; systemic effects include growth retardation). In addition, percutaneous absorption in the nappy area is likely to be increased by the occlusive and humid conditions [MeReC, 1999; DTB, 2003].
• CKS found no evidence to indicate the duration of use of a topical corticosteroid in nappy rash, so this recommendation is based on feedback from CKS expert reviewers of the CKS topic on Candida - skin, bearing in mind the potential for adverse effects (such as skin thinning and striae) with prolonged use [McKay, 1988; American Academy of Dermatology, 1996].
• CKS has extrapolated the recommendation to wait a few minutes between the application of an emollient and a topical corticosteroid when managing eczema, to the management of nappy rash. This recommendation was made by the National Institute for Health and Clinical Excellence and is based on expert opinion rather than controlled clinical trials [UKMI, 2008]. For more information, see the CKS recommendations on the use of topical corticosteroids in the CKS topic on Eczema - atopic.
• CKS found no evidence regarding combination products, but they have been included because they may be more practical than waiting a few minutes between the application of topical treatments.

Oral antibiotics

• Staphylococcus aureus is the most common bacterium isolated from children with secondarily-infected nappy rash [Brook, 1992], and is generally sensitive to flucloxacillin.

Treatment not recommended

• Talcum powder provides no skin protection, and causes friction and irritation to skin [Burns et al, 2004].
• Topical vitamin A and its derivatives — a Cochrane systematic review found no trials on vitamin A in the treatment of nappy rash [Davies et al, 2005].
• Topical antibiotics — there is limited evidence of the efficacy of topical antibiotics for nappy rash from one small study of children with severe perianal candidiasis and a heavy growth of Gram-positive organisms [de Wet et al, 1999]. There is also evidence that topical antibiotics are an effective treatment for impetigo. However, topical antibiotics are only recommended for small, localized areas of infection (for further information, see the CKS topic on Cellulitis - acute).
• Oral antifungals are not licensed for children under 5 years of age for the treatment of nappy rash. CKS found no studies comparing oral with topical azole antifungals in nappy rash. Evidence from a placebo-controlled study found no benefit from the use of oral and topical nystatin in children with nappy rash.

These recommendations are based on expert opinion from review articles [Atherton, 2004; Gupta and Skinner, 2004; Scheinfeld, 2005].

These recommendations are based on expert opinion from review articles [Scheinfeld, 2005; National Collaborating Centre for Primary Care, 2006].