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Diaper rash care and management.

There are many alternatives and products available in the management of diaper rash (DR). The differences may cause confusion to nurses. These options may reflect unfamiliarity of the products and ingredients, practitioner preference, availability, cost, and family customs and traditions. What may work for one child may not work for another. This article will give a brief review of diaper rash, skin care products and ingredients, and alternatives in care.

Diaper rash (DR) or diaper dermatitis is one of the most common skin disorders in infants and toddlers (Liptak, 2001). Diaper rash may occur at any time, to any child, and to the most meticulous parent, but it typically tends to wax and wane, and occurs most frequently between 9 and 12 months of age (Van Onselen, 1999; Jorden, Larson, Berg, Frandman, & Marrer, 1986). The etiology is multifocal and a diaper rash may present in various conditions in the pediatric community. The majority of cases are mild to moderately severe and subject to individual interpretation. Diaper dermatitis usually occurs as a primary reaction to irritation by urine, feces, moisture, or friction (Van Onselen, 1999; Berg, Buckingham, & Stewart, 1986; Zimmerer, Lawson, & Calvert, 1986; Buckingham & Berg, 1986). Care and management of diaper dermatitis can present a challenge for pediatric nurses and care providers. To identify the cause, an assessment and accurate history are necessary. A description of the rash must be documented along with continued assessment, evaluation, and the outcome of treatment.

There are many alternatives and products available in the management of DR, which may sometimes confuse the nurse. These options may reflect unfamiliarity of the products and ingredients, practitioner preference, availability, cost, and family customs and traditions. What may work for one child may not work for another. A brief review of diaper rash, skin care products and ingredients, and alternatives in care will be presented.

Common Causes of Diaper Dermatatis

One of the most common types of diaper dermatitis is irritant contact dermatitis. Distribution patterns may vary, but irritative dermatitis typically involves the convex surfaces where the skin is in greatest contact with the diaper. Irritative dermatitis usually spares the inquinal folds, and may be mild red, shiny, and with or without papules (elevated solid lesions varying in color) (Liptak, 2001; Wysocki & Bryant, 1992). Scaling may also be present.

The second most common pattern of diaper dermatitis is usually classified as candidal dermatitis. This pattern involves the skin folds and spares the convex surfaces. Rashes in the perineal area may be the result of diarrhea, moisture, and a secondary candida infection, which is the most common complication of irritant diaper dermatitis. The rash is bright red, denuded (red, raw, weepy skin) containing macules (flat, discolored lesions) or papules with satellite lesions, which can be inflamed and painful (Liptak, 2001; Wysocki & Bryant, 1992). A diaper rash presenting more than 72 hours will usually have a cadida infection. This yeast infection produces a protease that penetrates the skin and can cause a primary or secondary infection such us seborrheic dermatitis (Liptak, 2001; Spraker, 2000). Seborrhaic dermatitis is a common condition in infants up to 3 months of age (Van Onselen, 1999). It affects the face and skin folds, scalp (cradle cap) and the diaper area. Atopic dermatitis is uncommon in infants under 6 months of age and is usually generalized on the body and face (Liptak, 2001; Van Onselen, 1999). Seborrhea, primary herpes simplex, psoriasis, and scabies may begin or occur with an increased intensity in the diaper area (Liptak, 2001). Any form of diaper rash can become secondarily infected with bacterial microbes. Staphylococcus aureus or streptococcus organisms can lead to impetigo (Liptak, 2001). Serious illness must be considered when a child presents with a severe rash that does not respond to treatment. For example, a child with a recurrent severe candida infection (although rare) may result from un immune deficiency, including immunodeficiency virus (HIV) (Liptak, 2001).

The etiology of a DR is multifocal and the rash is not a single entity, but a reaction of the skin to several factors, both local and systemic (Liptak, 2001). There are several causative theories, ranging from food allergies to damage of the stratum corneum or the skin's top layer such as maceration, friction, and chapping (Liptak, 2001; Spraker, 2000). Wetness, dry skin, cleansing agents such as soap, elevated pH levels, fecal enzymes, fecal incontinence, and diarrhea due to infection or antibiotic use will alter skin integrity making the skin more susceptible to diaper dermatitis (Liptak, 2001; Spraker, 2000). Urinary incontinence may be associated with pediatric anomalies, neurological disorders, genetic syndromes, and trauma. Conditions associated with fecal incontinence may include: an ostomy takedown, anorectal malformations, perineal fistula, spina bifida, Hirshsprungs Disease, fecal impaction, and diarrhea.

Soaps strip away lipids, making the skin more permeable and vulnerable to diaper dermatitis. The normal pH of the skin is between 4.5-5.5. When urea from the urine and stool mix, urease breaks down the urine, increasing the hydrogen ion concentration (pH). Elevated pH levels increase the hydration of the skin and make the skin more permeable.

It was previously believed that ammonia was the primary cause of diaper dermatitis. Recent studies have disproved this, showing that when ammonia or urine is placed on the skin for 24 to 48 hours, no apparent skin damage occurs (Farrington, 1992; Berg et al., 1986). Urine ammonia levels are the same in infants with or without diaper dermatitis (Farrington, 1992). Ammonia may be a secondary irritant on damaged skin, but it is probably not a primary cause of diaper dermatitis on intact skin.

Prevention

The goal in the management of a diaper rash is prevention. This is achieved through maintenance of skin integrity to prevent damage to the stratum corneum, the skin's barrier. Keeping the baby dry, which entails frequent diaper changes is the ideal way to both treat and prevent irritant diaper dermatitis. The frequency of diaper dermatitis decreases in relation to the increased number of diaper changes (Jorden et al., 1986).

Soiled diapers should be changed as soon as possible. If diaper dermatitis is present, diapers should be changed at least every 2 hours during the day and once at night. If possible, the infant should go without a diaper.

Cloth diapers, diaper services, and disposable diapers are debatable and a matter of preference, convenience, time, and cost. Home washed cloth diapers and commercial laundered diapers have significant differences (Farrington, 1992). Home laundering of cloth diapers will vary. Soaking soiled diapers in washing soda (sodium carbonate), such as Arm and Hammer in cold water, will act as a laundry booster, assist in removing stains, and neutralize odors. Wash all diapers in detergent and bleach in hot water. The detergent is the cleansing agent and bleach will disinfect and whiten. Adding a laundry booster or vinegar to the wash cycle will eliminate odors, counteract ammonia, and rinse out residue. Rinse and double rinse in cold water to remove chemicals and residual detergent. Fabric softener may be added to keep the diapers soft and to prevent friction. If irritation persists, products will need to be changed. Plastic pants are occlusive and should be avoided. Diaper services will use very hot water to effectively destroy microorganisms, along with detergents, multiple rinses, and sterilization techniques (Farrington, 1992; Spraker, 2000). When selecting a disposable diaper, consider type, size, and cost. There are many varieties and sizes available. Super absorbent disposable diapers contain an absorbent gelling material (AGM) that wicks away moisture. Studies suggest that these diapers are associated with less-severe diaper rashes (Farrington, 1992; Wong et.al., 1992). Trial and error techniques may be required, and several types or different diaper brands may need to be tested before the appropriate one is found best for the child.

Water alone of "baby wipes" containing a non-soap cleanser may be used (Spraker, 2000). However, after stooling, cleanse the skin with soap and water, par dry, and apply a clean diaper. Diaper creams or ointments may be applied as prophylaxis, especially at night. Creams may be water in oil (greasy) of oil in water (non-greasy) emulsions. Creams or ointments may contain ingredients such as humectants, protectants, vitamins, antibacterial/antifungal components, antiflammatory ingredients and other properties to moisturize, protect, and to ease discomfort (see Table 1) (Henry Nix, 2000; Hess Thomas, 2000; Orchard & Western, 2001; Zatz, 2001). There are several over-the-counter products available. Pharmacists may assist the family with brand name ointments or creams and comparable alternative products.

Treatment

Treatment of a diaper rash will depend on the severity and etiology of the rash. Always obtain a history and attempt to eliminate the cause. Ask when the rash erupted, what treatments were initiated, and if the rash improved. A description of the DR must be documented along with assessment, reevaluation, and the outcome. When documenting and describing the rash, state what you see. Ask questions like where is the rash? Is the irritation on the trunk, thighs, and/or the scrotum? What pattern does it follow? What does it look like? Is it red, pink, wet of dry, and weepy with macules of papules, and satellite lesions as with a candida infection? Always check the infant's mouth for thrush if a candidal infection exists. Baby's hands may roam from the diaper area to their mouths. If thrush is found, most cases are effectively treated with oral nystatin suspension. Recurring candidiasis may result from maternal mastitis in breast-fed infants, maternal vaginitis in the newborn, and contaminated pacifiers and bottle nipples. Good hygiene and hand washing before and after feeds and after diaper changes will prevent reinfecting the mother and baby. To sanitize pacifiers and nipples, boil for 10 minutes. Fungal infections may also spread to other skin surfaces such as lips, face, and hands, as well as passed on to caretakers. Gloves should be worn when applying creams or ointments on infected areas, along with good hand-washing techniques as per infection control.

If a mild, irritant, noninfected dermatitis is found, a cream may be all that is needed. A cream containing zinc oxide will be appropriate. Zinc oxide is a skin protectant and soothing. The amount of zinc oxide is usually less in a cream than in an ointment. As with any patient with any condition, tailor the care to meet the individual child's needs. For example, if it is necessary for the child to continue antibiotic therapy and this is the cause of the rash, opt for an ointment. An ointment is a thicker barrier with petrolatum and offers more protection. These may be purchased over the counter and will have other ingredients included.

A severe diaper rash will require aggressive treatment. A paste will be the topical agent of choice. Pastes are thicker, contain petrolatum, higher concentrations of zinc oxide, karaya powder in some, moisturizers, and other additives to aid in protection, prevention, healing, and comfort. Secura Triple Care Extra Protective Cream (Smith-Nephew, Largo, FL), Critic-Aid Paste (Sween, N. Mankato, MN) of Ilex (Medcon Biolab Technologies, Grafton, MA) are examples of pastes. They are excellent barriers and adhere well to denuded, weepy skin. These formulas may be applied like icing on a cake and need not be removed with each diaper change. After stooling, cleanse the area with a mild soap (such as Cetaphil, Dove, or Johnson's Ultra Sensitive) and water, pat dry, and reapply the paste where it was removed, over grainy areas and/or over the existing layer. Do not be overzealous with cleansing or rubbing. This action may irritate the healing skin. No-rinse cleansers such as Peri Wash II (Sween, N. Mankato, MN) may be used intermittently for convenience when necessary.

It is suggested with some of these products to cover the paste with a thin layer of petroleum jelly so that the paste does not stick to the diaper or to prevent opposing skin surfaces from sticking together. Follow instructions provided in the package insert. Mineral oil (baby oil) may be helpful in removing the paste. Frequently, pastes will require a prescription. Consequently, cost and coverage may be an issue. These products are available through dealers, medical supply stores, and pharmacies. There are also institutional "butt balms" with cholestyramine (absorbs bile salts), nystatin, and hydrocortisone 1% (decreases inflammation) in an aquaphor base. These homemade diaper pastes are expensive and time consuming to make.

One must be cautious when adding an antifungal or hydrocortisone to the management of infants, especially neonates (Orchard & Western, 2001). The skin of a neonate is normally dry, more permeable, and fragile, and their organs are immature. Consequently, they are more vulnerable to increased absorption and toxic effects of these additives. Occlusive coverings such as plastic or rubber pants will increase absorption. In all infants with severe irritant dermatitis or recurrent dermatitis with severe inflammation a low potency, nonflourinated, nonhalogenated corticoidsteroid should be applied. This preparation is often considered less potent and with lower side effects (Raimer, 2001; Spraker, 2000). The 1% hydrocortisone cream should be applied no more than twice a day and limited to no more than 2 weeks.

Frequently, combination of products will provide excellent results. A diaper ointment or cream combined with a protective powder such as Stomahesive Protective Powder (Convatec, Princeton, NJ), karaya powder, or cornstarch may be used. Nystatin (Mycostatin Powder) is added if a fungal component exist. A hydrogel (commercial wound care product), such as Carrasyn V Wound Gel (Carrington Lab., Irving, TX), plus a protective powder has also been suggested. An alternative skin protective barrier containing dimethicone such as Proshield Plus (Healthpoint Medical, San Antonio, TX) has been used with success in diaper rashes from prophylaxis to severe. This product is clear, adheres to denuded skin, and is easily removed. What may work for one child may not work for another. Give the treatment at least 35 days to work. Some children may need to change products or require an alternative in management. Sometimes the rash will get worse before it gets better. Healing time may also vary in children.

Nursing Implications

Nurses must be aware of diaper dermatitis, etiology, preventative measures, management and alternatives in care products. The primary goal in nursing intervention is prevention and/or resolution of diaper dermatitis. Parent teaching focusing on these goals is essential. It is helpful to determine what actions were taken, what products were used in the past, and the results of these treatments. Parents can be quite innovative with customs and traditions playing a significant role in DR management. Depending on the severity, the compliance of the caregiver, and the daily routine of the parent and child, consider and implement options. Begin with the basics and progress to more aggressive treatments. Parents will appreciate helpful guidelines concerning DR. Suggestions with rationale will encourage compliance.

Conclusion

A diaper rash is not just a diaper rash. A diaper rash will hurt and it can be devastating. By being better informed and aware of options in care, nurses are in an ideal position to provide quality care. Continued assessment is necessary for success in prophylactic regimens and treatment of DR. Documentation of assessment, intervention, and outcome will allow the means to evaluate management. The key to prevention and treatment of all diaper dermatitis is frequent diaper changing, cleansing with a mild soap and water after each stool, and application of the appropriate topical agent.
Table 1. Examples of Some Skin Care Ingredients
Found in Diaper Rash Creams, Ointments, and Pastes

There are a host of products available for the care, management,
and maintenance of skin integrity. The following are examples of
ingredients frequently seen in skin care products.

Petrolatum               Skin protectant, water repellant, a barrier.

Zinc oxide               Skin protectant, soothes irritating skin.

Dimethicone              Skin protectant.

Vitamins A & D           Skin conditioner.

Karaya                   Viscosity modifier and absorbs moisture.

Mineral oil,             Emollient, softens and soothes irritated
lanolin, glycerin        skin, a lubricant.

                         Humectant, hydroscopic-brings water to
                         the surface of the skin producing a
                         moisturizing effect.

Vitamin E Acetate        Skin conditioner.

Isopropyl Palmitate      Skin conditioner

Purified water           Diluent.

Chloroxylenenol (PCMX)   Antimicrobial, kills or inhibits bacteria.

Isopropol alcohol        Antimicrobial.

Miconazole Nitrate       Antifungal.

Carboxymethylcelluse     Viscosity modifier.
Sodium

Methyl Glucose Dioleate  Emulsifier, added to water-oil preparations
                         to prevent the oil from separating from the
                         water.

Stearate Acid            Emulsifier

Butylparaben             Preservative, prevents breakdown of product
                         and destroys or prevents growth of bacteria.

Methlyparaben            Preservative.

Triethaolamine           pH adjuster (normal pH of skin is 4.5-5.5).

Aminomethyl Proponol.    pH adjuster.

Cetyl Alcohol            Emollient and thickening agent


References

Berg, R.W., Buckingham, K.W., & Stewart, RI. (1986). Etiologic factors in diaper dermatitis: The role of urine. Pediatric Dermatology, 3, 102-106.

Buckingham, K.W., & Berg, R.W. (1986). Etiologic factors in diaper dermatitis: The role of feces. Pediatric Dermatology, 3, 107-112.

Farrington, E. (1992). Diaper dermatitis. Pediatric Nursing, 18(8), 81-82.

Henry Nix, D. (2000). Factors to consider when selecting cleansing products. Journal of Wound, Ostomy, Continence Nursing, 27(5), 260-267.

Hess Thomas, K. (2000). Skin care basics. Advances in Skin and Wound Care, 13(3), 127-128.

Jorden, W.E., Larson, K.D., Berg, R.W., Frandman, J.J., & Marrer, A.M. (1986). Diaper dermatitis: Frequency and severity among a general infant population. Pediatric Dermatology, 3, 198-207.

Liptak, G.S. (2001). Diaper rash. In R. Heekelman et al. (Eds) Pediatric primary care (pp. 1225- 1228).

Orchard, D., & Western, L.W. (2001, April). The importance of vehicles in pediatric topical therapy. Pediatric Annals, 30(4), 208-210.

Raimer, S.S. (2001). The safe use of topical corticosteroids in children. Pediatric Annals, 30(4), 225-229.

Spraker, M. (2000, Spring). Diaper rash prevention and treatment. Pediatric Basics, 91, 20-23.

Wong, D., Brantly, D., Clutter, L, De Simone, D., Lammert, D., Nix, K., Perry, K., Phillips Smith, D., & White, K. (1992). Diapering choices: A critical review of the issues. Pediatric Nursing, 18(1), 41-54.

Wysocki, B.A., & Bryant, A.R. (1992). Skin. In A.R. Bryant (Ed). Acute and chronic wounds nursing management (pp. 1-30). St. Louis: Mosby Yearbook.

Van Onselen, J. (1999, September 15). Rash advice. Nursing Times Skin Care, p. 12.

Zatz, J. (2001). The quality of skin care products and their ingredients. Journal of Wound, Ostomy, Continence Nursing, 47(2), 22-32.

Zimmerer, R.E. Lawson, K.D., & Calvert, C.J. (1986). The effect of wearing diapers on the skin. Pediatric Dermatology, 3, 95-101.

Suzanne Borkowski, MS, PNP, ETN, is a retired Enterostomal Therapy Nurse Practitioner. She resides in Buffalo, NY.
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