Red Flags of Diaper Rash and Recommended Barrier Products

Parents should refer to a doctor, when presenting with diaper rash characterized by any of the following:

• Acute onset with oozing, pus, vesicles or ulceration at lesion site(s)

• Frequent recurrences, especially with no rash-free period in between

• Moderate or severe presentation with or without systemic signs and symptoms such as fever, nausea or vomiting

• Rash or skin lesions present outside the diaper area

• Complicated secondary infection (e.g., infection of penis or vulva, skin erosion or breakdown, bleeding, systemic symptoms such as fever) or comorbid urinary tract infection

• Significant behavioural changes (e.g., incessant crying, lethargy, sleep)

• Signs of abuse or neglect (e.g., caregiver who delays or refuses treatment for DD)

• Patient is immunocompromised

• Fails to improve despite 7 days of appropriate treatment, or fails to resolve after 14 days of appropriate treatment

• Symptoms are part of or caused by another disease state, which requires further investigation and supervised therapy.

Barrier products are recommended for both the prevention and treatment of DD. They are considered the cornerstone of therapy for DD and can be of 2 types: 1) those that provide a water-impermeable barrier only and 2) those that provide a barrier and absorb water. Both types shield the skin from irritants, protect surfaces that are healing, and lubricate against maceration and friction. Barrier-absorptive bases also lessen overhydration and are generally preferred, as loss of barrier function and overhydration are both considered critical in the development of DD.

Barrier-only products suitable for use in DD are either oleaginous hydrocarbon–based (petrolatum), silicone-based or ceramide-based. Absorption bases (anhydrous lanolin, anhydrous eucerin) are not generally recommended because they are strong contact allergens.

Barrier-absorptive bases are usually creams or pastes with various percentages of zinc oxide. Zinc oxide, a mild antiseptic, is astringent and also functions as an absorptive powder at higher concentrations. Moderate concentrations of zinc oxide (e.g., 10–20%) are usually creams that are easy to spread and good for daily maintenance to prevent DD. Higher concentrations (up to 40%) are stiff, have enhanced absorptive and astringent properties, and are suitable for treatment of DD. Pastes are especially useful for DD associated with diarrhea or increased stool output They may need to be spread gently with a tongue depressor or spatula and removed with mineral oil. Although zinc absorption through the skin has been reported in a child with acrodermatitis enteropathica, zinc is a naturally occurring essential mineral and part of daily dietary requirements

Barrier bases may also contain additives, some of which are of dubious value, and other additives, which may be contact sensitizers. Vitamin A and dexpanthenol (a vitamin B₅ derivative), for example, are popular additives, but these products show no additional benefit over zinc oxide, lanolin or petrolatum alone Similarly, a study involving 114 newborns showed no difference in DD treated with an ointment containing vitamin A versus the vehicle alone.​ Glycerin, a humectant at concentrations of 20–45%, is frequently added to products at lower concentrations (at which it is inactive as a humectant) to ensure shelf-life only. Other additives, including astringents like hamamelis (witch hazel), are sensitizing, making plain barrier products preferable.

The effectiveness of topical creams may be limited by their short duration of effect and removal with diaper changes. Topical films (solutions and sprays that dry to form a semipermeable barrier on the skin) may be an alternative. They are intended to remain in place to protect the skin from direct contact with irritants and to facilitate barrier repair. Films also minimize skin stripping from cleansing procedures. Trials of these products lacked sufficient participants to conclusively determine the effectiveness and time course of improvement relative to conventional barrier creams

The use of hydrocolloid dressings for the treatment of DD in hospitalized infants has also been evaluated. Infants treated with hydrocolloid dressings and individualized nursing care had significantly better healing rates and fewer adverse events than infants treated with mupirocin plaster or zinc oxide plaster and routine nursing care. These findings are promising, but data on the safety and efficacy of hydrocolloid dressings in the setting of DD is limited and further evaluation is warranted.

Powders have been traditionally used as barrier products in the diaper area; however, it is now recommended that they be avoided (or used only with extreme caution) due to risk of inadvertent inhalation. If used, powders should be applied to a cotton puff or to the hands and dabbed on to decrease risk of aspiration. Cornstarch reduces friction and may absorb some moisture (inefficiently compared with zinc oxide pastes), yet does not wick moisture away from the skin surface. It may also serve as a culture medium for C. albicans. Talc, a finely milled form of hydrous magnesium silicate, reduces friction and adheres to the skin well, but has more lubricant than absorbent properties. It has been shown to be less effective than topical zinc oxide for the prevention of DD. Baking soda has been reported to cause metabolic alkalosis in an infant being treated for DD​^[36] and is not recommended. If applied to broken or oozing skin, powders may form a crust and bleed upon removal or lead to infection.