Introduction

Diaper rash, more officially known as incontinence-associated dermatitis (IAD), affects hospitalized and incontinent patients of all ages. In my years as a WOC Nurse in a pediatric hospital, IAD has been by far the most frequently treated condition. However, outside of a health care setting, IAD is the most common skin problem in infants and young children who are not yet toilet trained.^1,2 Diaper rash has plagued babies and new parents for centuries, yet its treatment remains highly debated. For the purpose of this article, I am focusing on the prevention and treatment of diaper rashes in infants and young children, although the principles of topical treatment discussed here apply to all patients.

A Recipe for Confusion: The Challenges of Finding a Proper Treatment

An Internet search or a trip to the drugstore provides an abundance of topical treatment options, which can be very confusing, particularly to frustrated parents who are struggling to treat their baby’s worsening skin breakdown. Well-meaning pediatricians, who are highly trusted by parents, may order compounded formulations containing a mix of topical antibiotics, antifungals, and steroids. These ingredients are often unnecessary and fail to provide an effective moisture barrier.¹

Parents may seek recommendations from online social media forums, where strangers share anecdotal success of home remedies containing everything from toasted flour to breast milk and blended concoctions of emollients and essential oils. Everyone has their own “secret formula” that claims to work magic. Old myths persist, even in health care settings. These include blowing a hairdryer or oxygen mask on little bottoms or putting undiapered babies in the sun to “dry up” diaper rash.

The Basics of Prevention

Why Skin Breaks Down

Supporting the skin’s acidic pH of 4-6 is essential to maintain an intact skin barrier. Skin cleansers, lotions, and wipes should be pH neutral. Stool and urine are alkaline, so prolonged contact causes breakdown of the skin’s natural barrier.^1,3 Topical antacids and baking soda should not be used to prevent or treat any skin breakdown and could exacerbate the issue.

How Diapers Help (or Hinder) Diaper Rash Prevention

Disposable diapers offer excellent absorption, wicking moisture away from the skin into the diaper’s core. Although reusable cloth diapers are environmentally friendly, they may hold excess moisture on the skin. Any variety of diaper should be changed frequently to keep skin dry.^1-4 Repetitive or aggressive wiping should be avoided during diaper changes. The act of vigorous wiping can cause mechanical skin damage and worsen IAD.¹ Diaper creams should not be applied to the inside of the diaper because they block absorption and increase moisture on the skin.

How to Choose to the Right Treatment Option for Diaper Rash or Incontinence-Associated Dermatitis

Use of Topical Moisture Barriers

Maintaining a topical moisture barrier on intact skin in the diaper area may prevent IAD.^1,3 Topical moisture barrier products come in many forms:

• Clear liquid films
• Clear creams and ointments
• Thick, opaque, zinc-based preparations
• Carboxymethylcellulose (CMC) or pectin-based powders

Skin cleaning wipes that contain dimethicone or other moisture barriers are particularly beneficial. For skin that is intact and free from breakdown, clear barrier products offer lighter protection and allow frequent assessment of the skin.

Treating Mild Skin Breakdown

In the setting of increased skin moisture and lowered pH, such as an illness that causes diarrhea, IAD prevention measures may fail. Skin breakdown in the diaper area can range from mild redness to large patches of denuded skin that are weeping or perhaps even bleeding. In early stages of IAD, the skin is tender and appears pink or red in patients with lighter skin tones. In darker skin, patches of IAD appear pale and overhydrated or reddish and shiny.

A thick layer of zinc-based cream should be maintained on the diaper area at all times and should be reapplied with each diaper change. It is often taught to apply diaper cream like cake icing. It is not necessary to remove all of the cream with every diaper change.^1,3 There is no evidence that supports the effectiveness of one diaper cream over another.1 In my experience, consistency with frequent application is more important than the product brand.

Crusting: Treating Denuded Skin With Stoma Powder and a Skin Film Barrier

For skin that is denuded, my go-to treatment is “crusting.” Crusting has long been the standard treatment for skin breakdown around enterostomies. Over the last few years, crusting has gained popularity as an effective treatment for IAD in the diaper area. Crusting is widely recommended in current literature and the Wound, Ostomy and Continence Nursing Society’s core curriculum.^3,4

The procedure for crusting is to sprinkle stoma powder on denuded areas and then seal it by applying a skin barrier film. This film dries in 10 seconds or so, and then another layer of powder and skin barrier film should be applied, creating a very durable layer of protection to promote healing and prevent further breakdown. Zinc-based barrier cream should then be applied over the layer of “crust.” With diaper changes, the soiled layer of barrier products should be skimmed off gently, and then more cream should be applied.

Crusting should be repeated on remaining denuded areas when all products wear off the skin or after bathing. I have personally treated thousands of patients successfully with the crusting method. It is unfortunate that stoma powder and skin barrier film for crusting are not widely available in stores, but they can be purchased online.

The Big Guns: Cyanoacrylate Film and Hypochlorous Acid Solution to Treat Severe Diaper Rash

For the most severe cases of IAD, including those that are chronic or have other factors that exacerbate breakdown or prevent healing (eg, Crohn's disease, compromised nutrition, immune suppression), a cyanoacrylate film is the most durable skin barrier product.⁴ This film can be applied to denuded skin in the diaper area to promote healing.

Cyanoacrylate film creates a purple film on the wounds and skin. It dries quickly, but care should be taken to separate skin folds and not touch the skin or allow any material to touch the skin while the film dries. The film will wear off over hours to days as the skin heals. It should not be picked or peeled off prematurely. The film can be reapplied as needed to areas that remain open. This can be a miraculous treatment for even the most severe cases of IAD. In my practice, I clean the skin with a hypochlorous acid solution soak for at least 60 seconds before applying cyanoacrylate film. There are recent case studies that support the use of hypochlorous acid soaks for treatment of IAD in infants.

Identifying and Treating Fungal Dermatitis

In some cases, IAD may be complicated by fungal dermatitis. This condition manifests as patches of erythema in combination with scattered red or pink satellite lesions that may be flat or raised. Fungal rashes often cover a larger area and may extend into inguinal creases.³

This type of rash is also very itchy, and babies may be scratching at their diaper area. In darker-pigmented skin, a fungal rash may not appear red or pink. Instead, lesions may be darker or lighter than the surrounding skin tone. Fungal rashes typically cause the skin to appear dry, flaky, or peeling as they are resolving. Fungal dermatitis should be treated with a topical antifungal such as nystatin or clotrimazole or miconazole.

Nystatin is commonly used in pediatrics, but the other choices are more broad spectrum. Some barrier creams contain these antifungal ingredients. Zinc-based moisture barrier creams may also be applied on top of antifungal creams.³ In cases of very stubborn fungal dermatitis that does not respond to topical treatment, a systemic antifungal may be needed. Failing to recognize the signs of fungal dermatitis may lead caregivers down the wrong treatment path. Home remedies containing cornstarch or flour, as well as topical steroids, may exacerbate fungal dermatitis.

Other Factors

Additional causes of skin irritation should be considered if diaper rash is recalcitrant. These causes may include allergies or skin sensitivities to ingredients in diapers, wipes, or other topical products. Food sensitivities, medication reactions, and underlying disease processes may also play a role in persistent IAD.

Conclusion

Although diaper rash is certainly not a new issue, many parents continue to struggle with effective prevention and treatment strategies. It is often difficult for parents to choose an appropriate treatment because of the overwhelming number of topical products available, as well as variations among recommendations. It is particularly confusing that products used for evidence-based treatments, such as crusting, are not readily available outside of a health care setting. My goal is to empower parents and caregivers with the knowledge and tools to keep their kids’ skin healthy. I recommend that parents seek advice from reputable sources such as Certified WOC Nurses and other health care providers who are experienced in treating IAD.

References

1. Lim YSL, Carville K. Prevention and management of incontinence-associated dermatitis in the pediatric population: an integrative review. J Wound Ostomy Continence Nurs. 2019;46(1):30-37.
2. Baharestani MM. An overview of neonatal and pediatric wound care knowledge and considerations. Ostomy Wound Manage. 2007;53(6):34-55.
3. Lund C, Singh C. Skin and wound care for neonatal and pediatric populations. In: Doughty DB, McNichol LL, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum Wound Management. Wolters Kluwer; 2016:198-219.
4. King A, Stellar JJ, Blevins A, Shah KN. Dressings and products in pediatric wound care. Adv Wound Care (New Rochelle). 2014;3(4):324-334.

About the Author

Elizabeth Day Dechant, BSN, RN, CWOCN, CFCN is a Certified Wound Ostomy Continence Nurse at Children’s of Alabama, where she provides wound treatment recommendations and wound management for both inpatients and outpatients with acute and chronic wounds. She provides staff education on skin and wound care, ostomy care, and pressure injury prevention. Elizabeth works diligently with the hospital’s Pressure Injury Prevention Team to track and reduce hospital-acquired pressure injuries.