In the neonatal period and early infancy the skin's defenses are not yet fully developed, and it is much more vulnerable to chemical, physical and microbial attack. Apart from the depressed skin defenses, the surface area to weight ratio is higher than at other times and there is a greater hazard from increased absorption of topically applied medicaments.
The vascular network in the skin seems more labile than in the adult. A rash may change from a vivid scarlet to a pale pink within a few hours. During the early weeks of life the newborn child possesses hormones that found in the mothers blood may be of special significance for the sebaceous glands, which react to the circulating androgenic compounds leading to increased sebum secretion.
Several different skin disorders localize to the napkin area which is perhaps the physical assault that the wearing of napkins provides. Nappy rash affects almost all infants to some extent.
Cause:
The main causes are chemical irritation and infantile seborrheic eczema. Chemical irritation of the nappy area is due to occlusive contact of urine and feces with the perineal skin. Most cases of napkin or diaper dermatitis are due to irritation from prolonged exposure to alkaline urine and faeces. In long-standing dermatitis and when systemic antibiotics are being taken, secondary invasion skin colonization with Candida albicans is common. The choice of cloth versus disposable diaper has little effect on incidence of diaper dermatitis.
Appearance:
Red, glazed, fissured and even eroded areas develop on the skin at sites in contact with the napkin. The flexures are mostly spared with the worst areas appearing on the convexities. There is often a strong ammoniacal smell when the napkin is removed. This is due to the release of ammonia from the action of the urea’s released from the faecal bacteria on the urea in the urine. The rash is bounded by the margins of the nappy with sparing of the skin folds. Infantile seborreic eczema involves the flexures and the nappy area is usually affected as part of a more widespread eruption.
Treatment:
1. The condition responds when the child is nursed without napkins for two or three days. If this is not possible, other measures have to be adopted. This should include encouraging more frequent napkin changes and the use of soft muslin napkins rather than abrasive toweling napkins, or the use of disposables that leave the skin surface dry.
2. Avoid occlusive plastic pants and allow the diaper area to air dry, leaving diapers off as much as is practical.
3. Irritants (soaps, bubble bath, and detergents) should be avoided.
4. Barrier creams and ointments as a prophylactic protective covering of zinc oxide and castor oil cream after each nappy change can help in prevention of dermatitis by providing a protective layer against urine and feces. Cornstarch powder can reduce chafing. These products do not promote yeast infection. Oil-based emollients (Vaseline) can worsen the dermatitis by blocking pores.
5. In the presence of Candida infection, topical nystatin cream should be applied tid and used for 5 to 7 days following cleaning. Oral thrush should be treated simultaneously.
6. Treatment of established nappy rash comprises an anti-candida/ hydrocortisone application. For example; clotrimazole and hydrocortisone; miconazole and hydrocortisone. Strong topical steroids are contraindicated.
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