US Pharm. 2012;37(3):12-15.

Diaper rash is a multi-factorial condition that is extremely uncomfortable for the baby and tin cause a great bargain of anxiety for parents. To farther compound the trouble, while truthful diaper rash (also known as irritant diaper dermatitis) is fairly simple to recognize and care for, diapers can worsen such dermatologic disorders as seborrheic dermatitis, psoriasis, and atopic dermatitis.

Manifestations of Diaper Rash

Diaper rash generally presents as a bright red irritation on the scrotum and penis in boys and on the labia and vagina in girls.1 It includes a wide range of dermatoses, such as scaling, blistering, ulcers, large bumps, pimples, or purulent sores. Children who are able to do and so may scratch the area during diaper changes. If the area exhibits a beefy-cerise advent, if in that location are small cherry-red bumps at the outer edges of the affected area, or if the child cries violently when urine touches the skin, candidal colonization is likely and a physician referral is mandatory.2,3

Safe Handling of Diaper Rash

Obviously, infants are very vulnerable to dangerous chemicals applied to the peel. This is especially true considering that the diaper is an occlusive dressing, enhancing absorption of whatever topically practical, pharmacologically active ingredient. Additionally, the skin of the infant with diaper rash is often damaged or broken, farther increasing the extent of absorption. For this reason, only the safest and nearly thoroughly investigated ingredients accept been canonical equally protectants. Some protectants are chemically inert, but all embrace and protect peel surfaces. They provide a mechanical bulwark to exclude irritants, exclude or remove wetness, and protect peel that contacts opposing skin (intertriginous pare).2

The FDA's general instructions for skin protectant products include advice to discontinue their employ and seek dr. care if symptoms persist for more than than vii days, and to alter wet and soiled diapers promptly, cleansing the diaper expanse and assuasive it to dry.2 Some other reliable federal Web site recommends seeking physician care if the area worsens or is not completely healed in ii to iii days, a safer fourth dimension limit.one Parents are also brash to apply the ointment, cream, or pulverization liberally equally frequently as necessary, with each diaper change, and especially at bedtime or someday when exposure to wet diapers may be prolonged. For powder products, parents are further instructed to apply powder close to the body only away from the child'south face, and to carefully shake the pulverization into the diaper or into the manus and use to the diaper area.

Specific Protectant Ingredients

If the infant's skin is broken, the parent should be advised to meet a physician.ii Even so, if the irritation is limited to inflammation, protectants are safe and effective. Allantoin (0.v%-2%), calamine (one%-25%), dimethicone (1%-30%), and kaolin (4%-20%) are all safe protectants.ii Cod liver oil (5%-13.56%) is also safe and effective, but it has an unpleasant odour, so it is combined with other ingredients to foreclose this odor. Lanolin 15.v% is safe and effective, but information technology should be avoided as information technology is a contact sensitizer.ii,4 Products containing lanolin include A+D Original Ointment, Weleda Baby Calendula Baby Foam, Belli Infant Protect Me Diaper Rash Cream, and Grandma El's Diaper Rash Remedy & Prevention.

Mineral oil (fifty%-100%) is a prophylactic and constructive emollient protectant for diaper rash. It is water-insoluble, giving it a barrier outcome. Withal, it remains on the peel indefinitely until physically removed, and may build up on the skin if non periodically cleansed away.2 Since the FDA directs the caregiver to cleanse the diaper expanse with each diaper modify, mineral oil should not accrue. However, if patients neglect to cleanse the infant properly, it could cause chronic peel irritation and folliculitis. It is the active ingredient in Johnson'southward Infant Oil.

Zinc oxide (25%-40%) pastes and ointments are prophylactic and effective for diaper rash, but in higher concentration they are difficult to remove from the baby's peel due to their thick and adherent nature. It is the major active ingredient in such products as Desitin Paste Maximum Strength (40% zinc oxide) and A+D Diaper Rash Cream (10%).

Petrolatum (30%-100%) is the ideal diaper rash protectant. It is virtually nonallergenic, lacks an unpleasant scent, is easily removed from the pare, and is effective as a single ingredient without the potential for folliculitis or irritation.2 It is the unmarried active ingredient in Vaseline Petroleum Jelly and Vaseline Infant.

Cornstarch (10%-98%) is formulated equally a pulverization. It is widely believed to be a prophylactic infant powder, just it may be hazardous. In one such case, a 1-month-old infant was brought to an emergency room because of poor eating habits and impaired breathing.5 The physicians ordered a chest ten-ray, which revealed diffuse opacification in both lungs, with dark-bluish polygon-shaped crystals visible on a Gram-stain. The crystals were eventually demonstrated to be cornstarch. The female parent admitted that she used cornstarch pulverization during diaper changes. The physicians diagnosed cornstarch pneumonitis, cautioning that the devil-may-care use of the powder could atomic number 82 to accidental aspiration with subsequent severe respiratory disease.

Another concern near cornstarch is that information technology may serve as a civilization medium for Candida albicans.6 Because of this, the pharmacist should recommend against the use of cornstarch. Products containing cornstarch include Johnson'south Babe Pure Cornstarch with Magnolia Petals. The magnolia petals in this product are not approved for use as protectants. The National Institutes of Health (NIH) recommends against use of cornstarch at any time as information technology can worsen a diaper rash with candidal infection.1

Talc (45%-100%) was one time thought to be condom and effective as an absorbent in preventing and treating diaper rash, but it tin exist dangerous in the form of talcum powder if not used appropriately and must never be recommended.1 Products containing talcum powder include Johnson's Infant Pulverisation. Talcum powder presents respiratory and dermatologic risks to the infant. Adventitious inhalation tin can be deadly, a fact of which at least 42% of mothers (of infants under the historic period of 2 years) are completely unaware.7,eight In ane report of episodes of inhalation of talcum powder, 55% of the victims were under i year of age, and 41% were in their second year.7,8

In some of the worst cases cited by the FDA, one child developed aspiration pneumonia, and another required several days on a respirator.viii In an singular case, a 3-twelvemonth-onetime sibling poured talcum powder into the oral fissure and olfactory organ of a i-month-former, who required resuscitation for cardiopulmonary arrest, but did survive. Some other child of 22 months played with talcum powder, inhaling sufficient grit to produce respiratory distress and perioral cyanosis. After xx hours of intendance, he expired of intractable cardiopulmonary failure.viii

This issue was of such great concern to the FDA that a public coming together was held in 1994 to discuss the safe use of talcum pulverisation in consumer products.ix Of special interest was a study by the National Toxicology Program that exposed rodents to talcum pulverization, finding that in that location was a take a chance of chronic pulmonary damage and decease. The FDA requires a mandatory alert on products containing talcum powder to help minimize the danger of aspiration: "Go along pulverisation away from child'south face up to avert inhalation, which can cause breathing bug."8

Talcum powder presents dermatologic dangers to infants. If it is practical to broken skin, talcum powder can crusade crusting, infection, and skin granulomas. For this reason, products containing talcum pulverization must acquit the alarm, "Do not use on broken peel." Diaper dermatitis treated but with powders may not resolve adequately. In one such case, a 6-month-old baby with mild diaper dermatitis treated only with powders developed granulomatous tissue on the buttocks, possibly as a event of the employ of dusting powders.ten

The pharmacist should suggest against use of talcum powder as a peel protectant considering of its dermatologic and respiratory dangers, as recommended by the NIH.1 If parents purchase the product in spite of this advice, they should exist cautioned to take care in application as warned past the FDA, but the parent or caregiver should farther exist cautioned to go along the products stored away from children, much as poisons are stored. These precautions utilise specifically to talcum powder, but can exist generalized to the apply of all powders in infants, regardless of the ingredients.

Unknown Ingredients in Diaper Rash Products

Diaper rash products are available under a large number of well-known brands (e.m., Vaseline, Desitin, A+D, Johnson'south), but also as a host of strangely named, obscure products.11 Some of the erstwhile and many of the latter load their products with ingredients of unknown safety and efficacy for diaper rash. They oft include multiple plant-derived ingredients, which could be allergenic or toxic if absorbed. It is appropriate to avert these overloaded formulations in favor of those containing a single safe and effective protectant (e.m., petrolatum).

Boric acid is known to present dangers to babies, but it is included in such products every bit Boudreaux's Butt Paste.2 Nonfat dry milk and goat'southward milk are inexplicably included in such products every bit The Kickoff Years Bottom Care Diaper Rash Relief System and Canus Li'l Goat'south Milk Ointment. Tea tree oil is found in Bum Boosa Bamboo Diaper Rash Ointment and California Baby Not-Burning & Calming Diaper Surface area Wash. Although they also contain zinc oxide, miscellaneous plant ingredients are found in Aveeno Baby Soothing Relief Diaper Rash Cream, Aveeno Baby Organic Harvest Diaper Rash Cream, Balmex Diaper Rash Cream, and Puristics Baby Zinc Oxide Diaper Rash Cream.xi

Some parents may ask nearly the employ of topical antifungals for diaper rash. It is true that broken pare under the diaper is oftentimes colonized with Candida, only a physician appointment is mandatory.2 Currently available nonprescription antifungals are only indicated for fungal weather such as tinea pedis, tinea cruris, and tinea corporis. Their efficacy on Candida is unknown.

PATIENT Information


Choosing the Correct Type of Diaper

Diaper rash tin cause a great deal of discomfort for the baby. Since the goal is to keep the skin dry out, parents should cull diapers that are labeled as superabsorbent or ultra-absorbent. These prevent diaper rash better than older, regular absorbency diapers. Some parents adopt material diapers for reasons of economics, sanitation, or conservation, merely disposables are far better than reusable material diapers in preventing diaper rash. If cloth diapers are used, they should never exist covered by plastic pants, since the plastic keeps wet trapped inside the diaper and makes diaper rash more probable.

During an agile case of diaper rash, the skin is very sensitive. Near commercial diaper wipes should exist avoided during this time, as these products may contain chemicals that irritate the skin afflicted by the rash. Immediate cleaning of the expanse with mild soap is the safest alternative.

Skin Protectants

Skin protectants are the safest ingredients for treating diaper rash. These include such ingredients as allantoin, calamine, cod liver oil, dimethicone, kaolin, lanolin, mineral oil, petrolatum, talc, topical starch (besides known as cornstarch), white petrolatum, and zinc oxide. However, some of these are ameliorate than others. Petrolatum (due east.g., Vaseline) is an excellent choice.

Powders containing kaolin, cornstarch, or talc tin crusade problems if the baby's skin is cleaved or wounded and should be avoided. If you choose to utilize them anyway, keep whatsoever powder diaper rash product well away from the child'south confront while you are putting it on your hands or applying information technology to the baby'due south bottom. If yous allow the powder to get into the air, the baby will inhale it while breathing, potentially producing chemical pneumonia that tin pb to permanent breathing problems or expiry.

The best way to apply powders is to become to a location away from the baby. Place the container close to your body and away from your face. Gently shake a pocket-sized corporeality of powder onto a paw. When the powder has settled, arroyo the baby and apply it to the diaper area. Never let an older sibling play with the powders either by themselves or around the baby for the same reasons.

Products to Avoid

Some chemicals should never be used on the baby. Do non use homemade preparations such as baking soda since their condom would be questionable. Whatever product containing boric acid or borax is unsafe and must be avoided. Chemicals such every bit aloe vera, benzyl alcohol, castor seed, Peruvian balsam, nonfat dry milk, arnica, borage, thymol, calendula, rose hip oil, and tea tree oil are non FDA-canonical protectants. Some may be listed every bit inactive ingredients, but could still cause allergic reactions or other bug. Antibody ointments containing such ingredients as neomycin, polymyxin, or bacitracin should not be used for diaper rash. Hydrocortisone products should not be used without a physician recommendation. Y'all should not use any antifungal or anticandidal products on diaper rash.

Remember, if you lot have questions, Consult Your Pharmacist.

REFERENCES

1. Diaper rash. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/000964.htm. Accessed January 30, 2012.
ii. Pray WS. Nonprescription Production Therapeutics. 2nd ed. Baltimore, Doc: Lippincott Williams & Wilkins; 2006.
3. Rash—child under 2 years. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/003259.htm. Accessed Jan thirty, 2012.
4. Kligman AM. Lanolin allergy: crisis or one-act. Contact Dermatitis. 1983;9:99-107.
5. Silver P, Sagy M, Rubin 50. Respiratory failure from corn starch aspiration: a hazard of diaper changing. Pediatr Emerg Intendance. 1996;12:108-110.
six. Farrington Due east. Diaper dermatitis. Pediatr Nurs. 1992;18:81-82.
7. Preston SL, Bryant BG. Etiology and treatment of diaper dermatitis. Hosp Pharm. 1994;29:1086-1088,1097.
8. Skin protectant drug products for over-the-counter human being use; proposed rulemaking for diaper rash drug products. Fed Regist. 1990;55:25204-25232.
nine. Talc; consumer uses and health perspectives; public meetings. Fed Regist. 1994;59:2319.
10. Konya J, Gow E. Granuloma gluteale infantum. Australas J Dermatol. 1996;37:57-58.

11. Diaper rash products. www.drugstore.com. Accessed February 7, 2012.
12. Semiz S, Balci YI, Ergin South, et al. 2 cases of Cushing's syndrome due to overuse of topical steroid in the diaper surface area. Pediatr Dermatol. 2008;25:544-547.
thirteen. Tempark T, Phatarakijnirund V, Chatproedprai S, et al. Exogenous Cushing'southward syndrome due to topical corticosteroid application: case study and review literature. Endocrine. 2010;38:328-334.

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