US Pharm. 2012;37(3):12-15.
Diaper rash is a multi-factorial condition that isextremely uncomfortable for the infant and can cause a great deal ofanxiety for parents. To further compound the problem, while true diaperrash (also known as irritant diaper dermatitis) is fairly simpleto recognize and treat, diapers can worsen such dermatologic disordersas 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 vagin* in girls.1It includes a wide range of dermatoses, such as scaling, blistering,ulcers, large bumps, pimples, or purulent sores. Children who are ableto do so may scratch the area during diaper changes. If the areaexhibits a beefy-red appearance, if there are small red bumps at theouter edges of the affected area, or if the child cries violently whenurine touches the skin, candidal colonization is likely and a physicianreferral is mandatory.2,3
Safe Treatment of Diaper Rash
Obviously, infants are very vulnerable to dangerouschemicals applied to the skin. This is especially true considering thatthe diaper is an occlusive dressing, enhancing absorption of anytopically applied, pharmacologically active ingredient. Additionally,the skin of the infant with diaper rash is often damaged or broken,further increasing the extent of absorption. For this reason, only thesafest and most thoroughly investigated ingredients have been approvedas protectants. Some protectants are chemically inert, but all cover andprotect skin surfaces. They provide a mechanical barrier to excludeirritants, exclude or remove wetness, and protect skin that contactsopposing skin (intertriginous skin).2
The FDA’s general instructions for skin protectantproducts include advice to discontinue their use and seek physician careif symptoms persist for more than 7 days, and to change wet and soileddiapers promptly, cleansing the diaper area and allowing it to dry.2Another reliable federal Web site recommends seeking physician care ifthe area worsens or is not completely healed in 2 to 3 days, a safertime limit.1 Parents are also advised to apply the ointment,cream, or powder liberally as often as necessary, with each diaperchange, and especially at bedtime or anytime when exposure to wetdiapers may be prolonged. For powder products, parents are furtherinstructed to apply powder close to the body but away from the child’sface, and to carefully shake the powder into the diaper or into the handand apply to the diaper area.
Specific Protectant Ingredients
If the infant’s skin is broken, the parent should be advised to see a physician.2However, if the irritation is limited to inflammation, protectants aresafe and effective. Allantoin (0.5%-2%), calamine (1%-25%), dimethicone(1%-30%), and kaolin (4%-20%) are all safe protectants.2 Codliver oil (5%-13.56%) is also safe and effective, but it has anunpleasant smell, so it is combined with other ingredients to preventthis odor. Lanolin 15.5% is safe and effective, but it should be avoidedas it is a contact sensitizer.2,4 Products containinglanolin include A+D Original Ointment, Weleda Baby Calendula Baby Cream,Belli Baby Protect Me Diaper Rash Cream, and Grandma El’s Diaper RashRemedy & Prevention.
Mineral oil (50%-100%) is a safe and effective emollientprotectant for diaper rash. It is water-insoluble, giving it a barriereffect. However, it remains on the skin indefinitely until physicallyremoved, and may build up on the skin if not periodically cleansed away.2Since the FDA directs the caregiver to cleanse the diaper area witheach diaper change, mineral oil should not accumulate. However, ifpatients fail to cleanse the baby properly, it could cause chronic skinirritation and folliculitis. It is the active ingredient in Johnson’sBaby Oil.
Zinc oxide (25%-40%) pastes and ointments are safe andeffective for diaper rash, but in higher concentration they aredifficult to remove from the baby’s skin due to their thick and adherentnature. It is the major active ingredient in such products as DesitinPaste 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 odor, is easilyremoved from the skin, and is effective as a single ingredient withoutthe potential for folliculitis or irritation.2 It is the single active ingredient in Vaseline Petroleum Jelly and Vaseline Baby.
Cornstarch (10%-98%) is formulated as a powder. It iswidely believed to be a safe infant powder, but it may be hazardous. Inone such case, a 1-month-old infant was brought to an emergency roombecause of poor eating habits and impaired breathing.5 Thephysicians ordered a chest x-ray, which revealed diffuse opacificationin both lungs, with dark-blue polygon-shaped crystals visible on aGram-stain. The crystals were eventually demonstrated to be cornstarch.The mother admitted that she used cornstarch powder during diaperchanges. The physicians diagnosed cornstarch pneumonitis, cautioningthat the careless use of the powder could lead to accidental aspirationwith subsequent severe respiratory disease.
Another concern about cornstarch is that it may serve as a culture medium for Candida albicans.6Because of this, the pharmacist should recommend against the use ofcornstarch. Products containing cornstarch include Johnson’s Baby PureCornstarch with Magnolia Petals. The magnolia petals in this product arenot approved for use as protectants. The National Institutes of Health(NIH) recommends against use of cornstarch at any time as it can worsen adiaper rash with candidal infection.1
Talc (45%-100%) was once thought to be safe and effectiveas an absorbent in preventing and treating diaper rash, but it can bedangerous in the form of talcum powder if not used appropriately andmust never be recommended.1 Products containing talcum powderinclude Johnson’s Baby Powder. Talcum powder presents respiratory anddermatologic risks to the baby. Accidental inhalation can be deadly, afact of which at least 42% of mothers (of infants under the age of 2years) are completely unaware.7,8 In one study of episodes ofinhalation of talcum powder, 55% of the victims were under 1 year ofa*ge, and 41% were in their second year.7,8
In some of the worst cases cited by the FDA, one childdeveloped aspiration pneumonia, and another required several days on arespirator.8 In an atypical case, a 3-year-old sibling pouredtalcum powder into the mouth and nose of a 1-month-old, who requiredresuscitation for cardiopulmonary arrest, but did survive. Another childof 22 months played with talcum powder, inhaling sufficient dust toproduce respiratory distress and perioral cyanosis. After 20 hours ofcare, he expired of intractable cardiopulmonary failure.8
This issue was of such great concern to the FDA that apublic meeting was held in 1994 to discuss the safe use of talcum powderin consumer products.9 Of special interest was a study bythe National Toxicology Program that exposed rodents to talcum powder,finding that there was a risk of chronic pulmonary damage and death. TheFDA requires a mandatory warning on products containing talcum powderto help minimize the danger of aspiration: “Keep powder away fromchild’s face to avoid inhalation, which can cause breathing problems.”8
Talcum powder presents dermatologic dangers to infants. Ifit is applied to broken skin, talcum powder can cause crusting,infection, and skin granulomas. For this reason, products containingtalcum powder must carry the warning, “Do not use on broken skin.”Diaper dermatitis treated only with powders may not resolve adequately.In one such case, a 6-month-old infant with mild diaper dermatitistreated only with powders developed granulomatous tissue on thebuttocks, perhaps as a result of the use of dusting powders.10
The pharmacist should advise against use of talcum powderas a skin protectant because of its dermatologic and respiratorydangers, as recommended by the NIH.1 If parents purchase theproduct in spite of this advice, they should be cautioned to take carein application as warned by the FDA, but the parent or caregiver shouldfurther be cautioned to keep the products stored away from children,much as poisons are stored. These precautions apply specifically totalcum powder, but can be generalized to the use of all powders ininfants, regardless of the ingredients.
Unknown Ingredients in Diaper Rash Products
Diaper rash products are available under a large number ofwell-known brands (e.g., Vaseline, Desitin, A+D, Johnson’s), but alsoas a host of strangely named, obscure products.11 Some of theformer and many of the latter load their products with ingredients ofunknown safety and efficacy for diaper rash. They often include multipleplant-derived ingredients, which could be allergenic or toxic ifabsorbed. It is advisable to avoid these overloaded formulations infavor of those containing a single safe and effective protectant (e.g.,petrolatum).
Boric acid is known to present dangers to babies, but it is included in such products as Boudreaux’s Butt Paste.2Nonfat dry milk and goat’s milk are inexplicably included in suchproducts as The First Years Bottom Care Diaper Rash Relief System andCanus Li’l Goat’s Milk Ointment. Tea tree oil is found in Bum BoosaBamboo Diaper Rash Ointment and California Baby Non-Burning &Calming Diaper Area Wash. Although they also contain zinc oxide,miscellaneous plant ingredients are found in Aveeno Baby Soothing ReliefDiaper Rash Cream, Aveeno Baby Organic Harvest Diaper Rash Cream,Balmex Diaper Rash Cream, and Puristics Baby Zinc Oxide Diaper RashCream.11
Some parents may ask about the use of topical antifungalsfor diaper rash. It is true that broken skin under the diaper is oftencolonized with Candida, but a physician appointment is mandatory.2Currently available nonprescription antifungals are only indicated forfungal conditions such as tinea pedis, tinea cruris, and tinea corporis.Their efficacy on Candida is unknown.
PATIENT INFORMATION
Choosing the Right Type of Diaper
Diaper rash can cause a great deal of discomfort for thebaby. Since the goal is to keep the skin dry, parents should choosediapers that are labeled as superabsorbent or ultra-absorbent. Theseprevent diaper rash better than older, regular absorbency diapers. Someparents prefer cloth diapers for reasons of economics, sanitation, orconservation, but disposables are far better than reusable cloth diapersin preventing diaper rash. If cloth diapers are used, they should neverbe covered by plastic pants, since the plastic keeps moisture trappedinside the diaper and makes diaper rash more likely.
During an active case of diaper rash, the skin is verysensitive. Most commercial diaper wipes should be avoided during thistime, as these products may contain chemicals that irritate the skinaffected by the rash. Immediate cleaning of the area with mild soap isthe safest alternative.
Skin Protectants
Skin protectants are the safest ingredients for treatingdiaper rash. These include such ingredients as allantoin, calamine, codliver oil, dimethicone, kaolin, lanolin, mineral oil, petrolatum, talc,topical starch (also known as cornstarch), white petrolatum, andzinc oxide. However, some of these are better than others. Petrolatum(e.g., Vaseline) is an excellent choice.
Powders containing kaolin, cornstarch, or talc can causeproblems if the baby’s skin is broken or wounded and should be avoided.If you choose to use them anyway, keep any powder diaper rash productwell away from the child’s face while you are putting it on your handsor applying it to the baby’s bottom. If you allow the powder to get intothe air, the baby will inhale it while breathing, potentially producingchemical pneumonia that can lead to permanent breathing problems ordeath.
The best way to apply powders is to go to a location awayfrom the baby. Place the container close to your body and away from yourface. Gently shake a small amount of powder onto a hand. When thepowder has settled, approach the baby and apply it to the diaper area.Never let an older sibling play with the powders either by themselves oraround the baby for the same reasons.
Products to Avoid
Some chemicals should never be used on the baby. Do notuse homemade preparations such as baking soda since their safety wouldbe questionable. Any product containing boric acid or borax is unsafeand must be avoided. Chemicals such as aloe vera, benzyl alcohol, castorseed, Peruvian balsam, nonfat dry milk, arnica, borage, thymol,calendula, rose hip oil, and tea tree oil are not FDA-approvedprotectants. Some may be listed as inactive ingredients, but could stillcause allergic reactions or other problems. Antibiotic ointmentscontaining such ingredients as neomycin, polymyxin, or bacitracin shouldnot be used for diaper rash. Hydrocortisone products should not be usedwithout a physician recommendation. You should not use any antifungalor anticandidal products on diaper rash.
Remember, if you have questions, Consult Your Pharmacist.
REFERENCES
1. Diaper rash. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/000964.htm. Accessed January 30, 2012.
2. Pray WS. Nonprescription Product Therapeutics. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2006.
3. Rash—child under 2 years. MedlinePlus. www.nlm.nih.gov/medlineplus/ency/article/003259.htm. Accessed January 30, 2012.
4. Kligman AM. Lanolin allergy: crisis or comedy. Contact Dermatitis. 1983;9:99-107.
5. Silver P, Sagy M, Rubin L. Respiratory failure from corn starch aspiration: a hazard of diaper changing. Pediatr Emerg Care. 1996;12:108-110.
6. Farrington E. 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 use; proposed rulemaking for diaper rash drug products. Fed Regist. 1990;55:25204-25232.
9. 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 S, et al. Two cases of Cushing’s syndrome due to overuse of topical steroid in the diaper area. Pediatr Dermatol. 2008;25:544-547.
13. Tempark T, Phatarakijnirund V, Chatproedprai S, et al.Exogenous Cushing’s syndrome due to topical corticosteroid application:case report and review literature. Endocrine. 2010;38:328-334.
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