U.s.a. Pharm. 2012;37(three):12-15.

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

Manifestations of Diaper Rash

Diaper rash mostly 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 so may scratch the area during diaper changes. If the surface area exhibits a bulky-ruddy appearance, if in that location are pocket-sized ruby bumps at the outer edges of the affected area, or if the child cries violently when urine touches the peel, candidal colonization is probable and a physician referral is mandatory.2,three

Condom Treatment of Diaper Rash

Obviously, infants are very vulnerable to dangerous chemicals applied to the skin. This is specially true considering that the diaper is an occlusive dressing, enhancing absorption of any topically 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, merely the safest and nigh thoroughly investigated ingredients have been approved as protectants. Some protectants are chemically inert, just all embrace and protect peel surfaces. They provide a mechanical barrier to exclude irritants, exclude or remove wetness, and protect skin that contacts opposing skin (intertriginous skin).2

The FDA's general instructions for peel protectant products include advice to discontinue their use and seek physician intendance if symptoms persist for more than 7 days, and to modify wet and soiled diapers promptly, cleansing the diaper expanse and allowing it to dry.two Another reliable federal Web site recommends seeking medico care if the area worsens or is non completely healed in 2 to iii days, a safer fourth dimension limit.1 Parents are also brash to use the ointment, foam, or pulverization liberally as often as necessary, with each diaper modify, and especially at bedtime or someday when exposure to wet diapers may be prolonged. For powder products, parents are farther instructed to apply pulverization shut to the trunk just abroad from the child's face up, and to carefully shake the powder into the diaper or into the hand and apply to the diaper area.

Specific Protectant Ingredients

If the baby's skin is broken, the parent should be advised to see a doctor.ii However, if the irritation is limited to inflammation, protectants are safe and effective. Allantoin (0.5%-2%), calamine (ane%-25%), dimethicone (i%-30%), and kaolin (iv%-xx%) are all condom protectants.2 Cod liver oil (5%-13.56%) is as well condom and effective, but it has an unpleasant smell, and then it is combined with other ingredients to forbid this odor. Lanolin 15.5% is safe and effective, but it should be avoided as it is a contact sensitizer.2,four Products containing lanolin include A+D Original Ointment, Weleda Baby Calendula Infant Cream, Belli Baby Protect Me Diaper Rash Cream, and Grandma El's Diaper Rash Remedy & Prevention.

Mineral oil (50%-100%) is a safe and constructive emollient protectant for diaper rash. It is water-insoluble, giving it a barrier issue. However, it remains on the peel indefinitely until physically removed, and may build up on the pare if not periodically cleansed away.two Since the FDA directs the caregiver to cleanse the diaper area with each diaper modify, mineral oil should not accumulate. However, if patients neglect to cleanse the baby properly, it could cause chronic skin irritation and folliculitis. It is the active ingredient in Johnson's Baby Oil.

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

Petrolatum (30%-100%) is the platonic diaper rash protectant. It is virtually nonallergenic, lacks an unpleasant odor, is easily removed from the skin, and is constructive as a single ingredient without the potential for folliculitis or irritation.ii It is the single active ingredient in Vaseline Petroleum Jelly and Vaseline Infant.

Cornstarch (10%-98%) is formulated as a powder. It is widely believed to be a safe infant powder, simply it may be hazardous. In i such case, a 1-calendar month-one-time infant was brought to an emergency room because of poor eating habits and impaired animate.5 The physicians ordered a chest x-ray, which revealed diffuse opacification in both lungs, with dark-blue polygon-shaped crystals visible on a Gram-stain. The crystals were eventually demonstrated to be cornstarch. The mother admitted that she used cornstarch pulverization during diaper changes. The physicians diagnosed cornstarch pneumonitis, cautioning that the devil-may-care employ of the powder could pb to accidental aspiration with subsequent astringent respiratory disease.

Another business almost cornstarch is that it may serve as a culture medium for Candida albicans.6 Considering of this, the pharmacist should recommend confronting the utilise of cornstarch. Products containing cornstarch include Johnson's Baby 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 utilise of cornstarch at any time as it can worsen a diaper rash with candidal infection.1

Talc (45%-100%) was once thought to be condom and effective every bit an absorbent in preventing and treating diaper rash, but it tin can be unsafe in the form of talcum powder if not used accordingly and must never be recommended.1 Products containing talcum powder include Johnson'south Babe Powder. Talcum powder presents respiratory and dermatologic risks to the babe. Accidental inhalation can exist deadly, a fact of which at least 42% of mothers (of infants under the age of 2 years) are completely unaware.7,8 In one study of episodes of inhalation of talcum powder, 55% of the victims were nether 1 year of historic period, and 41% were in their second year.seven,8

In some of the worst cases cited by the FDA, ane child developed aspiration pneumonia, and another required several days on a respirator.8 In an atypical case, a 3-year-old sibling poured talcum powder into the mouth and nose of a 1-month-old, who required resuscitation for cardiopulmonary abort, merely did survive. Some other kid of 22 months played with talcum powder, inhaling sufficient dust to produce respiratory distress and perioral cyanosis. Subsequently 20 hours of intendance, he expired of intractable cardiopulmonary failure.eight

This issue was of such great business organisation to the FDA that a public meeting was held in 1994 to discuss the condom use of talcum powder in consumer products.nine Of special interest was a study by the National Toxicology Program that exposed rodents to talcum pulverisation, finding that in that location was a adventure of chronic pulmonary damage and death. The FDA requires a mandatory warning on products containing talcum powder to assistance minimize the danger of aspiration: "Continue powder away from kid's face to avoid inhalation, which can cause breathing issues."viii

Talcum pulverisation presents dermatologic dangers to infants. If information technology is applied to broken peel, talcum powder can cause crusting, infection, and peel granulomas. For this reason, products containing talcum powder must carry the warning, "Practise not use on broken skin." Diaper dermatitis treated only with powders may not resolve fairly. In ane such case, a 6-month-old baby with balmy diaper dermatitis treated only with powders adult granulomatous tissue on the buttocks, perhaps as a result of the utilise of dusting powders.10

The pharmacist should advise against use of talcum powder as a skin protectant because of its dermatologic and respiratory dangers, every bit recommended by the NIH.1 If parents purchase the product in spite of this advice, they should be cautioned to take care in application as warned by the FDA, just the parent or caregiver should farther be cautioned to keep the products stored away from children, much as poisons are stored. These precautions employ specifically to talcum powder, but tin exist generalized to the use of all powders in infants, regardless of the ingredients.

Unknown Ingredients in Diaper Rash Products

Diaper rash products are available under a big number of well-known brands (e.g., Vaseline, Desitin, A+D, Johnson's), just also equally a host of strangely named, obscure products.eleven Some of the former 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 captivated. It is advisable to avoid these overloaded formulations in favor of those containing a single rubber and effective protectant (e.g., petrolatum).

Boric acid is known to present dangers to babies, but it is included in such products as Boudreaux'south Barrel Paste.2 Nonfat dry milk and caprine animal's milk are inexplicably included in such products as The First Years Bottom Care Diaper Rash Relief Organisation and Canus Li'50 Goat's Milk Ointment. Tea tree oil is found in Bum Boosa Bamboo Diaper Rash Ointment and California Baby Not-Called-for & Calming Diaper Area Launder. Although they too contain zinc oxide, miscellaneous plant ingredients are plant in Aveeno Baby Soothing Relief Diaper Rash Cream, Aveeno Infant Organic Harvest Diaper Rash Foam, Balmex Diaper Rash Cream, and Puristics Baby Zinc Oxide Diaper Rash Cream.11

Some parents may enquire about the utilize of topical antifungals for diaper rash. It is truthful that broken skin under the diaper is frequently colonized with Candida, but a doc appointment is mandatory.2 Currently available nonprescription antifungals are only indicated for fungal weather condition such as tinea pedis, tinea cruris, and tinea corporis. Their efficacy on Candida is unknown.

PATIENT INFORMATION


Choosing the Right Blazon of Diaper

Diaper rash can cause a great deal of discomfort for the babe. Since the goal is to go on the peel dry, parents should choose diapers that are labeled as superabsorbent or ultra-absorbent. These prevent diaper rash better than older, regular absorbency diapers. Some parents prefer cloth diapers for reasons of economics, sanitation, or conservation, only disposables are far better than reusable cloth diapers in preventing diaper rash. If cloth diapers are used, they should never exist covered past plastic pants, since the plastic keeps moisture trapped within the diaper and makes diaper rash more likely.

During an active case of diaper rash, the skin is very sensitive. Most commercial diaper wipes should be avoided during this time, as these products may incorporate chemicals that irritate the skin affected by the rash. Firsthand cleaning of the area with mild soap is the safest alternative.

Peel Protectants

Pare 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 (also known as cornstarch), white petrolatum, and zinc oxide. Even so, some of these are better than others. Petrolatum (due east.g., Vaseline) is an excellent option.

Powders containing kaolin, cornstarch, or talc can cause problems if the baby'southward skin is broken or wounded and should exist avoided. If you choose to use them anyhow, keep any powder diaper rash production well away from the kid'south face up while y'all are putting it on your hands or applying information technology to the baby'southward lesser. If you allow the powder to go into the air, the baby volition inhale it while breathing, potentially producing chemic pneumonia that tin can atomic number 82 to permanent breathing problems or death.

The best way to use powders is to go to a location away from the baby. Place the container close to your trunk and away from your face. Gently milk shake a minor amount of powder onto a hand. When the pulverisation has settled, arroyo the baby and utilise it to the diaper area. Never let an older sibling play with the powders either by themselves or around the baby for the aforementioned reasons.

Products to Avoid

Some chemicals should never be used on the infant. Do not use homemade preparations such as blistering soda since their rubber would be questionable. Any product containing boric acid or borax is dangerous and must be avoided. Chemicals such as aloe vera, benzyl alcohol, castor seed, Peruvian balsam, nonfat dry milk, arnica, borage, thymol, calendula, rose hip oil, and tea tree oil are not FDA-canonical protectants. Some may exist listed as inactive ingredients, merely could notwithstanding crusade allergic reactions or other problems. Antibody ointments containing such ingredients equally neomycin, polymyxin, or bacitracin should non be used for diaper rash. Hydrocortisone products should not be used without a physician recommendation. You should not utilise whatsoever antifungal or anticandidal products on diaper rash.

Remember, if you have questions, Consult Your Pharmacist.

REFERENCES

1. Diaper rash. MedlinePlus. world wide web.nlm.nih.gov/medlineplus/ency/article/000964.htm. Accessed January 30, 2012.
2. Pray WS. Nonprescription Product Therapeutics. 2nd ed. Baltimore, Physician: Lippincott Williams & Wilkins; 2006.
iii. Rash—child under ii years. MedlinePlus. world wide web.nlm.nih.gov/medlineplus/ency/commodity/003259.htm. Accessed January 30, 2012.
4. Kligman AM. Lanolin allergy: crunch or comedy. Contact Dermatitis. 1983;nine:99-107.
five. Silver P, Sagy Chiliad, Rubin 50. 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.
seven. Preston SL, Bryant BG. Etiology and handling of diaper dermatitis. Hosp Pharm. 1994;29:1086-1088,1097.
8. Peel protectant drug products for over-the-counter man use; proposed rulemaking for diaper rash drug products. Fed Regist. 1990;55:25204-25232.
9. Talc; consumer uses and wellness perspectives; public meetings. Fed Regist. 1994;59:2319.
10. Konya J, Gow Eastward. Granuloma gluteale infantum. Australas J Dermatol. 1996;37:57-58.
11. Diaper rash products. world wide web.drugstore.com. Accessed February 7, 2012.
12. Semiz S, Balci YI, Ergin Due south, et al. 2 cases of Cushing's syndrome due to overuse of topical steroid in the diaper area. Pediatr Dermatol. 2008;25:544-547.
thirteen. Tempark T, Phatarakijnirund V, Chatproedprai Due south, et al. Exogenous Cushing's syndrome due to topical corticosteroid application: case written report and review literature. Endocrine. 2010;38:328-334.

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