An infant has worn a wet diaper too long, and has developed
an uncomfortable rash, which may range fron simple redness
to macerated and superinfected skin. Hallmarks of Candida
(monilia) infection are often present, including intensely
red, raw areas, satellite lesions, and white exudate.
What to do:
Instruct the parents that it is imperative that the child
go "bare" and wear no diaper until the rash has healed.
This may increase the laundry load, but it allows the skin
to dry, avoid physical trauma, and restore its natural
defenses. This is usually all that is necessary to clear
up a diaper rash in 2-3 days, but . . .
To speed recovery from the frequent superinfection of
Candida (present in the feces) and less-frequent
superinfection with other dermatophytes, you may add
topical treatment with clotrimazole (Lotrimin) or nystatin
(mycostatin) cream, applied 3 or 4 times daily until the
rash has been healed for 2 days.
Make sure the family has a pediatrician for further
followup.
What not to do:
Do not let the parents be distracted by drying or emolient
medications. Going bare is the basis of treatment.
Do not recommend talcum powder or "talcum free" powders
for use when diapers are changed. They add little in terms
of medication or absorbency, and are occasionally
aspirated by infants as their diapers are being changed.
Discussion
Superinfection with Candida is common enough to treat
presumptively in every case of diaper rash severe enough to
be brought to the ED.
