US Pharm. 2012;37(3):12-15.
Diaper rash is a multi-factorial condition that is
extremely uncomfortable for the infant and can cause a great deal of
anxiety for parents. To further 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 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 so may scratch the area during diaper changes. If the area
exhibits a beefy-red appearance, if there are small 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 Treatment of Diaper Rash
Obviously, infants are very vulnerable to dangerous
chemicals applied to the skin. This is especially 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, only the
safest and most thoroughly investigated ingredients have been approved
as protectants. Some protectants are chemically inert, but all cover and
protect skin 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 skin protectant
products include advice to discontinue their use and seek physician care
if symptoms persist for more than 7 days, and to change wet and soiled
diapers promptly, cleansing the diaper area and allowing it to dry.2
Another reliable federal Web site recommends seeking physician care if
the area worsens or is not completely healed in 2 to 3 days, a safer
time limit.1 Parents are also advised to apply the ointment,
cream, or powder liberally as often as necessary, with each diaper
change, and especially at bedtime or anytime when exposure to wet
diapers may be prolonged. For powder products, parents are further
instructed to apply powder close to the body but away from the child’s
face, and to carefully shake the powder into the diaper or into the hand
and apply to the diaper area.
Specific Protectant Ingredients
If the infant’s skin is broken, the parent should be advised to see a physician.2
However, if the irritation is limited to inflammation, protectants are
safe and effective. Allantoin (0.5%-2%), calamine (1%-25%), dimethicone
(1%-30%), and kaolin (4%-20%) are all safe protectants.2 Cod
liver oil (5%-13.56%) is also safe and effective, but it has an
unpleasant smell, so it is combined with other ingredients to prevent
this odor. Lanolin 15.5% is safe and effective, but it should be avoided
as it is a contact sensitizer.2,4 Products containing
lanolin include A+D Original Ointment, Weleda Baby Calendula Baby Cream,
Belli Baby Protect Me Diaper Rash Cream, and Grandma El’s Diaper Rash
Remedy & Prevention.
Mineral oil (50%-100%) is a safe and effective emollient
protectant for diaper rash. It is water-insoluble, giving it a barrier
effect. However, it remains on the skin indefinitely until physically
removed, and may build up on the skin if not periodically cleansed away.2
Since the FDA directs the caregiver to cleanse the diaper area with
each diaper change, mineral oil should not accumulate. However, if
patients fail to cleanse the baby properly, it could cause chronic skin
irritation and folliculitis. It is the active ingredient in Johnson’s
Zinc oxide (25%-40%) pastes and ointments are safe and
effective for diaper rash, but in higher concentration they are
difficult to remove from the baby’s skin 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 odor, is easily
removed from the skin, and is effective as a single ingredient without
the 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 is
widely believed to be a safe infant powder, but 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 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 powder during diaper
changes. The physicians diagnosed cornstarch pneumonitis, cautioning
that the careless use of the powder could lead to accidental aspiration
with subsequent severe respiratory disease.
Another concern about cornstarch is that it may serve as a culture medium for Candida albicans.6
Because of this, the pharmacist should recommend against the use 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 use of cornstarch at any time as it can worsen a
diaper rash with candidal infection.1
Talc (45%-100%) was once thought to be safe and effective
as an absorbent in preventing and treating diaper rash, but it can be
dangerous in the form of talcum powder if not used appropriately and
must never be recommended.1 Products containing talcum powder
include Johnson’s Baby Powder. Talcum powder presents respiratory and
dermatologic risks to the baby. Accidental inhalation can be 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 under 1 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.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 arrest, but did survive. Another child
of 22 months played with talcum powder, inhaling sufficient dust to
produce respiratory distress and perioral cyanosis. After 20 hours of
care, he expired of intractable cardiopulmonary failure.8
This issue was of such great concern to the FDA that a
public meeting was held in 1994 to discuss the safe use of talcum powder
in consumer products.9 Of special interest was a study by
the National Toxicology Program that exposed rodents to talcum powder,
finding that there was a risk of chronic pulmonary damage and death. The
FDA requires a mandatory warning on products containing talcum powder
to help minimize the danger of aspiration: “Keep powder away from
child’s face to avoid inhalation, which can cause breathing problems.”8
Talcum powder presents dermatologic dangers to infants. If
it is applied to broken skin, talcum powder can cause crusting,
infection, and skin granulomas. For this reason, products containing
talcum 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 dermatitis
treated only with powders developed granulomatous tissue on the
buttocks, perhaps as a result of the use of dusting powders.10
The pharmacist should advise against use of talcum powder
as a skin protectant because of its dermatologic and respiratory
dangers, as 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, but the parent or caregiver should
further be cautioned to keep the products stored away from children,
much as poisons are stored. These precautions apply specifically to
talcum powder, but can be 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 large number of
well-known brands (e.g., Vaseline, Desitin, A+D, Johnson’s), but also
as a host of strangely named, obscure products.11 Some of the
former and many of the latter load their products with ingredients of
unknown safety and efficacy for diaper rash. They often include multiple
plant-derived ingredients, which could be allergenic or toxic if
absorbed. It is advisable to avoid these overloaded formulations in
favor of those containing a single safe and effective protectant (e.g.,
Boric acid is known to present dangers to babies, but it is included in such products as Boudreaux’s Butt Paste.2
Nonfat dry milk and goat’s milk are inexplicably included in such
products as The First Years Bottom Care Diaper Rash Relief System and
Canus Li’l Goat’s Milk Ointment. Tea tree oil is found in Bum Boosa
Bamboo 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 Relief
Diaper Rash Cream, Aveeno Baby Organic Harvest Diaper Rash Cream,
Balmex Diaper Rash Cream, and Puristics Baby Zinc Oxide Diaper Rash
Some parents may ask about the use of topical antifungals
for diaper rash. It is true that broken skin under the diaper is often
colonized with Candida, but a physician appointment is mandatory.2
Currently available nonprescription antifungals are only indicated for
fungal conditions such as tinea pedis, tinea cruris, and tinea corporis.
Their efficacy on Candida is unknown.
Choosing the Right Type of Diaper
Diaper rash can cause a great deal of discomfort for the
baby. Since the goal is to keep the skin 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, but disposables are far better than reusable cloth diapers
in preventing diaper rash. If cloth diapers are used, they should never
be covered by plastic pants, since the plastic keeps moisture trapped
inside 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 contain chemicals that irritate the skin
affected by the rash. Immediate cleaning of the area with mild soap is
the safest alternative.
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 (also known as cornstarch), white petrolatum, and
zinc oxide. However, some of these are better than others. Petrolatum
(e.g., Vaseline) is an excellent choice.
Powders containing kaolin, cornstarch, or talc can cause
problems 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 product
well away from the child’s face while you are putting it on your hands
or applying it to the baby’s bottom. If you allow the powder to get into
the air, the baby will inhale it while breathing, potentially producing
chemical pneumonia that can lead to permanent breathing problems or
The best way to apply powders is to go to a location away
from the baby. Place the container close to your body and away from your
face. Gently shake a small amount of powder onto a hand. When the
powder has settled, approach 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 not
use homemade preparations such as baking soda since their safety would
be questionable. Any product containing boric acid or borax is unsafe
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-approved
protectants. Some may be listed as inactive ingredients, but could still
cause allergic reactions or other problems. Antibiotic 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. You should not use any antifungal
or anticandidal products on diaper rash.
Remember, if you have questions, Consult Your Pharmacist.
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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