Nappy rash and nappy thrush

You know that feeling of walking around in wet shorts and the rash you get from it? That can happen from nappies too, both disposable and reusable. When a rash is caused by a nappy or another continence product, it’s known as nappy rash (irritant diaper dermatitis). It is the most common skin irritation in babies and young children. 

Rest assured, nappy rash is not inevitable and there are several things you can do to prevent, minimise, and treat it:

• Change nappies frequently 
• Use the right amount of absorbency
• Add a stay-dry layer if the nappy doesn’t have one
• Use a zinc-based barrier cream
• Thoroughly wash cloth nappies 
• Use reusable cloth wipes

Change nappies frequently

Prolonged contact with wet fabric irritates the skin. Prompt and regular nappy changes are one of the most effective ways to minimise nappy rash.

Poo, especially loose poo, also irritates the skin. Change nappies as soon as possible after a poo. For wee-only nappies, aim to change them every 2 hours. 

Unplanned naps and long sleeps do happen. No need to wake your baby! Change them as soon as they wake. 

Use enough absorbency

A nappy that is sufficiently absorbent reduces the amount of moisture that sits against the skin.

If you have recently switched from disposable nappies you might find cloth nappies large and bulky. This bulk is the absorbent part of the nappy. Reusable nappies have the benefit of being more customisable than disposable nappies. This is helpful for making sure you have the absorbency in the right place. For example, add extra absorbency at the front for boys or tummy sleepers, and in the middle of the nappy for girls.

Nappies worn overnight tend to be even wetter, holding multiple wees instead of just one or two. It is even more important to make sure there is enough absorbency.

Tucking in frills around the legs in fitted nappies helps to prevent friction burns as it prevents wet fabrics rubbing against the skin.

If inserts are usually saturated at change time it means you need to add more absorbency.

Use a stay-dry layer 

Most modern cloth nappies include a stay-dry layer. These are often made from microfleece (sometimes called nursery fleece), athletic wicking jersey (AWJ) or suede cloth. These fabrics do not absorb moisture, they wick it away from baby’s skin and into the absorbent inserts underneath. This keeps baby’s skin dry. 

If the nappy does not have a stay-dry layer you can add one using a layer of microfleece. 

Avoid using disposable liners as these often hold moisture against the skin. 

Use a zinc-based barrier cream

If your baby has loose poo, or their skin is easily irritated, using barrier cream can help prevent friction burns anywhere wet fabrics rub skin. Some members apply a barrier cream at every change, some only use it overnight and others rarely use it.

Barrier creams are designed to form a barrier on the skin. Apply only a thin layer each time, a little goes a long way. Excessive amounts can rub off the skin and onto the fabric. When this happens, moisture can become trapped between the skin and the material of the nappy, exacerbating rashes.

All commercial barrier creams are safe to use with cloth nappies. However, you may need to increase the amount of detergent or wash on hot (60°C) if the cream is transferred from the skin onto the fabric.

Wash your nappies thoroughly 

Cloth nappies need to be thoroughly washed to remove wee and poo. If nappies are not washed properly they will develop ammonia. 

When skin comes into contact with a high concentration of ammonia it can cause a chemical burn. This burn looks similar to sunburn. 

If nappies begin to smell strongly like hair dye or a cat’s litterbox you have ammonia. Sanitise them using chlorine bleach or high heat before using them again. 

Stains, smells, and ammonia in night nappies are not normal! They are signs that nappies are not being cleaned thoroughly. Ask for troubleshooting help in our Facebook group if you experience these issues.

Use cloth wipes 

Disposable wipes can contain preservatives that irritate skin (methylisothiazolinone or other isothiazolinones). These preservatives are a common cause of skin irritation in babies. 

I notice disposable wipes flare my babies up real bad. I used cotton pads + warm water.

~ Marisa, Australia

Some medical sources suggest avoiding commercial disposable wipes altogether, due to how commonly they irritate babies’ skin.

Using cloth wipes with plain water avoids having to use disposable wipes at all, and many other benefits.

Other causes of skin irritation

Some people are sensitive to fragrances in laundry detergent and fabric softener. In this situation select a fragrance-free detergent.

Fragrance allergy is common and is believed to affect around 1% of adults. Rates in children and adolescents are around 1.8%. 

~ DermNet

A fragrance allergy will cause irritated skin in multiple places where clothing is in contact with the body. For example, irritation on the elbows or knees. If irritation is only in the nappy area, the issue is likely to be the nappies or how the nappies are being washed.

The active ingredient in laundry sanitisers, benzalkonium chloride (BAC), is another common skin irritant. Laundry sanitisers are not recommended as part of a cloth nappy wash routine. Long warm/ hot (40-60ºC) washes with quality detergent is enough to remove wee and poo from nappies.

When to see a doctor

See your doctor or health nurse if the nappy rash has not cleared within a week, or is severe or spotty. Fungal and bacterial skin infections are common causes of persistent nappy rashes. 

Treating fungal infections (nappy thrush)

Nappy thrush is a fungal infection of the nappy area. It usually occurs when a nappy rash does not heal quickly or thoroughly enough. Nappy thrush looks like a bright red and shiny rash with clear patches in the nappy area. Fungal infections require medical treatment with antifungal creams. 

Candida albicans is a fungus that lives on your body in small amounts, located in your mouth, skin and intestines. Candida is yeast that is responsible for infections like thrush and vaginal yeast infections if it is off-balance with healthy bacteria in your body. Infections are common and treated with antifungal medications.

~ Cleveland Clinic

If your child is diagnosed with a fungal nappy rash: 

• follow the medical treatment provided by your health professional. 
• Sanitise all cloth nappies and cloth wipes.
• Dispose of any open rash creams. 

If you want to continue cloth nappies and wipes during the treatment period, you must sanitise them after each use. Our chlorine bleach calculator steps through the initial sanitise procedure and how to continually sanitise during the treatment period. 

Nappies sit directly against delicate skin for prolonged periods. They are a warm, wet environment. Modern cloth nappy inserts usually have multi-layered inserts. All of these factors increase the risk profile of cloth nappies. 

Clothes that have been in contact with the affected skin also need to be cleaned. They have a lower risk profile than nappies as they are easier to wash (usually single layer) and spend less time in contact with the skin. Hot (60°C) washing is generally enough to clean these lower-risk items.

Oral and nipple thrush

Oral thrush infections can be passed back and forth between a breastfeeding mother and baby. 

High-risk items (nursing pads and bras) need to be sanitised after each use, but lower-risk items such as towels and clothing only need a hot (60°C) wash.

There is no need to sanitise nappies if a baby has oral thrush but not genital thrush. 

Are nappy rashes more common in children using reusable nappies?

Members sometimes contact us about the nappy rash article on Raising Children that states that nappy rash is more common in babies who use reusable nappies.

This information does not match research studies. Children using modern cloth nappies and disposable nappies get nappy rashes at the same rate.