Pictorial case study: Nappy candidiasis

The case
A mother brought her six-month-old baby to the surgery, concerned about her nappy area. She had been slightly unwell with a viral respiratory infection and diarrhoea for a few days, during which time her nappy area had become redder and sore. She was eating normally but cried when her mother cleaned her.

She was now well in herself but the nappy area was bright red and inflamed, with an irregular but definite margin and several satellite papules. The folds of the nappy area were free of the rash. What is the diagnosis, management and differential diagnosis? 

Diagnosis and management
The diagnosis is nappy candidiasis. Nappy rash or irritant contact dermatitis occurs as a reaction to the presence of urine and faeces held next to the skin under occlusion. Bacteria in faeces break down urea in urine to ammonia, which causes inflammation of the skin. Candida infection occurs secondary to the irritant dermatitis.

Advise the mother to treat by changing the nappy frequently and if possible leave it off the baby for some time. Clean the skin with warm water only, and pat it dry – do not rub. Dry the skin thoroughly and apply a topical antifungal agent. 

Possible different diagnoses

  • Seborrhoeic eczema.
  • Napkin psoriasis.

Differential diagnosis
Seborrhoeic eczema

  • Starts in the first few weeks of life.
  • Moist, shiny and well-demarcated scaly erythema.
  • Treat with emollients and 1 per cent hydrocortisone ointment. 

Contributed by Dr Gwen Lewis, a GP in Windsor, Berkshire

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