Rash - child under 2 years

Alternative names
Baby rash; Diaper rash; Miliaria/Milia; Prickly heat

Definition

A rash is any skin bumps or blotches. The rash can be red, skin-colored, or slightly lighter or darker than skin color. By far the most common skin problem in infants is diaper rash. Diaper rash is an irritation of the skin caused by dampness, urine, and feces. However, there are other skin disorders that can cause rash. These are usually not serious unless accompanied by other symptoms.

Considerations

Most bumps and blotches on a newborn baby are harmless and clear up by themselves. Diaper rash is very common - most babies who wear diapers will experience it to some degree. Diaper rash can be caused by continuously wet diapers, infrequently changed diapers, and using plastic pants to cover the diaper.

Common Causes

     
  • Diaper rash (rash in the diaper area) is a skin irritation caused by prolonged dampness and the interaction of urine and feces with the skin.  
  • Yeast diaper rash is caused by a type of yeast called candida, which also causes thrush in the mouth. The rash looks different from a regular diaper rash. It is very red, and there are usually small red bumps on the outer edges of the rash. This rash requires treatment with medication.  
  • Heat rash (caused by the blockage of the pores that lead to the sweat glands) is most common in very young children but can occur at any age. When the weather is hot or humid, the infant sweats, but because of the blockage of the sweat glands, this sweat is held within the skin and forms little red bumps, or occasionally small blisters in young infants.  
  • Prickly heat causes rash or blotches during hot weather or in a hot environment (the same as heat rash).  
  • Milia/miliaria are tiny white, clear or red bumps on the skin (usually on the face and chest). Usually the white or clear ones are seen in newborns. The red ones are also called heat rash or prickly heat.  
  • Erythema toxicum can cause flat red splotches (usually with a white, pimple-like bump in the middle) that appear in up to half of all babies. These blotches rarely appear after 5 days of age, are usually gone in 7 to 14 days, and are nothing to worry about.  
  • Baby acne is caused by exposure to the mother’s adult hormones. Little white dots often seen on a newborn’s nose represent an abnormal amount of normal skin oil that is a result of these hormones. Acne usually occurs between 2 and 4 weeks of age, but may appear up to 4 months after birth and can last for 12 to 18 months.  
  • Cradle cap causes greasy, scaling, crusty patches on the scalp that appear in a baby’s first 3 months. It usually goes away by itself, but some cases may require treatment with medication.  
  • Hives are red welts that appear to move around on the body. For example, if you drew a circle to mark one of the welts, a few hours later that circle would not have a welt in it, but there would be welts on other parts of the body. They differ in size and shape and are usually very itchy. The most common cause of hives is a viral infection. There is no treatment for the virus, and the hives may last for a few weeks. You can use antihistamine medication for the itching. Sometimes bacterial infections cause hives. These will be treated with antibiotics. Sometimes hives are a sign of an allergy. This will be determined by your health care provider.  
  • Eczema is a condition of the skin in which areas are dry, red (or darker than normal skin color) and itchy. When it goes on for a long time the areas become thickened. It is often associated with asthma and allergies, although it can often occur without either of these. Eczema often runs in families.

Home Care

DIAPER RASHES
Keep the skin dry. Change wet diapers as quickly as possible. Allow the baby’s skin to air dry as long as is practical. Launder cloth diapers in mild soap and rinse well. Avoid using plastic pants. Avoid irritating wipes (especially those containing alcohol) when cleaning the infant.

Ointments or creams may help reduce friction and protect the baby’s skin from irritation. Powders such as cornstarch or talc should be used cautiously, as they can be inhaled by the infant and may cause lung injury.

If your baby has a yeast diaper rash, then you will need a prescription cream from to treat it.

BABY RASHES
Heat rash (same as prickly heat, red milia/miliaria) is best treated by providing a cooler and less humid environment for the child.

Powders are unlikely to help treat heat rash and should be stored out of reach of the infant to prevent accidental inhalation. Avoid ointments and creams because they tend to keep the skin warmer and block the pores.

Erythema toxicum is normal in newborn babies and will go away on its own in a few days. You do not need to do anything for it.

White or clear milia/miliaria will go away on their own. You do not need to do anything for it.

BABY ACNE
Normal washing is usually all that is necessary to treat baby acne. Use plain water or mild baby soap and only bathe your baby every 2-3 days. Avoid acne medicines used by adolescents and adults.

OTHER SKIN PROBLEMS
For skin problems caused by eczema, the keys to reducing rash are to avoid scratching, and keep the skin moisturized.

     
  • Keep the baby’s fingernails short and consider putting soft gloves on the child at night to minimize scratching.  
  • Drying soaps and anything that has caused irritation in the past (including foods) should be avoided.  
  • Apply a moisturizing cream, petroleum jelly, or even vegetable shortening immediately after baths to avoid drying.  
  • Hot or long baths, or bubble baths, may be more drying and should be avoided.  
  • Loose, cotton clothing will help absorb perspiration.  
  • Consult a doctor if these measures do not control the eczema, (your child may need prescription medicines) or if the skin begins to appear infected.

While the majority of children with eczema will outgrow it, many will have sensitive skin as adults.

For cradle cap, wash the hair/scalp with water or a mild baby shampoo. Use a brush to remove the flakes of dry skin. If this cannot be removed easily, you can apply an oil to the scalp to soften it. Cradle cap usually disappears by 18 months. If it does not disappear or becomes infected, or if it is resistant to treatments, consult your doctor.

For hives, talk with your doctor to try to find the cause. Some specific causes require prescription medication, although most are caused by a virus and do not need anything other than antihistamine medications to help stop the itching.

Call your health care provider if

     
  • There are any blisters or small red patches beyond the diaper area.  
  • The rash is worse in the skin creases.  
  • The rash extends beyond the diaper area.  
  • There is no improvement after 3 days of home treatment.  
  • There is a fever, or other unexplained symptoms associated with the rash.  
  • There is a rash, spots, blister, or discoloration in an infant 3 months or younger.  
  • Your child is scratching a lot  
  • Any of the areas look infected

What to expect at your health care provider’s office

The health care provider will perform a physical examination and ask questions such as the following:

     
  • Type of rash       o Does it look like pinpoint red spots?       o Does it look like small red areas?       o Does it look like bruises?       o Has it occurred more than once without known cause (recurrent)?       o Does it look like hives (red welts that come and go on different parts of the body and are very itchy)?       o Does it look like blisters? Are they filled with yellow or honey-colored fluid?       o Does it look like ulcerations (craters in the skin)?       o Does it look like dry, tough skin growth (keratosis)? Is it associated with overexposure to sunlight (actinic keratosis)?       o Is the rash scaling or crusting?       o Does it look like small, solid, red, elevated bumps (papule)?       o Does it look like both a macule (flat area) and papule (small bump)?       o Is it a slightly elevated flat lesion (plaque)?  
  • Location       o Is it in the diaper area only?       o Is it on the rectum?       o Is it on the scalp or face?       o Is it on the trunk?       o Is it on the lower extremities (legs or feet)?       o Is it over the muscles that straighten the leg (extensor surfaces)?       o Is it on the upper extremities (arms or hands)?       o Is it over the muscles used to straighten the arm (extensor surfaces)       o Is it on the genitals?  
  • Distribution       o Is the rash spreading to other areas?       o Does the amount of skin area affected increase over time (enlarging)?       o Is the number of skin lesions increasing over time?       o Do the spots come and go, or do they always stay in the same place?       o Is it at the site of a skin injury (cut, scrape, etc.)?       o Is it at a site of chronically damaged skin (e.g., burn)?       o Do lesions affect one side of the body (unilateral) or both sides (bilateral)?       o Did the rash begin on hands or feet (distal extremities)?       o Have the sores gradually increased in size over months to years?       o Are the lesions on exposed skin?           + On sun exposed areas only?           + Did the lesions begin at the site of an exposure?  
  • Quality or color       o Is the skin darkening (hyperpigmentation) or thickening?       o Is the skin red (erythematous) or is it flesh colored?  
  • Shapes and borders       o Do the lesions have sharp, distinct borders?       o Do the lesions have a bulls eye shape (irisated)?  
  • Time pattern       o Did the rash begin suddenly (within hours) or slowly and gradually?       o How long did the rash last?       o Are there short-lasting episodes of rashes (transient)?       o Does the same type of rash occur repeatedly (recurrent)? How often does the rash occur?       o Did symptoms begin at birth or in infancy? What age?       o Has the rash been long-standing (chronic)?       o Did symptoms begin after a fever occurred and was relieved?       o During which months does the rash usually occur?       o Did you have a vesicle (blister) that appeared after a number of weeks? How many?  
  • Aggravating factors       o Is it worse after taking a bath (or other exposure to water)?       o Is it worse when you are stressed?       o Does it occur after cold exposure?       o Is it worse after you use skin softening or smoothing agents (emollients)?       o Is it worse after an exposure to the sun?  
  • Does the rash get better after you use skin softening or smoothing agents?  
  • Changes over time       o Did you have red cheeks followed within 2 days by a red spotty rash?       o Was the rash of a brief duration and then went away (evanescent)?       o Did the lesion change from a vesicle to an ulcer?       o Did the lesion change from an hard bump (nodule) to a “beefy” red ulcer?  
  • Cther       o What other symptoms are also present?           + Is there fever?           + Is there itching?           + Is there pain?           + Is there drainage? What kind?       o What laundry detergent do you use? How long have you used it?       o What kind of soap do you use? How long have you used it?       o Do you put anything on the skin (creams, lotions, oils, perfumes, etc)?       o Is your child taking any medications? How long has he/she taken them?       o Has your child eaten any new foods recently?       o Has your child been in contact with grasses/weeds/trees recently?       o Has your child had a recent illness?       o Does your child have any allergies?       o Do allergies run in your family?       o Do any skin problems run in your family?       o Does asthma run in your family (many times asthma and eczema are associated)?

The baby’s skin will be thoroughly examined to determine the extent and type of the rash.

Diagnostic tests are seldom required but may include the following:

     
  • Allergy skin tests  
  • Blood studies (such as CBC, blood differential)  
  • Microscopic examination of a sample of the affected skin

Nystatin cream may be prescribed for diaper rash caused by yeast. If the rash is severe, a corticosteroid cream may be recommended. Oral antibiotics may be prescribed if a bacterial infection is diagnosed.

For eczema, the doctor may prescribe ointments cortisone drugs to decrease inflammation. Antihistamines may be recommended to decrease itching.

For hives, antihistamines may be recommended to decrease itching.

Johns Hopkins patient information

Last revised: December 3, 2012
by Martin A. Harms, M.D.

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