Health ConditionsDiaper rash is defined as an inflammatory skin condition in the diaper area — encompassing the perineum, buttocks, lower abdomen, and inner thighs — caused by one or more of the following factors: moisture, occlusion, chafing, continued contact with urine or feces or both, or mechanical or chemical irritation. Also known as nappy rash, it is an inflammation of the skin covered by the nappy (diaper). Diaper dermatitis broadly refers to skin disorders that occur in the diaper area, including skin eruptions triggered by diapers, rashes exacerbated by the diaper, and other events that occur in the diaper area.
Approximately 70% of infants and young children suffer from diaper dermatitis at some point during their diaper-wearing years, and up to 25% of children seek healthcare due to this condition. In the United States, the prevalence has been variably reported from 4–35% during the first 2 years of life, and because fewer than 10% of all diaper rashes are reported by the family, the actual incidence is probably underestimated. Diaper dermatitis may account for up to 25% of dermatology visits to health care providers during the first year of life.
These conditions can range in severity from minor (persistent redness) to major (destruction of the epidermis). A typical sign is a red, itchy, and sometimes ulcerated rash in the diaper area, which may include the presence of papules and pustules. It manifests as an erythematous rash occurring on the convex surfaces of skin under the nappy. The primary diaper sites include the perineum, peri-genital area, perianal area, genital region, buttocks, and groin.
Several subtypes are recognized. Candidal diaper rash may present as confluent diaper area with tomato-red plaques, papules, pustules, and satellite papules. Friction rash is the most common form of diaper rash and affects almost all infants at some time; it is most common on areas where friction is most pronounced, such as the inner thighs or under the elastic of diapers that are too tight.
Diffuse skin diseases that may also present as diaper rash include seborrheic dermatitis, atopic dermatitis, psoriasis vulgaris, and infections such as candidiasis, scabies, bullous impetigo, and tinea cruris. Rarer causes include Langerhans cell histiocytosis, congenital syphilis, child abuse, and acrodermatitis enteropathica.
Diaper rash is primarily a disorder of the integumentary system — specifically the stratum corneum (the outermost layer of the epidermis). A key factor in the pathogenesis is the alteration in both the barrier function and the water-holding capacity of the stratum corneum. At full term, the skin of infants is an effective barrier to disease and is equal to adult skin with regard to permeability.
The gastrointestinal system is also directly implicated. Fecal lipase and protease activity is greatly increased by acceleration of gastrointestinal transit; this is the reason for the high incidence of irritant diaper dermatitis observed in babies who have had diarrhea in the previous 48 hours. The immune system is engaged in secondary infections: Candida albicans has been identified as another contributing factor to diaper dermatitis, and infection often occurs after 48–72 hours of active eruption. Bacteria may play a role in diaper dermatitis through reduction of fecal pH and the resultant activation of enzymes; fecal microorganisms probably also contribute to secondary infections when they occur.
The microbiome is an emerging focus. An acidic skin surface is essential for the maintenance of normal microflora, which provides innate antimicrobial protection against invasion by pathogenic bacteria and yeasts.
Common diaper dermatitis is a group of skin disorders that result from attack of the skin by physical, chemical, enzymatic, and microbial factors in the diaper environment. Such eruptions can be subdivided into primary diaper dermatitis — an acute inflammation of the skin in the diaper area with an ill-defined and multifactorial etiology — and secondary diaper dermatitis, which encompasses eruptions with defined etiologies. The most important factors in the development of primary diaper dermatitis are: (i) water/moisture, (ii) friction, (iii) urine, (iv) feces, and (v) microorganisms (sometimes).
The normal pH of the skin is between 4.5 and 5.5. When urea from the urine and stool mix, urease breaks down the urine, decreasing the hydrogen ion concentration (increasing pH). Elevated pH levels increase the hydration of the skin and make the skin more permeable. Superhydration urease enzyme found in the stratum corneum liberates ammonia from cutaneous bacteria. Urease has a mild irritant effect on nonintact skin. Lipases and proteases in feces mix with urine on nonintact skin and cause an alkaline surface pH, adding to the irritation.
The main irritants are fecal proteases and lipases, whose activity is increased greatly by elevated pH. Bile salts in the stools enhance the activity of fecal enzymes, adding to the effect. Previously, ammonia was believed to be the primary cause of diaper dermatitis. More recent studies have disproved this, showing that when ammonia or urine is placed on the skin for 24–48 hours, no apparent skin damage occurs.
Diaper rash can result from increased skin pH, zinc deficiency, prolonged exposure to moisture, and irritants like urine and feces. Among the uncommon causes of recalcitrant diaper dermatitis are nutritional deficiencies. Examples that may cause recalcitrant diaper dermatitis include fatty acid deficiencies, niacin deficiency, and zinc deficiency.
Zinc is an essential elemental nutrient required for normal growth and development. It plays an important role in protein, carbohydrate, and vitamin A metabolism; growth and development; cell proliferation; and healing and tissue repair. It is present in at least 100 metalloenzymes, such as carbonic anhydrase, alkaline phosphatase, RNA and DNA polymerase, and carboxypeptidases A and B.
Acrodermatitis enteropathica is a genetically driven form of zinc deficiency. Acrodermatitis enteropathica is a congenital zinc deficiency disorder caused by genetic mutations affecting the infant's intestinal zinc transporter proteins. Breastmilk is protective against this disorder, and symptoms typically develop after weaning from breastmilk feeding.
Acquired zinc deficiency in breastfed infants is also documented. Zinc deficiency in exclusively breastfed infants can occur. Clinical features include facial and groin rash, diarrhea, hair loss, disinterest in feeding, and failure to thrive. One known cause is below-normal milk zinc levels due to maternal genetic mutations affecting mammary zinc transport proteins. Zinc deficiency may also occur in infants born very preterm who are not supplemented with special human milk fortifiers. With both causes, direct administration of zinc drops to the infant quickly corrects the deficiency and alleviates symptoms.
Zinc deficiency should be suspected in the at-risk population, and in patients with recalcitrant diaper dermatitis particularly when associated with similar perioral lesions. Premature infants have a negative zinc balance and need adequate zinc intake.
Nutritional deficiencies are among the uncommon causes of recalcitrant diaper dermatitis, including fatty acid deficiencies and niacin deficiency. These rare presentations underscore that persistent or atypical rash patterns may signal underlying systemic nutritional insufficiencies.
Traditional use: Zinc oxide has a long history of use in dermatological preparations as a mild astringent and skin protectant. Zinc oxide is known to be effective when applied externally as a mild astringent for the skin, as a barrier material to prevent eczema, and as a barrier protective to slight excoriations; it has been used in pastes and creams in combination with many other topical actives.
Scientific evidence: Zinc oxide paste showed effectiveness in managing diaper dermatitis among neonates. The use of diaper cream or moisturizers, along with soap, was found to be effective in preventing nappy rash. A 2026 systematic review and meta-analysis published in Cureus drew on studies from a 20-year span (2004–2024): the effectiveness of barrier preparations in treating diaper dermatitis varies depending on the preparation and study design; clotrimazole shows potential, especially for suspected fungal infections; and additional research is necessary to identify factors influencing their efficacy.
The clinical benefit of combination barrier creams (zinc oxide), repair creams (dexpanthenol), enriched with anti-inflammatory properties (from taurine) and antimicrobial properties (from zinc gluconate) as effective treatments in diaper dermatitis has come to light in recent years. There have been 17 studies on the antimicrobial properties of zinc oxide, which has shown effective antibacterial properties against Streptococcus mutans.
A 2016 clinical trial also examined oral zinc: 89 normal newborn infants received 10 mg oral zinc supplements daily for 4 months and 90 others received a placebo; the zinc-supplemented group had a significant reduction in the incidence of diaper rash, and they gained slightly more in height and weight, although the growth differences were not significant. This early trial has not been widely replicated, so evidence for oral zinc supplementation in otherwise zinc-replete infants remains preliminary.
Traditional use: Calendula flowers have been used for centuries in European herbal medicine as a topical wound-healing and anti-inflammatory agent, prepared as ointments, infused oils, and poultices for irritated skin conditions.
Scientific evidence: In a randomized, double-blind trial, 66 infants with diaper dermatitis aged under 3 years were randomized to receive either Aloe vera cream (n=32) or Calendula ointment (n=34), treated three times a day for 10 days, with severity of dermatitis graded at baseline and at the end of trial using a 5-point scale. Although improvement in the severity of diaper dermatitis was observed in both treatment groups (P < 0.001), patients receiving Calendula ointment had significantly fewer rash sites compared to the Aloe group (P = 0.001). No adverse effect was reported from either of the medications.
A separate randomized controlled trial compared Calendula to bentonite clay: this double-blind RCT was undertaken on 100 patients of infantile diaper dermatitis, with 100 participants randomly assigned into two groups of 50, prescribed the coded medicine. Overall, 88% of lesions in the Bentonite group started improving in the first six hours, while this rate was 54% in the Calendula group (P<0.001). The risk ratio for improvement in the first six hours was 2.99-fold in the Bentonite group. Lesions in 86% of infants in the Bentonite group and 52% in the Calendula group were completely improved in the first three days after treatment (P<0.001). Results showed that in comparison with Calendula, Bentonite had a faster healing effect and was more effective on the improvement of infantile diaper dermatitis.
Limitations: The Calendula studies are small single-center trials with limited blinding, conducted primarily in Iran. Further large-scale, multicenter RCTs are needed to confirm efficacy and establish optimal formulations.
Traditional use: Aloe vera gel has been used across many traditional medicine systems — including Ayurvedic, African, and Central American healing traditions — applied topically to burns, wounds, and inflamed or irritated skin.
Scientific evidence: As described in the Calendula section above, the Panahi et al. (2012) randomized double-blind trial found that topical Aloe and in particular Calendula could serve as a safe and effective treatment for diaper dermatitis in infants. Both interventions produced statistically significant reductions in severity over 10 days, though Calendula outperformed Aloe in the number of rash sites cleared. Other natural remedies have been tried, including aloe vera, calendula, bee pollen, beeswax, and cod liver oil; further study is needed to prove their effectiveness for treating diaper rash. The overall evidence for aloe vera specifically in diaper rash is preliminary, resting primarily on this single small RCT and associated observational data.
Traditional use: Bentonite and other smectite clays have a long history of traditional use in various cultures for wound healing, skin inflammation, and gastrointestinal complaints.
Scientific evidence: Bentonite was effective on the improvement of diaper dermatitis and also had faster effects compared with Calendula. The double-blind RCT described above (Mahmoudi et al., published in Indian Journal of Medical Research, 2015) involving 100 infants is the principal clinical reference. The evidence is promising but limited to a single trial; independent replication is warranted.
Traditional use: Panthenol (provitamin B5) has been used in topical formulations for decades as a moisturizer and skin-repair agent.
Scientific evidence: Topical dexpanthenol has moisturizer-like properties attributed to its hygroscopic nature, acting as a humectant, though the full mechanism of action has not been well elucidated. Studies have evaluated dexpanthenol formulas in two different lipophilic vehicles on epidermal barrier function in vivo. When used for 7 days, these topicals improved stratum corneum hydration and reduced transepidermal water loss. A real-world observational study evaluating a 5% dexpanthenol-containing ointment for the treatment of irritant diaper dermatitis was published in Health Science Reports (2023), assessing the condition from the caregiver perspective, finding the product to be an established, well-tolerated option.
Scientific evidence (preliminary): Taurine in topical products has been shown to provide additional protection against oxidative stress associated with various inflammatory diseases. Topical taurine significantly stimulates the synthesis of all three classes of barrier lipids (ceramides, cholesterol, and fatty acids) in reconstructed epidermis. This evidence is derived from laboratory (in vitro) and limited clinical studies; independent large trials in diaper dermatitis specifically are lacking.
Traditional use: The topical application of human breast milk to skin conditions in infants — including rashes, conjunctivitis, and minor wounds — is a widespread traditional practice across many cultures globally.
Scientific evidence: In a randomized clinical trial that compared the efficacy of hydrocortisone 1% ointment with that of human breast milk in treating acute diaper dermatitis in infants ages 0 to 24 months, infants were treated with either hydrocortisone 1% ointment (n=70) or human breast milk (n=71) for 7 days. Improvement in the rash from baseline was seen in both treatment groups on days 3 and 7; there was no significant difference in total rash scores. Treatment with human breast milk was as effective as hydrocortisone 1% ointment alone.
A smaller Iranian clinical trial of 30 infants (ages 0–12 months) assessed breast milk applied to diaper dermatitis lesions: the findings revealed a significant difference between the case and control groups in the number and lesion score of rashes at the first and third day (P=0.013, P=0.005), with differences becoming more significant at the fifth day (P=0.004, P=0.001).
However, results are mixed on whether human breast milk applied to diaper rash is better than other treatments. Another study compared human breast milk with a cream made from zinc oxide and cod liver oil in newborns with diaper rash; treatment with the cream was more effective. The proposed mechanism includes antimicrobial components such as lactoferrin, lysozyme, and immunoglobulins, as well as anti-inflammatory cytokines and immune development compounds such as leukocytes and macrophages. Breast milk contains vitamins A, E, D, K, and B complex; vitamin E is a non-enzymatic antioxidant and protects skin from the damaging effects of oxidative stress.
Limitations: Breast milk trials in diaper rash are generally small, open-label or non-blinded, and conducted in single centers. Blinding is inherently difficult. Evidence strength is moderate for equivalence to low-potency hydrocortisone but inconsistent against barrier cream formulations.
Traditional use: Virgin coconut oil has been used in South Asian and Pacific Island traditional medicine as a moisturizer and antimicrobial skin preparation for infants.
Scientific evidence: Coconut oil has been proposed as an alternative that can be used to prevent or cure diaper rash through its skin health and antimicrobial properties. As indexed in the Cochrane Central Register of Controlled Trials (CENTRAL), a WHO-registered clinical trial titled "To study the role of coconut oil in prevention of diaper rash in newborn baby in NICU" (CTRI/2023/10/058372) was registered in 2023, indicating active clinical investigation. However, peer-reviewed published results of coconut oil-specific RCTs for diaper rash remain limited, and evidence is currently insufficient to draw firm conclusions.
Research has been conducted to develop formulations consisting of natural raw materials effective in diaper rash by taking advantage of the medicinal properties of zinc oxide, natural oils, and beeswax. Such formulation studies are physicochemical in nature and assess stability and safety margins; they do not constitute clinical efficacy trials. The evidence for beeswax and natural oils as standalone actives (rather than formulation excipients) in diaper rash remains preliminary and largely preclinical.
Breastfeeding has been proven to be a protective factor against diaper dermatitis. The mechanism involves multiple pathways: feces in breastfed infants have a lower pH, and breastfed infants are less susceptible to diaper dermatitis. Additionally, breastfeeding supports infant zinc status: breastmilk is an important potential source of bioavailable zinc, and breastfeeding protects against diarrhea, which causes excessive zinc losses.
Changes in diet as the infant grows are related to changes in intestinal microbiota and stool pH. The transition to solid foods alters the composition of stool — increasing enzymatic activity, changing pH, and introducing new microbial substrates — all of which collectively elevate risk. This is consistent with the observed peak incidence of diaper dermatitis at 9–12 months of age.
Fecal lipase and protease activity is greatly increased by acceleration of gastrointestinal transit; this is the reason for the high incidence of irritant diaper dermatitis observed in babies who have had diarrhea in the previous 48 hours. Diarrhea may result from infections, food intolerances, or antibiotic disruption of gut flora, each representing a dietary or pharmacological pathway to diaper rash exacerbation.
Antibiotics can contribute to a rash by killing bacteria that keep yeast growth in check. Antibiotic use also increases the risk of diarrhea. Breastfed babies whose mothers take antibiotics are also at increased risk of diaper rash. This pathway illustrates the indirect dietary/pharmacological disruption of the intestinal and skin microbiome as a contributing factor to diaper rash.
Frequency of diaper changes is a key lifestyle factor; prolonged contact with irritants such as urine and feces increases the risk of skin inflammation. A diaper that keeps skin drier results in skin that is less permeable to irritants, supports less microbial growth, is less susceptible to chafing damage, and has less contact with irritants in urine and feces. A diaper that maintains the environment closer to the normal acidic pH of skin promotes skin that is less permeable to irritants and reduces the irritancy of fecal enzymes.
Superabsorbent disposable diapers are known to reduce the incidence of diaper dermatitis. Disposable diapers come with features advantageous for newborns, particularly in terms of skin protection, lowering the incidence of diaper dermatitis through effective absorbency, and lowering the skin area pH.
Wipes containing alcohol and fragrance should be avoided. Soap and water should be used only if the baby's stool does not come off easily. pH-balanced wipes and simple washing or rinsing can help restore pH balance.
Allantoin (0.5–2%) is recognized by the FDA as a Category I safe and effective OTC skin protectant for diaper rash per the Skin Protectant Drug Products monograph. It promotes keratinocyte proliferation and re-epithelialization, accelerating healing of irritated skin. Multiple DailyMed-listed diaper rash products contain allantoin as an active ingredient alongside zinc oxide.
Aloe vera has been evaluated in multiple randomized clinical trials for diaper dermatitis. A 2012 RCT (Panahi et al., ScientificWorldJournal, PMC3346674) in 66 infants showed significant reduction in severity (p<0.001). A 2024 meta-analysis (n=214) confirmed a meaningful reduction in diaper dermatitis scores after topical aloe application.
Calendula officinalis ointment has been tested in multiple RCTs for diaper dermatitis and outperformed aloe vera on the number of rash sites. A 2015 Indian Journal of Medical Research RCT found it effective compared to bentonite. It is also a recognized inactive ingredient in multiple OTC diaper rash products including the Weleda Calendula Diaper Rash Cream (DailyMed NPN 80005250).
Chamomile ointment has been directly tested in a double-blind RCT (n=90 infants under 1 year) against calendula ointment for diaper rash severity over 7 days with evaluations on days 1, 3, and 7. Both demonstrated reduction in rash severity scores. Chamomile's anti-inflammatory properties are attributed to bisabolol and chamazulene.
A published RCT conducted in a neonatal ICU specifically evaluated coconut oil versus standard of care for prevention of diaper dermatitis (ScienceDirect, 2023). Coconut oil's antimicrobial and emollient properties are mechanistically plausible for diaper rash prevention and treatment; direct human trial evidence exists at the neonatal level.
Cod liver oil (5–13.56%) is recognized as a safe and effective OTC emollient and skin protectant for diaper rash by the FDA. StatPearls (NCBI Bookshelf) lists it among standard diaper dermatitis emollients. An RCT (Gozen et al., 2014, NICU population) evaluated a 40% zinc oxide with cod liver oil barrier cream formulation for neonatal diaper dermatitis.
Honey was evaluated alongside olive oil and beeswax in a clinical study (Al-Waili, Clin Microbiol Infect, 2005; 11:160-163) that reported clinical and mycological benefits in diaper dermatitis, including reduced erythema and Candida colonization. A 2023 clinical trial (NCT06134505) also assessed bee products including honey components for diaper dermatitis.
Olive oil has been evaluated in several clinical studies for diaper dermatitis. A triple-blind RCT (Sharifi-Heris et al., 2018, Dermatologic Therapy, e12731) compared olive oil and calendula ointments directly for diaper dermatitis. An earlier study in 173 children (cited in PMC3346674) showed significantly lower frequency of diaper rash with olive oil versus control.
Two clinical trials have demonstrated that dexpanthenol-containing ointment (notably Bepanthen) can help prevent and treat irritant diaper dermatitis (IDD) in infants. A 2023 real-world observational study further confirmed the efficacy and tolerability of 5% dexpanthenol ointment for IDD. It is a widely recommended first-line topical agent for this indication.
A 6-week randomized double-blind study (published in Dermatology Times, 2026) evaluated a shea butter-based emollient in diapers for pediatric erythema in the diapered area, comparing it to a petrolatum-based diaper; both showed a similar proportion of erythema-free patients. Shea butter is also a widely used inactive ingredient in OTC diaper rash creams.
Vitamin A (as retinol palmitate or via cod liver oil) is FDA conditionally approved as a skin protectant/healing agent for diaper rash. Multiple OTC diaper rash products (DailyMed) contain vitamin A as an inactive or active ingredient. Vitamin A supports epithelial regeneration and skin barrier integrity.
Vitamin D (cholecalciferol/calciferol) is FDA conditionally approved as a healing agent in diaper rash preparations, delivered via cod liver oil or as pure cholecalciferol. Multiple OTC diaper rash products (DailyMed) list vitamin D as an inactive ingredient. It supports skin barrier function and immune modulation.
Vitamin E (tocopherol/tocopheryl acetate) is FDA conditionally approved as a healing agent in diaper rash formulations and appears in multiple DailyMed OTC diaper rash products. It protects skin lipids from oxidative damage and supports epithelial barrier repair. A NICU study evaluated acetyl tocopherol as more effective than standard skin ointments for exulcerative neonatal skin lesions.
Zinc oxide is the primary FDA-recognized OTC active ingredient for treating and preventing diaper rash. It functions as a physical barrier, repelling moisture away from skin while providing mild astringent and antiseptic effects. Concentrations of 10–40% are used clinically, with higher concentrations reserved for more severe cases.
Coconut oil has been widely used as a traditional remedy for diaper rash due to its lauric acid content, which confers antimicrobial and anti-inflammatory properties. However, the most rigorous clinical trial (prospective RCT, n=149 NICU infants; ScienceDirect 2023) found that coconut oil did not prevent diaper dermatitis compared to standard of care.
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