What's That Rash?
Treating your baby's skin problems, from eczema to diaper rash.
Getting Under the Skin
Your baby's soft, beautiful skin is probably a pleasure to caress and squeeze. And then there's that heavenly scent. But beautiful baby skin can develop blotches and spots. Although most new parents know about diaper rash as a baby-specific phenomenon, they may be surprised by some of the other rashes that can crop up in childhood. Here are some of the common ones, most of which can be easily treated.
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At around 3 to 4 weeks of age, some babies get tiny, firm, pus-filled pimples with a slight redness around the base on their face, and these tiny blemishes can spread to the shoulders and back. (I jokingly tell parents that infant acne usually breaks out just before relatives from out of town arrive to see the new baby.) As far as I know, no one has studied whether infants who get acne as newborns have a higher incidence of adolescent acne, but the mechanism is probably similar. Hormones present at the end of your pregnancy stimulate oil glands in baby's skin, and the oil clogs pores. No treatment is necessary because the condition disappears on its own within a few weeks.
When to Worry:
Call the doctor if the pimples are not small and hard but large and squishy, and seem to have liquid pus in them, or if there is more than a little redness around the base. This may be a sign of a bacterial infection, which would need to be treated with antibiotics.
Eczema is a skin condition affecting 5 to 7 percent of children. And up to 75 percent of kids with eczema have a family history of eczema and allergies. The first signs of the rash usually develop by 3 months of age, and fortunately babies often outgrow eczema by age 3. However, many of these kids do go on to develop other allergies and/or asthma.
Eczema should be diagnosed by your pediatrician or a dermatologist. It looks different in infants than it does in older children. When infants develop the rash, it typically appears on their cheeks, trunk, or scalp; the areas look red, scaly, and sometimes crusty. In toddlers and older children, the rash is confined to the folds of the arms and legs and the diaper area; it looks red, but it isn't crusty or scaly. In severe cases, the skin can even thicken.
The condition is itchy and can cause significant discomfort. Older children may make the rash worse by scratching and infecting it with dirty fingernails. Young babies who can't scratch themselves may just be irritable.
For many years, cortisone creams have been the mainstay of eczema treatment. For mild eruptions and small areas, they are effective. However, for severe or widespread eczema or for long-term use, they are not wise. Using cortisone, especially the high-potency creams that your pediatrician may prescribe, for longer than seven days can cause changes in the skin, such as loss of pigment. For infants and young children with serious cases of eczema, there are now two prescription drugs available -- Elidel (pimecrolimus) and Protopic (tacrolimus) -- that are not cortisone-based and can be used safely for longer periods of time.
Because skin with eczema is sensitive to drying, moisturize your child's skin every day with a bland lubricant such as Vaseline, Aquaphor, or Eucerin; some doctors even suggest using vegetable shortening, such as Crisco. Moisturizer will also keep eczema from worsening. Apply the cream right after bathing your child, when it can be absorbed easily.
Even though water can dry the skin, it is not recommended that you forgo bathing. In fact, children who are bathed regularly are less likely to develop infections from scratching. Just don't let your child soak in water for a long time. Keep your child relatively cool, especially at night, and, if necessary, give her an over-the-counter antihistamine, such as Benadryl, to reduce the itchiness. For severe itching, your pediatrician can prescribe a stronger antihistamine. When to worry: If the eczema gets worse despite treatment, your child may have developed a bacterial infection. Sometimes antibiotics are necessary to clear it up. Eczema that isn't getting better could also be the result of an allergy, especially to foods such as milk or soy. You may need to consult an allergist to find out the specific cause.
When to Worry:
If the eczema gets worse despite treatment, your child may have developed a bacterial infection. Sometimes antibiotics are necessary to clear it up. Eczema that isn't getting better could also be the result of an allergy, especially to foods such as milk or soy. You may need to consult an allergist to find out the specific cause.
Weepy, yellowish scales that dry to a crust, called cradle cap, occur in about 40 percent of children in the first 3 months of life. The area can also get slightly red, but though it may look irritated, it does not itch. Most cases of cradle cap will clear up on their own by the time your baby is 8 to 12 months old, and often sooner, whether you treat it or not. But most parents want to do something because cradle cap looks so yucky.
To get rid of the thick scales, first soften them. Warm a bottle filled with olive, mineral, or baby oil in warm water. (Don't heat the oil in the microwave or you might make it hot enough to burn your baby.) Apply the oil to baby's scalp about 15 minutes before you wash her hair. Then use a mild dandruff shampoo and rub the scales gently with a soft brush, such as a baby hairbrush or toothbrush. The area usually looks better quickly, though some scales may remain.
In 10 percent of cases, cradle cap spreads to the face, behind the ears, and to the neck, armpits, and diaper area. If this happens, your doctor can suggest an over-the-counter cortisone cream to use twice a day for no more than a week (prolonged use of cortisone creams can alter skin texture and pigment).
When to Worry:
If the rash does not respond to simple measures or gets worse instead of better, your baby may have a secondary yeast infection. Consult your pediatrician for prompt prescription treatment.
A dry and bumpy or red and oozing rash with well-defined borders that's limited to a small area may be caused by baby's sensitivity to a specific irritant. The rash occurs only in areas that have been in contact with the offending material. For example, some children react to the adhesive on Band-Aids; babies with a sensitivity to soap may have an outbreak on their face and hands; and a reaction to laundry detergent can result in redness on the cheeks from where a baby has rubbed against bed sheets. In most cases, treatment involves simply avoiding the problematic substance and applying a mild cortisone cream until the rash subsides in a few days.
When to Worry:
Severe eruptions such as extensive poison ivy may require a short course of oral cortisone.
Flat or slightly raised red blotches with wavy borders that appear on any part of the body, and fade from one area while reappearing in others, are probably hives. About 15 percent of children get them. In babies and toddlers, the most common cause is an allergy to a food or medicine. But in older children and adults they can result from a host of factors, including cold, heat, viral infections, and even stress.
The cause of hives is sometimes elusive: You may suspect that a certain food is behind them, but the next time your child eats that same food, he has no reaction. If your child is taking a medication at the time the hives appear, your pediatrician may label your child as allergic to that drug. The trouble with this is that children sometimes react to the flavoring or coloring of the medication rather than to the drug itself. If you find that every antibiotic seems to cause hives, consult an allergist to determine the true sensitivity.
Hives usually itch. Cold compresses and an antihistamine such as Benadryl can help relieve itching and may speed the rash's disappearance.
When to Worry:
If hives are accompanied by swollen lips, difficulty breathing, and swollen eyes, call 911; your child is suffering from a severe allergic reaction. Hives accompanied by swollen lips and sore joints, or bruising or discoloration left after the hives fade, can be signs of an inflammation of small blood vessels that can affect the kidneys or other organs. See your pediatrician.
Super-absorbent diapers keep skin dry and have drastically decreased the incidence of diaper rash. However, they have not eliminated it. Urine and stool acting together create an acid environment that breaks down the skin, producing redness and sometimes open sores resembling a burn. When a baby has diarrhea, diaper rash is even more common because of the constant irritation.
Diaper rash occurs because your infant's skin is in contact with urine and stool; therefore, the drier and cleaner you can keep him, the less rashy he should be. To prevent diaper rash, change your baby frequently and wash the area gently with a mild soap such as Dove or Ivory after a bowel movement. Wipes are convenient, especially when you're away from home, but my personal preference is to use soap and water whenever possible. Barrier creams that coat the skin, such as A&D Ointment, Desitin, Triple Paste (my personal favorite), and Balmex can reduce the amount of contact skin has with urine and stool.
If your baby gets a rash, airing his bottom is the best treatment. Leave the diaper off for periods of time and let your baby play in the kitchen or bathroom, where the floor is easy to mop up, or out in the yard. Also use diaper creams liberally. Cortisone cream can help reduce the redness, but don't use it for more than a few days.
Diaper-rash sores can make it easier for yeast (which normally exists on the skin) to penetrate and create an infection. Yeast rashes are particularly common after a baby has taken antibiotics; the medicine changes the skin's normal bacteria balance, allowing yeast to overgrow. The subsequent rash looks dry and red with scaly edges, and each patch is surrounded by separate rashy spots. The good news is that the rash usually looks worse than it feels to your infant. If your pediatrician agrees that your child has a yeast rash, he'll recommend either an over-the-counter antifungal medicine, such as Nystatin or Lotrimin, or a prescription cream to clear it up.
When to Worry:
Severe rashes with open sores that do not heal easily sometimes need to be treated like a burn, using thick applications of prescription burn cream. If baby has large, soft, yellow-fluid-filled blisters, a staph infection may have developed. See your doctor; this needs prompt treatment with oral antibiotics.
Yellow, crusty, oozing sores caused by a skin infection with a staph or strep germ are most common around the buttocks (as described earlier) and face, but the infection, called impetigo, can occur anywhere the skin has been broken and bacteria can invade. It must be diagnosed by your pediatrician and is usually treated with antibiotics. You can soften the dried material with warm water and apply an antibiotic ointment as well to speed healing.
When to Worry:
If the outbreak does not begin clearing up quickly after your baby starts antibiotics, see your pediatrician again. A cluster of tiny blisters that scab in a couple of days may be a herpes infection (one on the mouth is called a cold sore) and not impetigo.
Loraine M. Stern, MD, is a clinical professor of pediatrics at the University of California at Los Angeles and a practicing pediatrician.
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