The term "diaper rash" is a misnomer. In fact "diaper rash" is just a term given to a common form of skin irritation or dermatitis that presents in the diaper area. Not all rashes and irritations that occur under the diaper are actually caused by the diaper or result from diaper use (i.e., skin sensitivity to the actual diaper, excessive wetness, infrequent diaper changes, or chafing).
When you have remedied all these common issues with diapers, yet the rash persists, is the cause really the diaper or diaper use? You changed diapers immediately after every poop and urination. You used diaper rash ointment. You changed diaper rash ointment. You went back to the first diaper rash ointment. Your mom suggested baking soda and sunlight. You switch diaper brands. You learned that some diapers contain bleach! You purchased more expensive, natural diapers. You cleaned extra well with baby wipes - maybe you weren't cleaning off all the poop and pee well enough. You missed an event because baby's bottom was just too inflamed to put into a diaper. You allowed baby to crawl around nude risking floor and carpet soiling just so you don't have to put on another diaper. Okay, maybe you didn't do that, but I did! I was desperate! I had researched and performed every possible remedy, but nothing worked.
Years ago, during a major diaper rash flare up I briefly stopped using baby wipes and diaper rash ointment (wipes just made the irritation worse because they were rough and the ointments stung) and I began washing my daughter's bottom in the sink with warm water and a mild soap after every poop. The rash cleared up. But, the minute I would resume use of wipes the rash would immediately reappear. So, I ditched the wipes completely and was relegated to a bottom-bath in the sink multiple times per day. That was not sustainable.
I took to Google in search of a solution and instead found thousands of parents experiencing the same thing - diaper rash that was not actually caused by the diaper. The culprit? Baby wipes, but why? Chemical preservatives such as methylisothiazolinone (MI) were being used in the wipes which were causing severe reactions in babies and kids. Many wipe brands have removed this specific preservative, but most wipe brands still contain harsh chemicals and known irritants such as formaldehyde and formaldehyde releasing agents, polyethylene (PEG), sodium lauryl sulfate (SLS), parabens, propylene glycol, and phenoxyethanol, just to name a few. "Fragrance", another ingredient commonly contained in baby wipes, is an animal unto itself. Under U.S. regulations, "fragrance" ingredients can simply be listed as "fragrance" without listing all of its component parts. But "fragrance" typically contains synthetic ingredients, preservatives or other harsh ingredients that you would want to know about.
Reactions to some of the ingredients can be minor and result in a rash, contact dermatitis and eczema. But other ingredients in many wipe brands are recognized carcinogens and endocrine disruptors. It is hard for parents to fathom that a baby product labeled as hypoallergenic and used for cleansing could cause problems. This is why so many parents overlook baby wipes as a cause of the problem. The grand majority of available research leads parents to believe that the diaper is the problem and that parents should treat the symptoms - i.e., change diapers more frequently, clean the bottom area better and use diaper rash ointment, until the rash clears up. But this can exacerbate the problem. Even the American Academy of Pediatrics says, "[a]void using diaper wipes which may irritate the skin further."
I confirmed this with my own pediatrician and nurses who said that when parents report persistent or severe diaper rash they instruct parents to ditch the wipes and use soft paper towels with mild soap and water instead. The harsh chemicals present in many wipe brands can cause or exacerbate the rash. Even if the wipe has benign or mostly natural ingredients, the nonwoven fabrics that make-up most wipes are made of rayon and plastic resin (polyester, polyethylene and polypropylene) which can be harsh and irritate the skin as well.
Most parents will look at you like you have four heads if you recommend ditching baby wipes. They are common, convenient, seemingly integral to parents' lives, and, most troubling, what other options are there? Actually, there is another option that thousand of parents are using. But, unless you have been looking, you may not be familiar with cloth or dry wipe solution. Basically, its a liquid in a spray bottle that you spray onto cloth or dry wipes or soft paper towels, while changing diapers. Prior to baby wipes, this method was commonly used by diapering parents. Cleansing with wipe solution is the main method of cleansing for parents who cloth diaper because its free of harsh chemicals, eco-friendly and cheaper than baby wipes, and these are the primary reasons parents choose to cloth diaper in the first place.
Wipe solution is gaining popularity with disposable diapering parents as well because parents are intent on avoiding the harsh chemicals and synthetic fibers in most brands of baby wipes. Wipe solution, such as Pristine, is sprayed onto a cloth wipe (basically a wash cloth), dry wipe (cotton or bamboo dry wipes that can be purchased on Amazon.com or in stores) or soft paper towels (yes, like the ones you have in your kitchen). Pristine is gentle enough to be sprayed directly onto baby's bottom for those epic poops. Pristine is especially helpful in situations where the poop has dried a little bit because the oils in Pristine help loosen the poop so wiping is easier and more gentle.
After ditching the baby wipes and adopting Pristine as my sole bottom cleansing method, my daughter never had another incident of diaper rash. My baby who is 11 months old has NEVER had diaper rash. My potty trained kids continue to use Pristine along with toilet paper to help clean better, but that's a topic for another time.
So, to answer the question presented, "when is diaper rash not caused by a diaper?", its when your baby wipes are filled with harsh chemicals and synthetic fibers that are universally known for causing rashes and skin irritation. Fortunately, Pristine presents a harsh-chemical free solution.