II. Definition
- Inflammation and secondary infection at skinfolds
III. Pathophysiology
- Friction between skin at folds
- Moisture increased and air flow decreased
- Inflammation and maceration results in epidermal erosions and other skin breakdown
- Conditions allow for secondary superinfection
IV. Risk Factors
-
Obesity
- Linear worsening in severity with increasing BMI > 30 kg/m2
- Diabetes Mellitus
- Immunocompromised state (especially HIV Infection)
- Incontinence of urine or stool (with occlusive barriers such as diapers)
- Immobility
- Hyperhidrosis
- Poor hygiene
- Hot and humid environments
V. Organisms
- Fungus
- Candidal Intertrigo or Candidiasis (most common)
- Presents with erythema, Scaling, satellite lesions and foul odor
- Dermatophytes
- See Tinea Pedis and Tinea Cruris
- Candidal Intertrigo or Candidiasis (most common)
-
Bacteria
- Staphylococcus aureus
- Beta-hemolytic Streptococcus
- Pseudomonas aeruginosa
- Proteus mirabilis
- Proteus vulgaris
- Corynebacterium minutissimum (Erythrasma)
VI. Distribution
- Most common sites
- Groin
- Axillae
- Inframammary folds
- Interdigital toe web space
- Athletes, laborers with closed-toe or tight shoes
- Less common sites
- Antecubital or popliteal fossa
- Umbilicus
- Perineum
- Neck area in infacts
- Angular Cheilitis
VII. Symptoms
- Itching, burning, and redness in affected skin fold
- Foul odor may be present
VIII. Signs
- Starts with mild erythema
- Later, area may become eroded, macerated, fissured
IX. Labs
- Potassium Hydroxide (KOH) for fungal organisms
- Wood's Lamp Examination
- Pseudomonas fluoresces green
- Erythrasma (Corynebacterium) fluoresces coral-red
X. Differential Diagnosis
- Inflammatory conditions
- Contact Dermatitis (Irritant or allergic)
- Atopic Dermatitis
- Skin Infections
- Chronic skin disorders
- Skin manifestations of endocrine disorders
-
Skin Malignancy
- Bowen Disease (squamous cell cancer in situ)
- Paget Disease
XI. Management
-
General
- Eliminate skin friction
- Consider absorbent (e.g. gauze) or breathable barrier agents between overlapping skin
- Eliminate moisture in skin folds with drying agents
- Talcum powder
- Barrier ointment
- Petroleum Jelly (Petrolatum, Vaseline)
- Zinc Oxide
- Wear light, breathable, or absorbent clothing
- Eliminate skin friction
- Treat infection
- Space application 2-3 hours from topical drying or barrier agents
- Antifungals
- Consider initial empiric Antifungal therapy
- Perform additional testing (e.g. KOH Preparation) if fails to improve after initial therapy
- First-line: Topical Antifungals
- Imidazoles (e.g. Clotrimazole, Oxiconazole, Econazole) cover all fungus (including candida and dermatophytes)
- Nystatin covers only Cutaneous Candidiasis (but this is most common)
- Second-line: Broad-spectrum Topical Antifungals
- Third-line: Oral Antifungals
- Fluconazole (Diflucan) 100-200 mg daily for 7 days (adult dose)
- Itraconazole (Sporanox)
- Consider initial empiric Antifungal therapy
- Antibiotics for Streptococcus or Staphylococcus
- See Erythrasma
- See Tinea Pedis
- See Interdigital Intertrigo Secondary Infection
- Topical Mupirocin (Bactroban)
- Oral Antibiotics
- See Cellulitis
- Streptococcus or MSSA
- MRSA (consider if abscess present, poorly demarcated or refractory to MSSA Antibiotics)
- Add trimethoprim-sulfamethoxazole (e.g. Septra) to Dicloxacillin or Cephalexin OR
- Doxycycline OR
- Clindamycin (depending on MRSA sensitivity in community)
- Consider Antibiotic in combination with topical low dose Corticosteroids (e.g. 1% Hydrocortisone)
XII. Prevention
- Keep intertriginous areas clean and dry
- Change moist or soiled clothing multiple times daily
- Weight loss
- Avoid heat and humidity
- Wear open-toe shoes
- Apply skin Emollients and barrier agents frequently
XIII. References
- Habif (2004) Clinical Dermatology, p. 446-50
- Janniger (2005) Am Fam Physician 72(5):833-8 [PubMed]
- Kalra (2014) Am Fam Physician 89(7): 569-73 [PubMed]