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Intertrigo

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Intertrigo

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