What are the treatment options for intertrigo?

Differentiating Fungal and Candidal Intertrigo and Treatment Options

Candidal intertrigo is a specific type of fungal intertrigo caused by Candida species, distinguished primarily by the presence of satellite pustules and lesions beyond the main affected area. 1

Diagnostic Differences Between Fungal and Candidal Intertrigo

Clinical Appearance

• Candidal intertrigo:

  • Erythematous patches with peripheral scaling in skin folds
  • Characteristic satellite pustules or papules extending beyond the main area of inflammation
  • Often bright red, macerated appearance with well-defined edges
  • May have pustular or exudative appearance 1

• Non-candidal fungal intertrigo (dermatophyte):

  • More defined border with active, scaly edge
  • Less exudative/moist appearance
  • Typically lacks satellite lesions
  • May show more peripheral spreading pattern 2

Diagnostic Confirmation

• Potassium hydroxide (KOH) preparation:

  • Candida: Shows pseudohyphae and budding yeast cells
  • Dermatophytes: Shows septate hyphae without yeast forms 1

• Culture:

  • Particularly useful in treatment-resistant or recurrent cases
  • Helps identify specific fungal species and guide targeted therapy 3

Treatment Algorithm for Intertrigo

Step 1: General Measures for All Types of Intertrigo

• Keep affected areas clean and dry
• Use absorptive powders (cornstarch) or barrier creams
• Wear light, non-constricting, absorbent clothing
• Avoid heat and humidity when possible
• Shower after exercise and thoroughly dry skin folds 4

Step 2: Specific Treatment Based on Type

For Candidal Intertrigo:

1. First-line therapy:

   • Topical antifungals: nystatin, clotrimazole, miconazole, ketoconazole, or econazole
   • Apply twice daily for 2-4 weeks 2

2. For resistant cases:

   • Oral fluconazole 150mg once weekly until clinical improvement (typically 2-4 weeks) 1, 3

3. For recurrent cases:

   • Consider maintenance therapy with weekly oral fluconazole 150mg for up to 6 months
   • Identify and treat possible sources of reinfection (intestinal colonization, periorificial infections) 3

For Non-candidal Fungal Intertrigo (Dermatophytes):

1. First-line therapy:

   • Topical azoles (clotrimazole, miconazole)
   • Terbinafine or tolnaftate
   • Apply twice daily for 2-4 weeks 5

2. For resistant cases:

   • Consider oral terbinafine or griseofulvin 5

Step 3: Managing Secondary Bacterial Infections

• For streptococcal superinfection:

  • Topical mupirocin or oral penicillin 1

• For Corynebacterium infection:

  • Oral erythromycin 1

Special Considerations for Recurrent Intertrigo

1. Address predisposing factors:

   • Weight loss for obese patients
   • Glycemic control for diabetic patients
   • Evaluation for immunosuppressive conditions 3, 6

2. Consider moisture-wicking textiles:

   • Place within skin folds to reduce skin-on-skin friction
   • Helps wick away moisture and reduce secondary infection 6

3. Maintenance therapy:

   • Regular use of antifungal powders in susceptible areas
   • Intermittent use of topical antifungals during high-risk periods (summer, increased activity) 3

Common Pitfalls and How to Avoid Them

1. Misdiagnosis:

   • Always confirm diagnosis with KOH preparation or culture in resistant cases
   • Don't assume all intertrigo is candidal without confirmation 1, 3

2. Inadequate treatment duration:

   • Continue treatment for 1-2 weeks after clinical resolution
   • Premature discontinuation leads to recurrence 2

3. Overlooking predisposing factors:

   • Failure to address underlying conditions (diabetes, obesity, immunosuppression)
   • Not managing excessive moisture and friction 3, 6

4. Missing secondary infections:

   • Be alert for changes in appearance suggesting bacterial superinfection
   • Culture when necessary to guide appropriate antimicrobial therapy 1

By following this structured approach to diagnosis and management, most cases of intertrigo can be effectively treated, with significant improvement in patient comfort and quality of life.