What is intertrigo and how is it treated?

Intertrigo: Diagnosis and Treatment

Intertrigo is an inflammatory skin condition caused by skin-on-skin friction in body folds, resulting in maceration and irritation, often complicated by secondary infections that require targeted treatment based on the causative organism. 1

Definition and Pathophysiology

Intertrigo is characterized by:

• Inflammation occurring where two opposing skin surfaces touch and rub against each other 2
• Facilitated by moisture trapped in deep skin folds where air circulation is limited 2
• Can affect any body area where skin surfaces are in close contact 3
• Common locations include axillary, inframammary, umbilical, inguinal areas, and toe webs 4

Risk Factors

• Obesity (creates additional skin folds) 3
• Diabetes mellitus 2, 5
• Heat and humidity exposure 2
• Immunosuppressive conditions 5
• Poor hygiene 4

Clinical Presentation

• Erythematous, macerated skin in skin folds
• May present with:
  • Burning sensation
  • Itching
  • Pain
  • Unpleasant odor
• Secondary infections may show additional features:
  • Candidal: Satellite pustules, white coating 5
  • Bacterial: Increased erythema, exudate, malodor 6
  • Dermatophyte: Scaling, advancing border 7

Diagnosis

Diagnosis is primarily clinical based on characteristic appearance and location. In treatment-resistant cases, consider:

• Microscopic examination with potassium hydroxide (KOH) preparation to identify fungal elements 6
• Bacterial or fungal cultures for persistent cases 6
• Skin scrapings for dermatophyte identification 6

Treatment Approach

1. Primary Management (All Cases)

The cornerstone of intertrigo management is minimizing moisture and friction in affected areas. 4

• Keep skin folds dry and clean:

  • Gentle cleansing with mild, non-alkaline cleansers
  • Thorough drying after bathing/showering
  • Use of absorbent powders (e.g., cornstarch) in skin folds 4
  • Consider moisture-wicking textiles within skin folds 1

• Reduce friction:

  • Wear light, non-constricting, absorbent clothing
  • Avoid wool and synthetic fibers 4
  • Open-toed shoes for toe web intertrigo 4

2. Treatment of Secondary Infections

Candidal Intertrigo

When satellite pustules or white coating is present:

• Topical antifungal agents are the treatment of choice for candidal intertrigo 7
  • Miconazole cream or powder applied 1-2 times daily for 2-4 weeks 7
  • Clotrimazole cream as an alternative
  • For resistant cases, consider nystatin powder or cream 5

Bacterial Intertrigo

When increased erythema, exudate, or malodor suggests bacterial infection:

• Topical antibiotics effective against Gram-positive bacteria 6
• Bacitracin can be applied 1-3 times daily to affected areas 8
• For suspected MRSA, consider appropriate antibiotics based on local resistance patterns 6

Mixed Infections

• Combination antifungal-antibacterial-corticosteroid preparations may be useful for mixed infections
• Use for short durations (1-2 weeks) to avoid skin atrophy from steroid component

3. Management of Recurrent Cases

For recurrent intertrigo, especially candidal:

• Identify and address underlying conditions (diabetes, obesity) 5
• Consider treating intestinal colonization in recurrent candidal cases 5
• Implement preventive measures more rigorously 1
• For immunocompromised patients with recurrent infections, consider systemic antifungals 5

Prevention

• Weight loss for obese patients 5
• Optimal glycemic control for diabetic patients
• Regular skin fold hygiene and inspection
• Avoid tight clothing and excessive heat/humidity exposure
• Prompt treatment of early symptoms to prevent progression

Common Pitfalls

• Failure to identify and address underlying conditions (especially diabetes)
• Misdiagnosis of other intertriginous eruptions as simple intertrigo
• Inadequate duration of antifungal treatment leading to recurrence
• Overuse of topical corticosteroids causing skin atrophy and worsening of fungal infections
• Neglecting preventive measures after successful treatment

By addressing both the primary condition and any secondary infections while implementing preventive measures, most cases of intertrigo can be effectively managed and recurrences minimized.