What is the best treatment for intertrigo?

Management of Intertrigo

The best treatment for intertrigo is a combination of addressing predisposing factors and using topical antifungal agents, particularly azoles like miconazole for fungal intertrigo or antibiotics for bacterial intertrigo, along with measures to keep the affected area dry and reduce friction 1.

Diagnosis

Clinical Presentation

• Erythematous, macerated skin in opposing skin folds
• May present with peripheral scaling
• Often accompanied by pruritus, burning, or pain
• Secondary infections may present with:
  • Candidal infection: satellite pustules or papules beyond the main area
  • Bacterial infection: increased erythema, exudate, and malodor

Diagnostic Testing

• Potassium hydroxide (KOH) preparation to identify fungal elements
• Bacterial or fungal cultures for persistent cases
• Wood lamp examination may help identify certain bacterial infections

Treatment Algorithm

Step 1: Address Underlying Factors

• Reduce moisture and friction in affected areas
• Maintain proper hygiene with gentle cleansing and thorough drying
• Use absorptive powders (e.g., cornstarch) or barrier creams
• Wear light, non-constricting, absorbent clothing
• Avoid synthetic fibers and wool

Step 2: Treat Based on Etiology

For Candidal Intertrigo:

• First-line: Topical azoles (miconazole, clotrimazole, econazole)
  • Apply twice daily for 2-4 weeks 2, 3
• Alternative: Topical nystatin
  • Apply 2-3 times daily until resolution
• For resistant cases: Oral fluconazole 150-200 mg weekly for 2-4 weeks 2

For Bacterial Intertrigo:

• For Gram-positive infections: Topical mupirocin 2% ointment
  • Apply three times daily for 7-10 days 2
• For streptococcal infections: Oral penicillin or appropriate alternative
• For Corynebacterium infections: Oral erythromycin 2
• For suspected MRSA: Appropriate antibiotics based on local resistance patterns 1

For Mixed Infections:

• Combination therapy with antifungal and antibacterial agents
• Consider combination products containing both antifungal and mild corticosteroid for inflammation

Step 3: Maintenance and Prevention

• Regular skin fold hygiene and inspection
• Continue use of absorptive powders or barrier products
• Consider moisture-wicking textiles within skin folds 4
• Weight loss for obese patients
• Optimal glycemic control for diabetic patients 1, 3

Special Considerations

Recurrent Intertrigo

• Investigate and treat possible intestinal colonization or periorificial infections 3
• Ensure complete treatment course even after symptoms improve
• Consider maintenance therapy with weekly topical antifungals in recurrent cases

Resistant Cases

• Confirm diagnosis with appropriate laboratory tests
• Consider systemic therapy for widespread or resistant fungal infections
• Evaluate for underlying immunosuppressive conditions 3

Common Pitfalls to Avoid

1. Failure to address underlying predisposing factors
2. Inadequate treatment duration leading to recurrence
3. Missing secondary infections that require specific treatment
4. Not confirming fungal etiology before treatment
5. Overlooking systemic conditions that predispose to intertrigo (diabetes, immunosuppression)

Conclusion

Successful management of intertrigo requires both treatment of the current condition and prevention of recurrence through addressing predisposing factors. Topical antifungals and antibiotics are effective for most cases, with systemic therapy reserved for resistant or widespread infections.