How to manage intertrigo (inflammation of skin folds) unresponsive to nystatin (antifungal medication)?

Management of Intertrigo Unresponsive to Nystatin

For intertrigo unresponsive to nystatin, switch to topical azole antifungals such as clotrimazole or miconazole, and in cases of Candida glabrata infection, use topical boric acid 600 mg daily for 14 days. 1

Assessment of Treatment Failure

When intertrigo fails to respond to initial nystatin treatment, consider:

1. Incorrect diagnosis or mixed infection:

   • Confirm diagnosis with potassium hydroxide (KOH) preparation 2
   • Consider bacterial culture to rule out secondary bacterial infection 2
   • Check for non-albicans Candida species, particularly C. glabrata which is often resistant to azoles 1

2. Contributing factors:

   • Evaluate for underlying conditions such as diabetes or obesity 3
   • Assess for poor skin fold ventilation and excessive moisture 4

Treatment Algorithm for Nystatin-Resistant Intertrigo

Step 1: Identify the Causative Agent

• Perform KOH preparation and/or fungal culture to identify specific pathogen
• Consider Wood lamp examination to identify bacterial superinfections 2

Step 2: Topical Antifungal Options (First-Line for Resistant Cases)

• For presumed Candida albicans:

  • Switch to topical azoles (clotrimazole, miconazole, ketoconazole) 1, 2
  • Apply twice daily for 14 days

• For confirmed C. glabrata or non-albicans species:

  • Topical boric acid 600 mg daily in a gelatin capsule for 14 days (strong recommendation) 1
  • Alternative: Topical 17% flucytosine cream alone or with 3% amphotericin B cream daily for 14 days 1

Step 3: For Severe or Widespread Cases

• Oral fluconazole 150 mg every 72 hours for 2-3 doses 1
• For resistant cases, consider oral itraconazole solution (>200 mg/day) 1

Step 4: Address Secondary Bacterial Infections

• For streptococcal superinfection: topical mupirocin or oral penicillin 2
• For Corynebacterium infection: oral erythromycin 2

Essential Adjunctive Measures

1. Keep the area dry:

   • Use absorbing powders (non-medicated) 5
   • Apply astringent compresses 5
   • Ensure proper ventilation of skin folds 4

2. Reduce friction:

   • Use barrier products between skin folds
   • Wear loose-fitting, breathable clothing

3. Manage underlying conditions:

   • Optimize glycemic control in diabetic patients
   • Weight loss counseling for obese patients 3

Important Caveats

• Avoid fluorinated steroids in skin fold areas as they can worsen the condition 5
• Complete the full course of treatment even if symptoms improve quickly 3
• Recurrent cases may require maintenance therapy or more aggressive management of predisposing factors 3
• Nystatin failure may indicate either resistance or misdiagnosis; don't simply increase the dose of the same medication 6

For Recurrent Cases

• Implement a regular preventive regimen with weekly azole treatment
• Consider long-term suppressive therapy in patients with unavoidable risk factors
• Thoroughly evaluate for and address intestinal colonization or periorificial infections 3

Remember that keeping the affected area dry is just as important as the antifungal therapy itself, as moisture is a key factor in intertrigo development and persistence 1, 4.