What is the best treatment for intertrigo?

Treatment of Intertrigo

The best treatment for intertrigo involves minimizing moisture and friction with absorptive powders such as cornstarch or barrier creams, combined with appropriate topical antifungal agents for candidal infections, which are the most common secondary complications. 1

Pathophysiology and Clinical Presentation

• Intertrigo is inflammation of skin folds caused by skin-on-skin friction
• Commonly affects opposing cutaneous or mucocutaneous surfaces
• Appears in natural and obesity-created body folds
• Physical examination reveals regions of erythema with peripheral scaling
• Friction and moisture can lead to skin breakdown and secondary infections

First-Line Treatment Approach

Non-pharmacological Interventions

• Keep affected areas clean and dry
• Minimize moisture and friction with:
  • Absorptive powders (cornstarch)
  • Barrier creams
• Wear light, non-constricting, and absorbent clothing
• Avoid wool and synthetic fibers
• Shower after physical exercise and dry intertriginous areas thoroughly
• Wear open-toed shoes for toe web intertrigo 1

Pharmacological Treatment

1. For uncomplicated intertrigo without infection:

   • Barrier creams or absorptive powders alone

2. For candidal intertrigo (most common secondary infection):

   • Topical antifungals:
     • Nystatin powder or cream
     • Azoles: clotrimazole, ketoconazole, oxiconazole, or econazole 2
   • Apply twice daily for 2-4 weeks

3. For resistant candidal intertrigo:

   • Oral fluconazole 200-400 mg daily for 14 days 3, 4

4. For bacterial superinfections:

   • Streptococcal infections: topical mupirocin or oral penicillin
   • Corynebacterium infections: oral erythromycin 2

Treatment Algorithm Based on Clinical Presentation

Step 1: Identify and correct predisposing factors

• Weight loss for obesity
• Glycemic control for diabetes
• Address immunosuppressive conditions 5

Step 2: Basic skin care and prevention

• Keep skin folds dry and clean
• Use moisture-wicking textiles within skin folds 6
• Apply barrier creams or absorptive powders

Step 3: Treat based on clinical presentation and causative agent

For simple intertrigo without secondary infection:

• Continue non-pharmacological measures
• Apply zinc oxide or petrolatum-based barrier preparations

For candidal intertrigo (satellite pustules present):

• Apply topical antifungal (nystatin, clotrimazole, or ketoconazole)
• For severe or extensive cases: oral fluconazole 200 mg daily for 14 days 2

For bacterial superinfection:

• Culture to identify pathogen
• Apply appropriate topical or oral antibiotic based on culture results

Special Considerations

Recurrent Candidal Intertrigo

• Identify and manage predisposing factors (diabetes, obesity)
• Consider longer treatment courses
• Evaluate for intestinal colonization or periorificial infections 5
• For resistant cases: oral fluconazole 200-400 mg daily for 14-21 days 4

Prevention of Recurrence

• Continue preventive measures even after clinical resolution
• Regular use of barrier preparations in susceptible areas
• Address underlying conditions (weight loss, diabetes control)
• Wear appropriate clothing and maintain good hygiene practices

Monitoring and Follow-up

• Evaluate response to treatment after 7-10 days
• For resistant cases, consider potassium hydroxide preparation or culture to confirm diagnosis
• Continue treatment for 1-2 weeks after clinical resolution to prevent recurrence 4

Common Pitfalls to Avoid

• Failure to identify and address underlying predisposing factors
• Inadequate drying of affected areas
• Premature discontinuation of treatment
• Missing secondary infections
• Using topical corticosteroids alone without addressing infectious components

By following this structured approach to the management of intertrigo, clinicians can effectively treat this common condition and prevent recurrences that significantly impact patients' quality of life.