What is the treatment for pediatric intertrigo?

Treatment of Pediatric Intertrigo

The first-line treatment for pediatric intertrigo is keeping the affected area clean and dry, followed by application of topical antifungal agents such as nystatin, clotrimazole, or miconazole for cases with fungal involvement. 1, 2

Pathophysiology and Clinical Presentation

Intertrigo is inflammation of skin folds caused by skin-on-skin friction, creating a warm, moist environment that can lead to secondary infections. In children, it commonly presents as:

• Erythematous, macerated skin in opposing skin folds
• Possible satellite lesions (suggestive of candidal infection)
• Common locations: neck folds, axillae, diaper area, and intertriginous areas

Treatment Algorithm

Step 1: Basic Management (All Cases)

• Keep affected areas clean and thoroughly dry
• Minimize moisture and friction with absorbent, light clothing
• Apply barrier preparations to reduce skin-on-skin contact
• Use absorptive powders such as cornstarch (avoid talc-containing products) 3

Step 2: Identify and Treat Secondary Infections

For Candidal Infection (most common):

• Clinical signs: bright red, macerated skin with satellite pustules
• Confirmation: Optional KOH preparation showing pseudohyphae and budding yeast
• Treatment:
  • Topical antifungal agents:
    • Nystatin cream/ointment applied 2-4 times daily 1
    • Azoles (clotrimazole, miconazole) applied 2-3 times daily 2, 4
  • For resistant cases: Oral fluconazole may be required 2

For Bacterial Infection:

• Clinical signs: malodorous erosions, honey-colored crusting, or greenish-blue staining of clothing (Pseudomonas)
• Treatment based on suspected organism:
  • Streptococcal: Topical mupirocin or oral penicillin 2
  • Staphylococcal: Topical mupirocin or retapamulin 5
  • Pseudomonas: Oral ciprofloxacin (for older children) 6
  • Corynebacterium: Oral erythromycin 2

For Mixed Infections:

• Combination therapy may be required
• Consider combination antifungal/mild corticosteroid preparations for inflammation with fungal infection

Special Considerations for Children

1. Diaper Area Intertrigo:

   • Frequent diaper changes
   • Gentle cleansing with water (avoid harsh soaps)
   • Allow diaper-free time when possible
   • Apply barrier cream with zinc oxide after each diaper change

2. Neck Fold Intertrigo in Infants:

   • Gently clean folds with warm water
   • Thoroughly dry (consider soft cotton cloth)
   • Apply thin layer of antifungal if candidal infection present

Prevention Strategies

• Regular bathing followed by thorough drying of skin folds
• Dress in light, breathable, non-constricting clothing
• For obese children, consider moisture-wicking fabrics
• Address underlying conditions (obesity, excessive sweating)
• Maintain good hygiene practices, especially in hot, humid weather

Treatment Duration and Follow-up

• Continue treatment until 2-3 days after resolution of symptoms
• Typical duration: 7-14 days for topical therapy
• Follow-up within 1 week if not improving
• Consider culture for resistant cases

Common Pitfalls to Avoid

• Inadequate drying after bathing
• Overuse of topical corticosteroids (can worsen fungal infections)
• Failure to identify and treat secondary infections
• Not addressing underlying predisposing factors
• Using occlusive dressings or ointments that trap moisture

While there is limited high-quality evidence specifically addressing pediatric intertrigo 7, clinical practice guidelines support the approach of keeping the area dry and treating secondary infections appropriately. The treatment should focus first on minimizing moisture and friction, followed by targeted antimicrobial therapy based on the suspected secondary infection.