What is the treatment for intertrigo?

Treatment for Intertrigo

The first-line treatment for intertrigo is topical antifungal agents such as clotrimazole 1% cream or miconazole 2% cream applied 2-3 times daily for 14 days, along with measures to keep the affected area clean and dry. 1

Pathophysiology and Clinical Presentation

Intertrigo is an inflammatory dermatitis occurring on opposing skin surfaces due to moisture, friction, and poor ventilation. It commonly affects:

• Intertriginous areas (skin folds)
• Axillae
• Inframammary regions
• Abdominal folds
• Groin
• Intergluteal areas
• Toe webs

Physical examination typically reveals:

• Erythematous patches with peripheral scaling
• Maceration
• Possible satellite lesions (suggestive of Candida infection)
• Fissuring in severe cases

Treatment Algorithm

Step 1: Primary Management

• Topical antifungal therapy:
  • First-line: Clotrimazole 1% cream or miconazole 2% cream applied 2-3 times daily for 14 days 1
  • Alternative: Nystatin 100,000 units/g with zinc oxide 20% ointment applied 2-3 times daily for 14 days 1
  • For resistant cases: Ketoconazole 2% cream applied 2-3 times daily for 14 days 1

Step 2: For Extensive or Resistant Infections

• Add oral antifungal therapy:
  • Fluconazole 150 mg every 72 hours for 2-3 doses 1
  • For fluconazole-resistant species (e.g., C. glabrata): Itraconazole 200 mg daily 1

Step 3: For Secondary Bacterial Infections

• Bacterial superinfections:
  • Streptococcal: Topical mupirocin or oral penicillin 2
  • Corynebacterium: Oral erythromycin 2
  • Consider antiseptic washes with chlorhexidine (dilution 5 parts in 1000-10,000) 1

Essential Supportive Measures

1. Keep the area clean and dry:

   • Gentle cleansing with mild soap-free cleansers
   • Thorough drying after bathing 1, 3

2. Reduce moisture and friction:

   • Apply absorptive powders like cornstarch (avoid talc) 3
   • Use barrier creams like zinc oxide after treatment 1, 3
   • Consider petroleum jelly to protect fissures and surrounding skin 1

3. Clothing and lifestyle modifications:

   • Wear light, non-constricting, absorbent cotton clothing
   • Avoid synthetic fabrics and tight clothing
   • Consider moisture-wicking fabric between skin folds if necessary 1, 3
   • Open-toed shoes for toe web intertrigo 3
   • Shower after exercise and thoroughly dry intertriginous areas 3

Special Considerations

For Immunocompromised Patients

• HIV-infected patients may require longer courses of treatment 1
• Antiretroviral therapy should be initiated to reduce recurrence risk 1

For Recurrent Cases

• Address underlying conditions:
  • Manage obesity and encourage weight loss 4
  • Optimize control of diabetes mellitus 4
  • Treat intestinal colonization or periorificial infections 4

Monitoring and Follow-up

• Evaluate response within 7 days of starting treatment 1
• Seek further evaluation if:
  • Condition worsens despite appropriate therapy
  • Infection spreads beyond initial area
  • Systemic symptoms develop
  • Significant pain or bleeding occurs 1

Common Pitfalls to Avoid

1. Failure to identify and treat secondary infections: Candidal intertrigo can be complicated by bacterial superinfections, requiring specific antimicrobial therapy 2

2. Overuse of irritant antiseptics: These may aggravate intertrigo and provoke allergic contact dermatitis 5

3. Neglecting underlying predisposing factors: Obesity, diabetes, and immunosuppression must be addressed to prevent recurrence 4

4. Inadequate drying of affected areas: Thorough drying after bathing is essential for successful treatment 3, 5

5. Insufficient treatment duration: Continue treatment until 7 days after clinical resolution to prevent recurrence 1

By following this structured approach to managing intertrigo, focusing on appropriate antifungal therapy, keeping the affected area clean and dry, and addressing underlying factors, most cases can be effectively treated with significant improvement in symptoms and quality of life.