What is the recommended treatment for intertrigo?

Treatment of Intertrigo

The recommended first-line treatment for intertrigo is to minimize moisture and friction with absorptive powders such as cornstarch and barrier creams, along with topical antifungals like clotrimazole 1% or miconazole 2% cream applied twice daily for 7-14 days when fungal infection is present. 1, 2

Diagnosis and Etiology

Intertrigo is an inflammatory condition of skin folds caused by skin-on-skin friction, often complicated by secondary infections:

• Appears in natural and obesity-created body folds
• Common locations: axillae, inframammary folds, abdominal folds, groin, intergluteal, and toe webs
• Often complicated by Candida species (most common fungal pathogen) or bacterial infections
• Diagnosis typically based on clinical appearance, but laboratory tests may confirm causative organisms in resistant cases 3

Treatment Algorithm

Step 1: Non-pharmacological Management (All Cases)

• Keep affected areas clean and dry
• Use mild soap-free cleansers and thoroughly dry after bathing
• Apply absorptive powders like cornstarch (avoid talc) 2
• Wear light, non-constricting, absorbent cotton clothing; avoid synthetic fabrics 1, 2
• Reduce heat and humidity exposure
• For toe web intertrigo, wear open-toed shoes 2

Step 2: Treat Based on Presence of Secondary Infection

For Simple Intertrigo Without Obvious Infection:

• Zinc oxide-based barrier creams
• Petroleum jelly to protect fissures and surrounding skin 1

For Candidal Intertrigo:

• Topical antifungals: clotrimazole 1% cream or miconazole 2% cream applied twice daily for 7-14 days 1
• For moderate to severe or recurrent cases: oral fluconazole 100-200 mg/day for 7-14 days 1, 3

For Bacterial Intertrigo:

• Topical antibiotics based on suspected organism
• For streptococcal intertrigo: oral penicillin or first-generation cephalosporins 4
• For staphylococcal infection: dicloxacillin or cephalexin; if MRSA is suspected, use doxycycline, clindamycin, or SMX-TMP 4

Special Considerations

For Recurrent Cases:

• Identify and address underlying conditions: obesity, diabetes, immunosuppression 3
• Consider maintenance therapy with intermittent use of topical antifungals
• For resistant fungal infections in immunocompromised patients, consider systemic antifungals 1

For Severe or Widespread Cases:

• Consider systemic therapy earlier
• For severe candidal infections: fluconazole 200-400 mg/day for 14-21 days 1
• For fluconazole-resistant species: consider alternative antifungals 1

Monitoring and Follow-up

• Evaluate response to treatment within 1-2 weeks
• If no improvement, consider:
  • Culture to identify specific pathogens
  • Alternative diagnoses (e.g., psoriasis, dermatophytosis, seborrheic dermatitis)
  • Referral to dermatology for resistant cases

Common Pitfalls and Caveats

• Failure to identify and address predisposing factors leads to recurrence 3
• Overuse of topical corticosteroids can worsen fungal infections
• Irritant antiseptics may aggravate intertrigo and provoke allergic contact dermatitis 5
• Misdiagnosis of other conditions that present in intertriginous areas (e.g., inverse psoriasis, Hailey-Hailey disease) 6
• Inadequate drying after cleansing perpetuates the condition

By addressing both the primary inflammatory condition and any secondary infections while implementing preventive measures, most cases of intertrigo can be effectively managed. Patient education regarding preventive measures is crucial for long-term management, especially in recurrent cases.