What is the best treatment for a red and excoriated rash in the skin folds?

Treatment for Red and Excoriated Rash in Skin Folds

For a red and excoriated rash in skin folds, the best treatment approach is to keep the area clean and dry, apply a topical antifungal agent (such as clotrimazole or miconazole), and consider a low-potency topical corticosteroid like hydrocortisone 1-2.5% for inflammation. 1, 2

Initial Assessment and General Management

• The primary step is to establish that the skin reaction is not due to any concomitant medication and to verify the correct diagnosis 3
• Maintain good hygiene by washing the affected area with a gentle, pH-neutral cleanser rather than soap, which can irritate the skin 3
• Thoroughly dry the area with a soft, clean towel after washing to minimize moisture 1
• Different topical treatments should be selected based on the specific area affected:
  • Drying pastes are appropriate for moist skin folds 3
  • Gels are useful in seborrhoeic areas 3
  • Creams can be used in areas outside skin folds 3

Specific Treatment Recommendations

For Fungal Infections (Common in Skin Folds)

• Apply topical azole antifungals (clotrimazole, miconazole) or polyenes (nystatin) directly to the affected area 2-3 times daily 1
• Keeping the infected area dry is crucial for successful treatment of fungal intertrigo 1, 4
• Continue treatment for 1-2 weeks after symptoms resolve to prevent recurrence 1

For Inflammation and Irritation

• Apply a low-potency topical corticosteroid such as hydrocortisone 1-2.5% to reduce inflammation 2, 3
• For adults, apply hydrocortisone to the affected area no more than 3-4 times daily 2
• Limit the use of corticosteroids to short-term treatment (2-3 weeks) to avoid skin thinning and other adverse effects 3

For Bacterial Superinfection

• If infection is suspected (increased pain, pustules, yellow crusts, discharge), obtain a bacterial culture before starting antibiotics 3
• Topical antibiotics should be reserved for confirmed superinfection and not used prophylactically 3
• For suspected streptococcal intertrigo (beefy-red, well-demarcated lesions without satellite lesions), appropriate antibiotics are needed 5

Prevention Strategies

• Advise patients to wear light, non-constricting, and absorbent clothing 4
• Avoid wool and synthetic fibers that can increase friction and moisture 4
• Consider using absorptive powders such as cornstarch or barrier creams to minimize moisture and friction 4
• For toe web intertrigo, wearing open-toed shoes can be beneficial 4
• After physical exercise, patients should shower and thoroughly dry intertriginous areas 4

Special Considerations

• Obese patients, diabetic patients, and those who are care-dependent are at higher risk for intertrigo and may require more aggressive management 6
• Avoid greasy topical products as they inhibit the absorption of wound exudate and can promote superinfection 3
• Consider using moisture-wicking textiles within skin folds to reduce skin-on-skin friction and wick away moisture 7
• For severe or recurrent cases that don't respond to standard treatment, consultation with a dermatologist is recommended 8

Treatment Algorithm

1. Clean and dry the affected area thoroughly
2. Apply topical antifungal if fungal infection is suspected
3. Apply low-potency corticosteroid for inflammation
4. If bacterial infection is suspected, obtain culture and treat with appropriate antibiotics
5. Implement preventive measures to reduce moisture and friction
6. Reassess after 2 weeks; if no improvement, consider dermatology referral