What treatment is recommended for a 20s male with persistent mild musty/cheesy odor in the left groin fold, suspected to be caused by a bacterial imbalance, after failed attempts with Hibiclens (chlorhexidine) and antifungal treatments?

Treatment Recommendation for Persistent Groin Odor with Suspected Bacterial Imbalance

For a young male with persistent musty/cheesy groin odor after fungal clearance and temporary chlorhexidine response, I recommend a trial of topical clindamycin 1% solution or gel applied twice daily for 2-4 weeks, targeting likely Corynebacterium overgrowth (erythrasma-like bacterial colonization). 1

Rationale for This Approach

Your clinical presentation strongly suggests erythrasma or Corynebacterium minutissimum colonization rather than active fungal infection or systemic bacterial vaginosis-type pathology. The key diagnostic clues are:

• Localized musty/cheesy odor in an intertriginous area (groin fold) without visible inflammation 1
• Temporary response to chlorhexidine (a membrane-active antibacterial agent), indicating bacterial rather than fungal etiology 2
• No response to repeat antifungal therapy after documented fungal clearance 1
• Odor returns within 24 hours, suggesting persistent bacterial colonization rather than acute infection 1

Specific Treatment Protocol

First-Line Topical Antibiotic Therapy

• Clindamycin 1% topical solution or gel applied to the affected groin fold twice daily for 14-21 days 3, 1
• This targets Corynebacterium and other Gram-positive bacteria that colonize intertriginous areas 1
• Topical clindamycin shows high efficacy for localized bacterial overgrowth without systemic antibiotic exposure 3

Alternative Topical Options (if clindamycin unavailable or ineffective)

• Erythromycin 2% topical solution twice daily for 14 days 1
• Benzoyl peroxide wash (2.5-5%) used during showering, as it has antibacterial properties and reduces odor-causing bacteria 3

Adjunctive Measures

• Continue chlorhexidine washes 2-3 times weekly (not daily) to maintain bacterial suppression without inducing resistance 2, 4
• Daily chlorhexidine use may select for resistant organisms, particularly in Gram-negative bacteria 4
• Maintain current hygiene practices (daily showering, powder for moisture control) 1

Why NOT Systemic Antibiotics or BV Treatment

The metronidazole/clindamycin combination marketed for "male BV" is NOT appropriate for your presentation for several critical reasons:

• Bacterial vaginosis is a vaginal microbiome disorder involving anaerobes (Gardnerella, Prevotella, Mobiluncus) that does not occur in male groin skin 3
• Your odor is from aerobic skin bacteria (Corynebacterium), not anaerobic genital tract organisms 1
• Systemic metronidazole targets anaerobes and would not address Corynebacterium colonization 3
• Unnecessary systemic antibiotic exposure increases resistance risk without clinical benefit 4

When to Consider Systemic Antibiotics

Systemic therapy would only be warranted if you develop:

• Visible erythema, scaling, or inflammation suggesting active erythrasma infection 1
• Spreading lesions or systemic symptoms (fever, malaise) 3
• Failure of 3-4 weeks of topical therapy 1

If systemic treatment becomes necessary:

• Oral erythromycin 250 mg four times daily for 14 days is the gold standard for erythrasma with cure rates approaching 100% 1
• Alternative: Doxycycline 100 mg twice daily for 7-14 days 5, 6

Discontinuing Gladskin (Staphylococcus-Targeted Therapy)

I recommend discontinuing the Gladskin product because:

• Your presentation does not suggest Staphylococcus aureus colonization (no folliculitis, boils, or purulent drainage) 3
• The product targets staph-specific endolysins, which won't address Corynebacterium 3
• Corynebacterium is the most common cause of intertriginous odor in non-inflamed skin folds 1

Diagnostic Confirmation (Optional but Helpful)

If topical clindamycin fails after 3-4 weeks, consider:

• Wood's lamp examination of the affected area (erythrasma shows coral-red fluorescence) 1
• Bacterial culture and sensitivity from skin swab to identify specific organisms and resistance patterns 3
• Dermatology re-evaluation to exclude other conditions (inverse psoriasis, seborrheic dermatitis) 1

Common Pitfalls to Avoid

• Don't use daily chlorhexidine long-term - this selects for resistant Gram-negative bacteria and may worsen dysbiosis 4
• Don't pursue systemic antibiotics without trying topical therapy first - localized bacterial colonization responds well to topical agents with less resistance risk 3, 1
• Don't assume this is fungal - the lack of scaling, redness, or response to antifungals rules out active tinea cruris 3
• Don't use the "male BV" treatment protocol - this is marketing for a non-existent condition in males and targets wrong organisms 3

Expected Timeline

• Odor reduction should begin within 7-10 days of starting topical clindamycin 1
• Complete resolution typically occurs by 14-21 days 1
• Maintenance with intermittent chlorhexidine washes (2-3 times weekly) may prevent recurrence 3, 2