What is the recommended treatment for intertrigo?

Intertrigo Treatment

The recommended treatment for intertrigo is keeping the affected area clean and dry combined with topical antifungal agents (clotrimazole, miconazole, or nystatin) as first-line therapy for candidal intertrigo, with topical antibacterials (mupirocin or clindamycin) when bacterial infection is suspected. 1, 2

Primary Management: The Foundation

• Moisture control is the single most critical intervention for successful treatment and must be implemented before or alongside any pharmacological therapy 1
• Thoroughly dry intertriginous areas after bathing using separate clean towels for the groin versus other body parts 2
• Use moisture-wicking textiles within skin folds to reduce skin-on-skin friction, wick away moisture, and prevent secondary infection 2, 3
• Patients should wear light, nonconstricting, absorbent clothing and avoid wool and synthetic fibers 4
• For toe web intertrigo specifically, wearing open-toed shoes provides benefit 4

Pharmacological Treatment Algorithm

For Candidal Intertrigo (Most Common)

First-line topical antifungals: 1, 5

• Azoles: clotrimazole cream or miconazole cream
• Polyenes: nystatin cream or powder
• Apply to affected areas after ensuring they are clean and dry

For extensive or resistant candidal cases: 1

• Oral fluconazole 100-200 mg daily for 7-14 days, OR
• Oral itraconazole solution 200 mg daily

For Bacterial Intertrigo

When bacterial infection is suspected (look for purulent drainage, crusting, or honey-colored exudate): 1

• Topical mupirocin ointment, OR
• Topical clindamycin lotion

For suspected MRSA involvement: 1

• Oral doxycycline, OR
• Oral trimethoprim-sulfamethoxazole

For bullous or nonbullous impetigo: 1

• Topical mupirocin twice daily for 5 days, OR
• Topical retapamulin twice daily for 5 days

Special Clinical Scenarios

High-Risk Patients Requiring Aggressive Management

Patients with obesity, diabetes mellitus, or immunocompromised status need more intensive treatment as these conditions perpetuate intertrigo 1, 6

• Address underlying predisposing factors: encourage weight loss, optimize glycemic control, manage immunosuppression 6
• Investigate and treat intestinal colonization or periorificial candidal infections in recurrent cases 6

Recurrent Intertrigo

• Implement maintenance therapy with intermittent application of topical antifungals 1
• Investigate potential sources of reinfection (intestinal colonization, periorificial sites) 6
• Consider novel systemic agents with higher potency if predisposing immunosuppressive conditions exist 6

Intertrigo with Inverse Psoriasis

This requires a different approach due to the inflammatory component: 1

• Use low-potency topical corticosteroids, OR
• Calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus) as steroid-sparing agents
• Avoid high-potency corticosteroids in skin folds due to increased risk of atrophy and systemic absorption 1
• Tacrolimus 0.1% ointment achieves clear or almost clear skin in 65% of patients after 8 weeks 1
• Calcineurin inhibitors are particularly useful for prolonged use (≥4 weeks) in thin-skinned intertriginous areas 1

Common Pitfalls to Avoid

• Do not use absorptive powders like cornstarch in candidal intertrigo, as these can serve as a nutrient source for Candida; barrier creams are preferred 4
• Avoid high-potency topical corticosteroids in skin folds even when inflammation is present, as the occlusive environment increases systemic absorption and atrophy risk 1
• Do not treat empirically without considering the infectious etiology: candidal intertrigo requires antifungals, bacterial requires antibacterials, and mixed infections require combination therapy 1, 4
• Patients should shower after physical exercise and thoroughly dry intertriginous areas, as moisture accumulation from sweat perpetuates the condition 4

Treatment Escalation Pathway

1. Initial approach: Basic hygiene measures + topical antifungal (if candidal suspected) or antibacterial (if bacterial suspected) 1
2. If persistent after 2 weeks: Consider oral antifungal therapy (fluconazole or itraconazole) 1
3. If recurrent: Implement maintenance therapy and investigate reinfection sources 1, 6
4. If treatment-resistant: Perform laboratory confirmation (KOH prep, culture) to establish differential diagnosis and guide targeted therapy 6