What is the best treatment for a rash in intertriginous folds?

Treatment of Intertriginous Rash

For uncomplicated candidal intertrigo, apply topical azoles (clotrimazole, miconazole, or nystatin) to the affected skin folds and keep the area dry; if bacterial superinfection is present, add topical mupirocin for streptococcal infections or oral erythromycin for Corynebacterium. 1, 2

Initial Assessment and Diagnosis

The key to effective treatment is identifying whether the rash is simple intertrigo or has secondary infection 2, 3:

• Look for satellite lesions surrounding the main area of erythema, which indicate candidal infection 2
• Check for yellow crusts or discharge, suggesting bacterial superinfection 2
• Examine for peripheral scaling at the edges of erythematous regions 2
• Consider Wood lamp examination if bacterial infection (particularly Corynebacterium) is suspected 2
• Obtain potassium hydroxide preparation if candidal diagnosis needs confirmation 2

Treatment Algorithm

Step 1: Address Moisture and Friction (All Cases)

• Keep the affected area dry as the most critical intervention 1, 3
• Apply absorptive powders such as cornstarch to minimize moisture 3
• Use barrier creams to reduce skin-on-skin friction 3
• Wear light, nonconstricting, absorbent clothing and avoid wool or synthetic fibers 3
• Consider moisture-wicking textiles within skin folds to reduce friction and secondary infection 4

Step 2: Treat Fungal Infection (If Present)

For candidal intertrigo 1, 2:

• Topical azoles: clotrimazole, miconazole, ketoconazole, oxiconazole, or econazole applied to affected areas 1, 2
• Topical nystatin is equally effective as an alternative 1, 2
• Apply twice daily until resolution 1

For resistant candidal cases 1:

• Oral fluconazole 100 mg daily for 7-14 days if topical therapy fails 1
• Topical boric acid or flucytosine for non-albicans Candida species 1

For rapid symptom relief with severe pruritus 5:

• Combination therapy with 1% isoconazole nitrate and 0.1% diflucortolone valerate applied twice daily can provide improvement within 2 days 5

Step 3: Treat Bacterial Superinfection (If Present)

For streptococcal infections 2:

• Topical mupirocin applied three times daily to affected areas 6, 2
• Oral penicillin as alternative systemic therapy 2

For Corynebacterium minutissimum infections 2:

• Oral erythromycin is the treatment of choice 2

For suspected infection with unclear pathogen 2:

• Obtain bacterial culture before initiating therapy 2
• Apply topical antiseptics while awaiting culture results 3

Step 4: Drainage for Complicated Cases

For paronychia or abscess formation 1:

• Drainage is the most important intervention to prevent progression to sepsis 1

Special Populations

For obese and diabetic patients 1:

• These patients are particularly susceptible to intertrigo in skin folds 1
• More aggressive moisture control measures are essential 3
• Regular monitoring for secondary infections is warranted 3

Prevention and Patient Education

• Shower after physical exercise and dry intertriginous areas thoroughly 3
• Avoid heat and humidity exposure when possible 3
• Wear open-toed shoes for toe web intertrigo 3
• Adopt structured skin care routine focusing on skin fold management 4

Common Pitfalls

• Do not use alcohol-containing preparations in skin folds, as they can worsen dryness and irritation 1
• Reassess within 3-5 days if no clinical response is observed 6
• Do not assume all intertriginous rashes are fungal—bacterial superinfection is common and requires different treatment 2, 3
• Avoid prolonged topical steroid use without antifungal coverage in candidal intertrigo, as this can worsen the infection 5