From the Research
For a morbidly obese sedentary patient with an erythematous gluteal cleft rash showing skin breakdown and cracking, I recommend a combination approach addressing both the moisture-associated skin damage and possible fungal infection. Begin with gentle cleansing using a pH-balanced cleanser and warm water after each bowel movement, followed by thorough but gentle drying. Apply a combination antifungal/steroid cream such as clotrimazole 1%/betamethasone 0.05% twice daily for 7-10 days to address both inflammation and potential fungal overgrowth, as clotrimazole has been shown to be effective against fungal infections and has anti-inflammatory properties 1. InterDry AG textile should be placed in the gluteal cleft after each cleansing and cream application, changing it once daily or when soiled. The antimicrobial silver in InterDry helps manage bacterial and fungal burden while wicking away moisture. For areas with skin breakdown, apply a thin layer of zinc oxide barrier cream to protect the skin. Encourage the patient to change positions frequently, avoid prolonged sitting, and wear loose cotton underwear. After 7-10 days, discontinue the steroid component to prevent skin thinning, but continue with an antifungal cream alone for another week if needed, as the use of high-potency corticosteroids like betamethasone can lead to skin atrophy 2, 3. This regimen addresses the multifactorial nature of intertrigo in the gluteal region, targeting moisture control, friction reduction, and treatment of secondary infection. Some studies have raised concerns about the use of combination antifungal/corticosteroid creams, citing their higher cost and lower effectiveness compared to single-agent antifungals 4, but in this case, the potential benefits of addressing both fungal and inflammatory components of the rash outweigh these concerns. It's also worth noting that naftifine has been shown to have anti-inflammatory properties comparable to clotrimazole/betamethasone dipropionate, but the most recent and highest quality evidence supports the use of clotrimazole 1.