Prescription for Zinc Oxide with Nystatin for Intertrigo
For intertrigo with suspected or confirmed candidal involvement, prescribe a combination of nystatin cream/ointment (100,000 units/g) applied to affected areas 2-3 times daily, combined with zinc oxide as a barrier protectant, continuing treatment for 7-14 days even after symptoms improve. 1, 2
Prescription Format
Medication: Nystatin 100,000 units/g cream or ointment with zinc oxide 20%
Directions:
- Apply thin layer to affected intertriginous areas 2-3 times daily 1, 3
- Continue for 7-14 days, even if symptoms improve earlier 2, 3
- Ensure area is clean and dry before application 1, 2
Quantity: Dispense sufficient amount based on body surface area affected (typically 30-60g tube)
Refills: 0-1 (reassess if no improvement after 7 days) 2
Clinical Rationale
Why This Combination Works
Nystatin addresses the fungal component: The Infectious Diseases Society of America confirms that topical polyenes including nystatin are effective for candidal skin infections occurring as intertrigo in skin folds 1
Zinc oxide provides barrier protection: Research demonstrates that zinc oxide does not decrease nystatin's antifungal efficacy and may actually protect against local maceration, which can worsen infection 4
Synergistic benefit: The combination addresses both the infectious component (Candida) and the mechanical irritation from skin-on-skin friction 5, 4
Essential Adjunctive Measures
These non-pharmacologic interventions are critical for treatment success:
- Keep the area dry - this is particularly emphasized as essential for successful treatment 1, 2, 3
- Frequent diaper changes (if diaper region) 3
- Absorptive powders like cornstarch between applications 5
- Light, non-constricting, absorbent clothing - avoid wool and synthetic fibers 5
- Thorough drying after bathing or physical activity 5
Treatment Duration and Monitoring
- Standard duration: 7-14 days of continuous treatment 1, 2, 3
- Critical pitfall: Do not discontinue prematurely after symptomatic improvement but before complete healing, as this leads to recurrence 2
- Reassessment trigger: If no improvement after 7 days, this indicates either treatment failure or misdiagnosis requiring reevaluation 2
Alternative Considerations
If nystatin with zinc oxide is unavailable or ineffective:
- Topical azoles (clotrimazole, miconazole 2%) are generally more effective than nystatin for candidal infections and can be combined with zinc oxide 1, 3
- Miconazole 2% cream is available over-the-counter 3
- Consider underlying predisposing conditions (diabetes, immunodeficiency) if infections are persistent or recurrent 2
Common Pitfalls to Avoid
- Failure to maintain dryness: Even appropriate antifungal therapy will fail if the area remains moist 1, 2
- Premature discontinuation: Stopping treatment when symptoms resolve but before complete healing 2
- Ignoring mechanical factors: Not addressing friction and moisture through clothing choices and hygiene measures 5
- Missing secondary bacterial infection: If not improving, consider adding antiseptics or antibiotics for bacterial superinfection 5