How to treat bacterial intertrigo in an adult patient with no significant medical history?

Treatment of Bacterial Intertrigo

For bacterial intertrigo in an adult with no significant medical history, initiate treatment with incision and drainage if purulent material is present, followed by topical antiseptics and oral antibiotics targeting the most likely pathogens—Pseudomonas aeruginosa and Staphylococcus aureus—while simultaneously addressing moisture control and predisposing factors.

Immediate Assessment and Diagnosis

• Obtain bacterial culture from any purulent drainage to guide definitive antibiotic therapy, especially in cases with significant exudate or green-tinged discharge suggesting Pseudomonas infection 1
• Look for clinical features that distinguish bacterial from fungal intertrigo: marked maceration with abundant malodorous exudate, vesicopustules, erosions, and complaints of burning pain rather than just itching suggest bacterial etiology 1
• Pseudomonas aeruginosa is the most common bacterial pathogen in intertrigo, often occurring alone or with other gram-negative bacteria (E. coli, Proteus mirabilis) or gram-positive organisms 1

Antibiotic Selection Based on Clinical Presentation

For Purulent Intertrigo with Green Discharge (Pseudomonas Suspected)

• Start oral fluoroquinolone immediately: ciprofloxacin or levofloxacin to cover Pseudomonas aeruginosa 2
• If significant swelling or abscess formation is present, perform immediate incision and drainage before initiating antibiotics 2
• The choice of specific antibiotic should be guided by antibiogram results to avoid antimicrobial resistance 1

For Non-Purulent Bacterial Intertrigo

• Consider empiric coverage for both Staphylococcus aureus and Streptococcus species 3, 4
• Oral options include: clindamycin, TMP-SMX, or doxycycline for community-acquired MRSA coverage 5
• For confirmed streptococcal infections, oral penicillin is appropriate 3
• For Corynebacterium minutissimum (erythrasma), oral erythromycin is the treatment of choice 3

Topical Therapy

• Apply topical antiseptics as adjunctive therapy: 2% povidone-iodine twice daily to affected areas 2
• Alternatively, perform antiseptic soaks with dilute vinegar (50:50 dilution) or povidone-iodine for 10-15 minutes twice daily 2
• For secondary streptococcal superinfection, topical mupirocin can be used 3

Duration of Treatment

• Continue oral antibiotics for 7-14 days depending on clinical response 5
• Reassess within 48 hours after initiating treatment to ensure improvement 2
• If no improvement after 2 weeks of appropriate treatment, consider referral to dermatology or infectious disease 2

Essential Moisture Control Measures

Keeping the affected area dry is as critical as antimicrobial therapy 6, 3, 4:

• Use absorptive powders such as cornstarch or barrier creams to minimize moisture and friction 4
• Patients should wear light, nonconstricting, absorbent clothing and avoid wool and synthetic fibers 4
• Consider moisture-wicking textiles within skin folds to reduce skin-on-skin friction 7
• Shower after physical exercise and thoroughly dry intertriginous areas 4

Address Predisposing Factors

• Identify and correct underlying conditions: obesity, diabetes mellitus, immunosuppression 8, 7
• Encourage weight loss in obese patients 8
• Ensure proper glycemic control in diabetic patients 8
• Educate patients about precautions regarding heat, humidity, and outdoor activities 4

Common Pitfalls to Avoid

• Do not treat empirically as fungal intertrigo without confirming the diagnosis, as bacterial intertrigo requires different management and can lead to serious complications if untreated 1
• Avoid using topical antifungals alone when bacterial infection is suspected, as this will not address the underlying pathogen 3, 4
• Do not ignore Pseudomonas as a potential pathogen, especially in toe web spaces and in patients with risk factors, as it can lead to potentially lethal complications if inadequately treated 1
• Failure to address moisture control will result in treatment failure regardless of appropriate antibiotic selection 6, 3

Prevention of Recurrence

• Trim nails straight across, not too short 2
• Wear protective gloves during water exposure or chemical handling 2
• For toe web intertrigo, wearing open-toed shoes can be beneficial 4
• Maintain structured skin care routine with regular attention to skin fold hygiene 7