What is the recommended management for intertrigo in an overweight, elderly diabetic patient, including hygiene, barrier protection, and treatment of possible fungal or bacterial superinfection?

Management of Intertrigo in an Overweight, Elderly Diabetic Patient

In an overweight, elderly diabetic patient with intertrigo, keep the affected skin folds dry and apply topical azole antifungals (clotrimazole, miconazole, or ketoconazole) twice daily for 7-14 days, continuing for at least one week after clinical resolution, while simultaneously optimizing glycemic control and implementing barrier protection strategies. 1, 2

Initial Assessment and Diagnosis

• Examine skin folds for erythema with peripheral scaling and satellite lesions, which indicate candidal superinfection—the most common secondary infection in intertrigo, particularly in diabetic patients where 84% of long-term care residents are colonized with yeast 3, 1
• Obtain potassium hydroxide (KOH) preparation if the diagnosis is uncertain or if the patient fails to respond to empirical antifungal therapy, as this confirms Candida species or dermatophyte presence 3, 4
• Perform bacterial culture or Wood lamp examination if you suspect bacterial superinfection (presence of purulent discharge, worsening erythema, or systemic signs) 4

Hygiene and Moisture Control (Most Critical Intervention)

Keeping affected areas dry is more important than any topical agent and represents the cornerstone of successful treatment 1, 2

• Instruct the patient to wash skin folds daily with mild soap and water, then thoroughly pat dry—never rub—with particular attention to complete drying 5, 6
• Apply absorptive powders such as cornstarch to skin folds after drying to minimize moisture accumulation 5
• Avoid hot showers and excessive soap use, which promote skin dehydration and worsen inflammation 2
• Have the patient shower immediately after physical activity and ensure thorough drying of intertriginous areas 5

Barrier Protection Strategies

• Apply barrier creams (zinc oxide-based preparations) to protect skin from friction and moisture after ensuring the area is completely dry 5
• Consider moisture-wicking textiles placed within skin folds to reduce skin-on-skin friction and wick away moisture 6
• Instruct the patient to wear light, nonconstricting, absorbent clothing and avoid wool and synthetic fibers that trap moisture 5
• Do NOT use greasy creams for routine skin-fold care, as they create an occlusive environment promoting folliculitis 2
• Do NOT apply alcohol-containing lotions or gels to inflamed intertriginous skin; instead use oil-in-water creams or ointments 2

Antifungal Treatment for Candidal Superinfection

Topical azole antifungals are first-line therapy for candidal intertrigo in this population 2, 4

• Apply clotrimazole, miconazole, ketoconazole, oxiconazole, or econazole twice daily to affected areas for a minimum of 7-14 days 2, 4
• Continue treatment for at least one week after all visible signs have cleared to prevent recurrence 2
• Nystatin is an equally effective alternative polyene antifungal with complete cure rates of 73-100% 2
• Consider oral fluconazole 100-200 mg daily for 7-14 days if topical therapy fails or disease is extensive 2, 4

Management of Bacterial Superinfection

• Treat secondary streptococcal infections with topical mupirocin or oral penicillin if bacterial culture confirms group A beta-hemolytic streptococcus 4
• Treat Corynebacterium minutissimum (erythrasma) with oral erythromycin if Wood lamp examination shows coral-red fluorescence 4
• Obtain Gram stain and culture if purulent discharge is present or the patient shows signs of systemic inflammation 3

Critical Pitfall: Topical Corticosteroids

Do NOT apply topical corticosteroids to intertriginous areas without dermatologic supervision, as prolonged use carries significant risk of skin atrophy in these vulnerable locations 2

Diabetes-Specific Management

Optimize glycemic control to prevent recurrence, as hyperglycemia promotes fungal overgrowth and impairs wound healing 2, 7

• Target glycosylated hemoglobin <7% with coordination from the patient's primary care physician or endocrinologist 3
• Screen for and treat intestinal Candida colonization or periorificial infections in recurrent or resistant cases, as these serve as reservoirs for reinfection 7
• Assess for peripheral neuropathy and peripheral arterial disease, which increase infection risk and complicate management 3

Weight Management and Prevention

Encourage weight loss, as obesity is the most significant modifiable risk factor for intertrigo development and recurrence 7, 8

• High BMI, diabetes mellitus, and care dependence are highly associated with intertrigo across all care settings 8
• Educate the patient about precautions regarding heat, humidity, and outdoor activities that increase perspiration 5
• Physical exercise is desirable but must be followed by immediate showering and thorough drying of skin folds 5

Follow-Up and Monitoring

• Re-evaluate within 7-14 days to assess treatment response 2
• If no improvement occurs, obtain KOH preparation and bacterial culture to identify resistant organisms or alternative diagnoses 3, 4
• For recurrent cases, investigate and correct predisposing factors including poorly controlled diabetes, immunosuppression, or persistent moisture sources 7, 6
• Consider systemic antifungal therapy with higher potency agents if predisposing immunosuppressive conditions exist or generalized infection develops 7