Candidal Intertrigo”: Could Inverse Psoriasis Be the True Culprit?

J Am Board Fam Med: first published as 10.3122/jabfm.2013.02.120210 on 7 March 2013. Downloaded from

BRIEF REPORT Resistant “Candidal Intertrigo”: Could Inverse Psoriasis Be the True Culprit?

Erin N. Wilmer, BS, and Robert L. Hatch, MD, MPH

Inverse psoriasis is a disorder of intertriginous areas of the skin that can easily masquerade as candidal intertrigo. Candidal rashes are commonly encountered in primary care and typically respond promptly to therapy. When treatment fails, nonadherence to treatment and medication resistance often are suspected; however, the possibility of an incorrect diagnosis should also be entertained. This article presents the case of a patient with inverse psoriasis who was misdiagnosed with recurrent candidal intertrigo multiple times. The diagnosis and treatment of inverse psoriasis is reviewed, and other conditions that may be confused with Candida and inverse psoriasis, including bacterial intertrigo, tinea, and seborrheic dermatitis, are discussed. When confronted with a case of “resistant Candida,” consideration of inverse psoriasis and other Candida mimics can allow physicians to diagnose and treat these conditions more effectively, avoiding the frustration experienced by our patient. (J Am Board Fam Med 2013; 26:211–214.)

Keywords: Candidiasis, Dermatology, Intertrigo, Psoriasis

A 68-year old woman with a history of poorly gluteal cleft. The skin lesions had been diagnosed copyright. controlled type 2 diabetes mellitus presented as a previously as candidiasis, but the patient was ada- new patient with exacerbation of chronic obstruc- mant that multiple trials with topical and oral an- tive pulmonary disease (COPD) and a rash. The tifungals did not help the rash. It is interesting that rash consisted of chronic, recurrent, erythematous she noted that the skin lesions always improved patches in the inframammary and inguinal folds when she was taking prednisone for the treatment (Figure 1). The patches were mildly macerated. of COPD exacerbations. Scanty satellite lesions were observed near the in- The patient was prescribed prednisone for her framammary but not the inguinal patches; scales COPD exacerbation and neomycin-polymyxin B- http://www.jabfm.org/ were absent in these locations. There was scaling hydrocortisone otic solution for presumed otitis and tenderness in both auditory canals, with mild externa. Antifungal cream was offered but the pa- scaling of each pinna. Over the past week, the tient was certain it would not help and insisted the patient had applied multiple topical medications to prednisone would resolve the rash. She was in- the rash, including clotrimazole, moisturizer, and structed to discontinue all topical products for the bacitracin/neomycin/polymyxin. She reported a

rash and to return for follow-up. She presented 1 on 25 September 2021 by guest. Protected 10-year history of similar rash affecting the axillae, week later with a dramatic improvement in her groin, inframammary folds, retroauricular area, and rash. However, within 2 weeks of terminating oral prednisone, the erythematous patches recurred in the inframammary folds and gluteal cleft. The dif- This article was externally peer reviewed. Submitted 16 August 2012; revised 8 October 2012; ac- ferential diagnosis included intertrigo, erythrasma, cepted 10 October 2012. seborrheic dermatitis, inverse psoriasis, and resis- From the Department of Community Health and Family Medicine (RLH, ENM), University of Florida College of tant Candida secondary to poorly controlled diabe- Medicine, Gainesville. tes. The affected areas were examined with a Funding: none. Conflict of interest: none declared. Wood’s lamp and demonstrated no signs of fluo- Corresponding author: Robert L. Hatch, Department of rescence that would suggest erythrasma. A fungal Community Health and Family Medicine, University of Florida College of Medicine, 1600 SW Archer Road, Box culture was obtained, and clotrimazole-betametha- 100222, Gainesville, FL 32610 (E-mail: hatch@ufl.edu). sone dipropionate topical cream was prescribed to doi: 10.3122/jabfm.2013.02.120210 Resistant “Candidal Intertrigo” 211 J Am Board Fam Med: first published as 10.3122/jabfm.2013.02.120210 on 7 March 2013. Downloaded from

Figure 1. Erythematous patch in the inframammary Plaque psoriasis is the most common form of fold. psoriasis. It is characterized by red, sharply demarcated papules or plaques with overlying, adherent, silvery-white scales that bleed when removed. Plaque psoriasis typically affects the scalp, sacrum, and extensor surfaces of elbows and knees in a symmetric pattern.1 In contrast, inverse psoriasis occurs in flexural areas such as the retroauricular area, axillae, inframammary creases, inguinal folds, and intergluteal cleft.6 As a consequence, inverse psoriasis may also be referred to as “flexural psoriasis” or “intertriginous psoriasis.” The lesions of inverse psoriasis are erythematous and sharply demarcated, as in plaque psoriasis, but scales are typically absent. The surface is smooth, moist, macerated, or all three and may contain fissures.7 Inverse psoriasis may be malodorous, pruritic, or both.1,7,8 cover both fungal and psoriatic etiologies. Four If present, psoriasiform lesions elsewhere on the weeks later, the fungal culture showed no growth body, a family history of psoriasis, and characteris- and the rash had improved. The lack of growth on tic nail abnormalities support a diagnosis of inverse the fungal culture and resolution of the rash with psoriasis.2,9 The most common nail disorders ob- oral and topical steroids suggested a diagnosis of served in psoriatic patients include oil spots, pit- inverse psoriasis. To avoid skin atrophy in inter- ting, subungual hypertrophy, and onycholysis.6 triginous areas from prolonged steroid use, the Inverse psoriasis is easily mistaken for infectious patient was prescribed topical tacrolimus for exac- dermatoses, particularly bacterial or fungal inter- copyright. erbations. trigo.10,11 Intertrigo is inflammation of opposed She had a good response to tacrolimus initially. skin folds caused by skin-on-skin friction that pres- When this response began to wane, she was re- ents as erythematous, macerated plaques. Second- ferred to dermatology, where a diagnosis of inverse ary bacterial and fungal infections are common psoriasis was confirmed. A daily regimen of topical because the moist, denuded skin provides an ideal tacrolimus was initiated, with desonide ointment environment for growth of microorganisms. Candida prescribed for flares. The rash was well controlled is the most common fungal organism associated with at follow-up 3 months later. intertrigo.9 Intertiginous candidiasis presents as well- http://www.jabfm.org/ demarcated, erythematous patches with satellite papules or pustules at the periphery.11 The presence of Discussion peripheral satellite papules or pustules can help Inverse psoriasis is considered an anatomic variant differentiate intertriginous candidiasis from inverse of psoriasis rather than a separate entity. It has not psoriasis. Potassium hydroxide examination of skin

been assigned a distinct code in the International scrapings should be performed if Candida is sus- on 25 September 2021 by guest. Protected Classification of Diseases, Ninth Revision, making the pected because pseudohyphae confirm the diagno- true incidence of inverse psoriasis difficult to de- sis of candidiasis.8,9 Two studies have demonstrated termine. However, the worldwide prevalence of an absence of Candida in inverse psoriasis le- psoriasis is approximately 1% to 3%,1 and recent sions.12,13 We did not identify any studies that studies suggest that 3% to 12% of psoriatic patients showed evidence of concomitant candidiasis and manifest inverse psoriasis.2–5 Although not partic- inverse psoriasis. ularly common, inverse psoriasis can mimic several Bacterial species that often complicate intertrigo conditions often encountered by primary care phy- include Staphylococcus aureus, group A ␤-hemolytic sicians. Thus it is an important diagnosis for the streptococcus, Pseudomonas aeruginosa, Proteus mira- family physician to consider when evaluating a pa- bilis, and Proteus vulgaris. Cutaneous erythrasma, tient who presents with an erythematous rash in an caused by Corynebacterium minutissimum, presents intertriginous area. as red-brown macules that can coalesce into

212 JABFM March–April 2013 Vol. 26 No. 2 http://www.jabfm.org J Am Board Fam Med: first published as 10.3122/jabfm.2013.02.120210 on 7 March 2013. Downloaded from patches with well-defined borders.9 This too may sent in psoriasis.18 Inverse psoriasis demonstrates mimic inverse psoriasis and Candida. Culture and the typical psoriasiform reaction, including par- sensitivity should be obtained if bacterial infection akeratosis, epidermal hyperplasia, and elongation is suspected. Examination with a Wood’s light can of rete ridges.19,20 help identify P. aeruginosa (green fluorescence) and If inverse psoriasis is diagnosed, short-term C. minutissimum (coral red-fluorescence).9 S. aureus treatment (2 to 4 weeks) should be initiated with has been shown to colonize psoriatic skin lesions, low- to mid-potency topical steroids, such as beta- and a small number of case reports describe group methasone valerate. The frequency of application A ␤-hemolytic streptococcus infection inducing can be tapered and ultimately discontinued if the guttate psoriasis.14 Therefore, a positive bacterial psoriasis improves. Frequent and long-term use of culture does not necessarily rule out underlying low-potency topical steroids in intertriginous areas inverse psoriasis. This is an important consider- can result in atrophy, striae, and telangiectasia. For ation in suspected bacterial intertrigo that is unre- continued therapy beyond 2 to 4 weeks, calcipot- sponsive to treatment. riene, pimecrolimus, or tacrolimus should be initi- Tinea corporis and tinea cruris, both dermato- ated, or the low-dose topical steroid can be used 1 phytic fungal infections, also have a clinical presen- or 2 times per week for maintenance therapy.21 tation similar to inverse psoriasis and Candida. More resistant cases, like the one described herein, Tinea corporis presents with a raised, annular bor- may require combination therapy. Other therapeu- der that may be active, with pustules or vesicles tic options include botulinum toxin22,23 and efali- present; central scales may be appreciated in early zumab,24 although evidence of their effectiveness is lesions, whereas peripheral scales with central limited to case reports. clearing is suggestive of more advanced lesions.1 Tinea cruris often manifests as well-demarcated, Conclusion erythematous plaques with central clearing and el-

Inverse psoriasis may mimic candidal intertrigo. copyright. evated, scaling borders that may be active, with Features that suggest inverse psoriasis include his- pustules or vesicles present.15 The raised border tory of a similar rash that did not respond to anti- and presence of pustules, vesicles, or scales can help fungal treatment, a family history of psoriasis, the differentiate tinea from inverse psoriasis. However, presence of classic psoriatic lesions elsewhere, and potassium hydroxide examination of skin scrapings psoriatic nail changes. The rash usually responds that demonstrates branching hyphae is the refer- well to topical steroids, topical immune modula- ence standard for diagnosis of tinea.9 Fungal cul- tors, or both. To avoid skin atrophy, topical ste- ture can conﬁrm the genus and species,1 although

roids should not be used too freely; the rash is http://www.jabfm.org/ culture techniques have a limited role in evaluation typically chronic and occurs in areas at higher risk because of the expense and time requirements.15 for skin atrophy. Seborrheic dermatitis is another cutaneous disease that can resemble inverse psoriasis or Can- dida.6,9,10 Typical locations for seborrheic dermati- References tis include the scalp, eyebrows, eyelids, nasolabial 1. Habif TP, ed. Skin Disease, Diagnosis and Treat- ment. 3rd ed. Philadelphia: Elsevier Saunders; 2011. creases, ears, chest, intertriginous areas, axilla, on 25 September 2021 by guest. Protected 16 2. Wang G, Li C, Gao T, Liu Y. Clinical analysis of 48 groin, buttocks, and inframammary folds. Sebor- cases of inverse psoriasis: a hospital-based study. Eur rheic dermatitis of body folds presents as a sharply J Dermatol 2005;15:176–8. marginated, brightly erythematous eruption, often 3. Seyhan M, Coskun BK, Saglam H, Ozcan H, Kar- with erosions and fissures.11 The presence of yel- incaoglu Y. Psoriasis in childhood and adolescence: low, greasy scales can help differentiate seborrheic evaluation of demographic and clinical features. Pe- dermatitis from inverse psoriasis, but these scales diatr Int 2006;48:525–30. may be absent in flexural areas. Seborrheic der- 4. Kundakci N, Tursen U, Babiker MO, Gurgey E. matitis of the flexural folds is uncommon in chil- The evaluation of the sociodemographic and clinical 17 features of Turkish psoriasis patients. Int J Dermatol dren and usually suggests immunodeficiency. 2002;41:220–4. Skin biopsy may help differentiate seborrheic 5. Dubertret L, Mrowietz U, Ranki A, et al; EUROPSO dermatitis from inverse psoriasis, with the former Patient Survey Group. European patient perspec- showing a “spongiform” appearance that is ab- tives on the impact of psoriasis: the EUROPSO doi: 10.3122/jabfm.2013.02.120210 Resistant “Candidal Intertrigo” 213 J Am Board Fam Med: first published as 10.3122/jabfm.2013.02.120210 on 7 March 2013. Downloaded from

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