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Home , Dermatitis, Intergluteal cleft, Intertrigo, Itch, Perspiration

A Practical Approach to the Prevention and Management of , or Moisture-associated Damage, due to : Expert Consensus on Best Practice

Consensus panel

R. Gary Sibbald MD Professor, Medicine and Public University of Toronto Toronto, ON

Judith Kelley RN, BSN, CWON Henry Ford Hospital – Main Campus Detroit, MI

Karen Lou Kennedy-Evans RN, FNP, APRN-BC KL Kennedy LLC Tucson, AZ

Chantal Labrecque RN, BSN, MSN CliniConseil Inc. Montreal, QC

Nicola RN, MSc, PhD(c) Assistant Professor, Nursing Mount Royal University A supplement of Calgary, AB The development of this consensus document has been supported by Coloplast. Editorial support was provided by Joanna Gorski of Prescriptum Health Care Communications Inc. This supplement is published by Wound Care Canada and is available at www.woundcarecanada.ca. All rights reserved. Contents may not be reproduced without written permission of the Canadian Association of Wound Care. © 2013.

2 Wound Care Canada – Supplement Volume 11, Number 2 · Fall 2013 Contents

Introduction...... 4 Complications of Intertrigo...... 11 Moisture-associated skin damage Secondary ...... 11 and intertrigo...... 4 Organisms in intertrigo...... 11 Consensus Statements...... 5 Specific types of infection...... 11 Methodology: Literature Search...... 6 ...... 12 Epidemiology...... 6 ...... 12 Risk Factors for Intertrigo...... 6 Bacterial infections: ...... 12 Skin folds...... 6 Streptococcal intertrigo...... 13 Perspiration...... 7 ...... 13 ...... 7 Interdigital intertrigo...... 13 Inframammary intertrigo: Predisposing Deeper infection...... 13 factors...... 7 Assessment of Intertrigo...... 13 Pathophysiology of Intertrigo: Moisture History...... 13 Barrier of the Skin...... 8 ...... 14 Increased pH...... 8 Diagnosis...... 14 Aging...... 8 Management of Intertrigo...... 14 Obesity...... 8 Evidence...... 14 ...... 9 Management principles...... 15 Location-specific Intertrigo: Clinical Features...... 9 Prevention...... 15 Inframammary and pannus intertrigo...... 9 Treatment...... 16 and perianal intertrigo...... 9 Ineffective therapies...... 17 Toeweb and fingerweb intertrigo...... 9 ...... 17 Common Differential Diagnoses of Intertrigo...... 9 Intertrigo and moisture-wicking ...... 10 textile with silver...... 17 Seborrheic of the flexural areas.....10 Common- approaches...... 18 of the flexural areas...... 10 Conclusion...... 19 Incontinence-associated dermatitis...... 10 References...... 20 of the flexural areas...... 10

Volume 11, Number 2 · Fall 2013 Wound Care Canada – Supplement 3 A Practical Approach to the Prevention and Management of Intertrigo, or Moisture-associated Skin Damage, due to Perspiration: Expert Consensus on Best Practice

Consensus panel Introduction R. Gary Sibbald MD Moisture-associated skin damage and intertrigo Professor, Medicine and Public Health Moisture is an important risk factor contributing to the University of Toronto 1 Toronto, ON development of chronic wounds. Excessive moisture on Judith Kelley RN, BSN, CWON the skin for a prolonged period of time may result in a Henry Ford Hospital – Main Campus spectrum of reversible and preventable skin damage that Detroit, MI ranges from to maceration (increased stratum Karen Lou Kennedy-Evans RN, FNP, APRN-BC corneum moisture content) and erosion (loss of surface KL Kennedy LLC with an epidermal base). Erythema is the initial Tucson, AZ observable change in moisture-associated skin damage Chantal Labrecque RN, BSN, MSN (MASD). Prolonged exposure to moisture may result in CliniConseil Inc. Montreal, QC more pronounced or erosion, which may

Nicola Waters RN, MSc, PhD(c) include both epidermal and dermal loss (dermal or deeper Assistant Professor, Nursing Mount Royal University base in ulcers), creating a partial-thickness wound and a Calgary, AB risk of secondary infection. MASD is distinct from damage due to pressure, vascular insufficiency, neuropathy, or other factors, but the development of a wound may be associated with several risk factors.

4 Wound Care Canada – Supplement Volume 11, Number 2 · Fall 2013 Consensus Statements b. Counsel patients to wear open-toed shoes and 1. Moisture-associated skin 7. Diagnosis of intertrigo: loose-fitting, lightweight damage: Moisture is a risk The diagnosis of intertrigo clothing of natural fab- factor for the development is based on the history and rics or athletic clothing of chronic wounds that characteristic physical find- that wicks moisture away is distinct from other risk ings supplemented with from the skin . factors, including pressure, laboratory testing to rule c. Advise patients to wear arterial insufficiency, venous out secondary infection. proper supportive gar- stasis, and neuropathy. 8. Evidence for intertrigo ments, such as brassieres, 2. Definition of intertrigo: treatment: No well-de- to reduce skin-on-skin con- Intertrigo, or intertriginous signed clinical trials are tact. dermatitis, may be defined available to support ther- d. Consider using a mois- as inflammation resulting apies commonly used to ture-wicking textile from moisture trapped in treat or prevent intertrigo. with silver within large skin folds subjected to fric- 9. Principles of management skin folds to translocate tion. of intertrigo: Prevention excessive moisture. 3. Disease classification of and treatment of intertrigo 11. Treatment of intertrigo: intertrigo: A disease code should maximize the intrin- The following approaches sic moisture barrier function for intertrigo could improve may help treat intertrigo: of the skin by focusing on diagnosis of the condi- a. Follow recommended at least one of the following tion and support research preventive strategies to goals: efforts. keep skin folds dry and a. Minimize skin-on-skin 4. Epidemiology of inter- prevent or treat second- contact and friction. trigo: The true incidence ary infection. b. Remove irritants from the and prevalence of intertrigo b. Consider using a mois- skin, and protect the skin is currently unknown. ture-wicking textile with from additional exposure silver between affected 5. Risk factors for intertrigo: to irritants. skin folds. The major documented risk c. Wick moisture away from c. Continue treatment until factors for intertrigo include affected and at-risk skin. intertriginous dermatitis hyperhidrosis; obesity, d. Control or divert the has been controlled. especially with pendulous moisture source. breasts; deep skin folds; e. Prevent secondary infec- d. Treat secondary infection immobility and tion. with appropriate system- mellitus; all risk factors are 10. Prevention of intertrigo: ic and topical agents. aggravated by hot and The following strategies e. Revisit the diagnosis humid conditions. may help prevent intertrigo in cases that do not 6. Complications of inter- from developing or recur- respond to usual therapy. trigo: Secondary bacterial ring: f. Initiate a prevention pro- infection is a common com- a. Cleanse skin folds gently, gram that can include plication of intertrigo that dry gently but thorough- , a skin-fold must be treated effectively ly (pat, do not rub), and hygiene program, and to prevent deep and sur- educate patients about early detection and treat- rounding invasive infection. proper skin-fold hygiene. ment of recurrences.

Volume 11, Number 2 · Fall 2013 Wound Care Canada – Supplement 5 Consensus statement #1: There is no uniform nomencla- Epidemiology Moisture-associated ture or assigned code in the Intertrigo may be found in International Classification of patients in care, rehabili- skin damage Diseases-10 for intertriginous tation, extended-care facilities, Moisture is a risk factor for dermatitis.4 Intertrigo is usual- hospices and in home care.6 the development of chronic ly listed under “miscellaneous” European studies have found the wounds that is distinct from prevalence of intertrigo to be other risk factors, including or “other” dermatologic codes, 17% in a group of nursing home pressure, arterial insufficiency, especially once the condition patients and 20% in home care is secondarily infected.5 This venous stasis and neuropathy. patients.7 Overall, little evidence hampers both the diagnosis of quantifies the incidence and MASD can be defined as “inflam- the condition and systematic prevalence of intertrigo. mation and erosion of the skin research into intertrigo. caused by prolonged exposure to various sources of moisture, Consensus statement #4: Consensus statement #3: including or stool, perspir- Epidemiology of ation, wound exudate, mucus, Disease classification or saliva.”2 This type of skin intertrigo damage includes intertriginous of intertrigo The true incidence and preva- (skin-fold) dermatitis, incontin- A disease code for intertrigo lence of intertrigo is currently unknown. ence-associated dermatitis, could improve diagnosis of periwound moisture-associated the condition and support dermatitis, and peristomal mois- research efforts. Risk Factors for ture-associated dermatitis.2 Intertrigo This consensus document Methodology: No formal risk assessment tool focuses on intertriginous derma- Literature Search exists for intertriginous derma- titis, which is due to perspiration titis.4 A MEDLINE search was per- trapped in skin folds plus the Risk factors for intertrigo formed using the key word effect of friction. Intertriginous are numerous, with the most dermatitis has been defined as “an “intertrigo.” The only limits important including hyperhid- inflammatory dermatosis [derma- placed on the search were rosis, obesity and diabetes mel- titis] involving the body folds, English language and litus.8 Immunocompromise and notably those of the sub-mam- studies. The search returned increased skin surface bacterial mary [under the breasts] and 375 citations. Abstracts were burden may also be risk factors, genitocrural regions,”3 and as “an reviewed and 47 articles were as may poor hygiene, malnutri- inflammatory dermatosis [derma- obtained for complete review. tion, tight and closed shoes, titis] of opposing skin surfaces The articles included 15 case and large, prominent skin folds. 4 caused by moisture.” reports, 7 cases series, 1 survey, In fact, any patients with skin folds have a risk of intertriginous 11 studies, 10 review or overview dermatitis. A hot and humid cli- Consensus statement #2: articles, 2 consensus documents, mate promotes the development and 1 symposium summary. Definition of intertrigo of intertrigo, although this has Intertrigo, or intertriginous Additional references were iden- not been studied in detail. dermatitis, may be defined as tified from the reference lists of inflammation resulting from reviewed articles. Overall, little Skin folds moisture trapped in skin folds evidence is available on the Skin folds that may develop subjected to friction. topic of intertrigo. intertrigo include those in the

6 Wound Care Canada – Supplement Volume 11, Number 2 · Fall 2013 ; in the ; under the Perspiration tus was diagnosed in 87 patients, breasts, especially if they are Sweat is composed of con- and of these, 33 patients had pendulous; in the lateral taining , glucose, and elec- intertrigo. Boza et al. compared area; between the trolytes, including and the prevalence of skin condi- chloride.2 On most parts of the (gluteal cleft, intergluteal cleft); tions in 76 obese patients with body, perspiration is not linked in the groin; in the creases those seen in 73 normal-weight to MASD, as sweat usually evap- of the or ; and 13 orates readily. However, chronic controls. Among the skin prob- between the and . perspiration that accumulates in lems with a statistically signifi- Intertriginous dermatitis may a skin fold, especially in an obese cant relationship with obesity be seen in lean individuals and individual with deep skin folds, was intertrigo, which was found in the neck region of . may result in MASD. in 45% of the obese group. In a Patients with lymphedema may discussion of the dermatological develop skin folds in the affect- Obesity complications of obesity, Garcia- ed limb. Patients who are bedrid- Brown et al. performed a self-re- Hidalgo found a linear relation den or incontinent are prone to port survey to identify skin prob- intertrigo, especially in the groin lems in 100 patients with obesity between intertrigo and the 14 and perianal region, and they and to determine whether they degree of obesity. may have co-existing incontin- sought professional help.10 At ence-associated dermatitis.9 least one skin problem was Inframammary intertrigo: Obese patients also develop identified in 75% of patients, Predisposing factors multiple additional skin folds, especially itchiness and dry skin, McMahon et al. performed and 63% reported more than including lateral folds above the a point prevalence study of one problem. The most prevalent waist, folds across the back just inframammary (below the locations for problems were the below the scapulae (sometimes groin, limbs, beneath the breasts, breasts) skin problems found called angel wings), abdominal and the . The major among inpatients in a district folds, pannus, and folds in the perceived causes were perspir- health authority in England.15 legs and . “Angel wings” ation and friction. Although The survey included 131 wards develop both in overweight 25% of survey respondents had with 1,116 female patients. individuals, even with a body sought no help, 59% had seen Among these individuals, 5.8% mass index (BMI) less than 30 a physician and 16% had con- had active inframammary lesions kg/m2, and in the elderly who sulted other health-care profes- and 5.4% had a lesion that had have lost height. In patients with sionals. healed during their hospital stay, a BMI above 40 kg/m2, skin also Several authors have evaluated for a total of 11.2% of female folds over at the waist laterally skin conditions associated with patients. The prevalence was and then centrally as weight obesity. Mathur et al. described intertrigo as a skin problem highest in wards with elderly increases. Lateral flank folds are in adolescents with obesity.11 prone to trauma and to devel- patients and those with patients Al-Mutairi performed a study of oping chronic low-grade infec- with acute mental illness. 437 overweight or obese adults Patients with active or healed tion. Pannus (abdominal fold) is to identify the spectrum of skin lesions had a higher than aver- graded from 1 to 5, with a grade diseases in the obese popu- 1 pannus apron reaching the lation.12 Among the diseases age body weight, and patients hairline and mons pubis but not identified in this population, with active lesions had signifi- the genitals, and a grade 5 pan- intertrigo was present in 97 indi- cantly higher body weight than nus apron reaching to the knees. viduals, or 22%. Diabetes melli- those with healed lesions.

Volume 11, Number 2 · Fall 2013 Wound Care Canada – Supplement 7 Consensus statement #5: movement out of the body and with those of normal controls. preventing excessive environ- The authors found a significantly Risk factors for 2 mental water absorption. The increased skin pH in three areas intertrigo moisture barrier consists of in persons with diabetes; the The major documented risk hygroscopic (water-attracting) inguinal and axillary regions factors for intertrigo include molecules and lipids within the hyperhidrosis; obesity, espe- . The hygro- (p <.0001) and the inframam- cially with pendulous breasts; scopic molecules are humec- mary area (p <.01) of female par- deep skin folds; immobility tants (molecules that bind water ticipants. Increased skin surface and diabetes mellitus; all risk in the stratum corneum) that pH also predisposes the skin to factors are exacerbated by hot maintain 20% water content invasion by , yeasts and and humid conditions. within the stratum corneum and other microorganisms. As would comprise natural moisturizing be predicted with increased pH Pathophysiology of factor. The lipids act as emol- and diabetes, six persons in this Intertrigo: Moisture lients, enhancing the effect of natural moisturizing factor. study had intertriginous can- Barrier of the Skin The pH of healthy skin is didal infections. The pH of the Although much remains to be between 5.5 and 5.9.2 Skin alka- skin varies in different locations. elucidated about the patho- physiology of intertrigo, or inter- triginous dermatitis, exposure to moisture alone is insufficient “Although much remains to be elucidated to produce skin damage.2 Both about the pathophysiology of intertrigo, or moisture and friction in skin intertriginous dermatitis, exposure to moisture folds are required. These two alone is insufficient to produce skin damage. Both promoting factors may result in erosions and secondary infec- moisture and friction in skin folds are required.” tion, if potentially pathogenic microorganisms are present.8 Although erosion is a common linity, or increased skin pH, nega- Aging manifestation of intertrigo, the tively affects the skin’s moisture The efficiency of the moisture mechanisms leading to erosion barrier, along with other factors barrier slowly declines with age, are not fully elucidated,2 but a that disturb the barrier function, until the stratum corneum water combination of moisture and such as increasing age, obesity, content drops to less than 10% friction is most likely. and atopy. in the elderly.17 This to dry The clinical course of inter- skin, or winter , comprom- trigo2 usually starts with ery- Increased pH ising the normal barrier func- thema and inflammation, with Increased stratum corneum pH tion; in this situation, the skin the occurrence of erosions in prevents lipids from assuming has a very fine reticulate scale the presence of moisture due their normal structure,2 interfer- (crackled eczema, or eczema to macerated keratin and wet ing with the skin’s barrier func- craquele). . Some or all of these fea- tion. A study by Yosipovitch et al. tures may present concurrently of skin pH and moisture includ- Obesity or individually. ed 50 patients with type 2 dia- Moisture barrier function is The skin’s moisture barrier betes and 40 healthy controls.16 also impaired in obesity, with functions to maintain bodily The study compared the pH of increased sweating after over- by slowing water persons with heating among obese compared

8 Wound Care Canada – Supplement Volume 11, Number 2 · Fall 2013 with lean individuals.18 Obese limus, may actually improve systemic or immuno- individuals are less efficient than moisture barrier function. suppressive therapy. lean comparators in regulating In males, tinea infection is body by sweating. more common in the groin This inefficiency increases the Location-specific region. There is often an active duration of sweating and the Intertrigo: Clinical red border to the eruption, exposure of the skin to moisture. Features where the follicles may be Sweating is most pronounced involved in advance of the bor- in skin folds, where moisture is der. A fine surface scale is often Inframammary and pannus prevented from evaporating. associated with the proximal intertrigo Obese individuals also have margin of the eruption on the more alkaline skin pH than lean Intertrigo in the inframammary inner . Central clearing individuals. area is often due to large or towards the inguinal crease is A study by Nino et al. of 65 pendulous breasts; abdominal often associated with sparing of overweight children and 30 nor- crease intertrigo occurs with the . mal-weight controls included abdominal pannus formation. In a clinical evaluation and calcu- both situations a hot and moist Toeweb and fingerweb lation of transepidermal water environment predisposes to intertrigo loss.19 The study discovered a intertrigo. The most common Intertrigo of the toewebs often significantly higher transepi- symptom is itch, but symp- starts in the webspace between dermal water loss in obese toms can vary from nothing to the fourth and fifth and than in normal weight children, burning or stinging with severe spreads proximally. Erythema suggesting that obese children irritant contact dermatitis. The and scale are often replaced by sweat more because of over- presence of satellite or maceration of the webspace heating, due to the thick layers pustules with a bright red col- keratin as the eruption spreads of subcutaneous fat and the our or confluent inframammary proximally. The moisture-asso- lower skin surface area relative erythema is often indicative of a ciated damage is often compli- to body mass. secondary candidal infection. cated by tinea infection. Fingerweb intertrigo is most Atopy Groin and perianal intertrigo common in individuals with In atopy, the genetic predis- Intertrigo due to irritant con- substantial water exposure, position to develop allergic including cooks, bartenders and tact dermatitis from sweat and reactions may be related to health-care workers. Moisture friction is common in the groin mutations in one of the proteins accumulating in the middle fin- region. In females, older or obese involved in natural moisturiz- ger webspaces along with fric- individuals and persons with ing factor; this may result in tion leads to intertrigo that can diabetes, intertrigo of this region compromised moisture barrier become secondarily infected, is often complicated by candidal function, increasing skin sus- most commonly with Candida. ceptibility to irritants, including intertrigo with the characteris- excessive moisture.20 Atopic tic bright red appearance and individuals in many studies have satellite (small lesions near the Common Differential demonstrated a decreased skin main one) papules and pustules Diagnoses of Intertrigo barrier function that is further that are usually, but not always Common differential diagnoses compromised by the common present. Candidal infection of of intertrigo include inflamma- use of topical ; topical the groin is also more common tory conditions, such as psoria- immune response modifiers, in individuals with vaginal yeast sis, atopic dermatitis and, less such as and pimecro- infections and in those receiving commonly, lichen planus. Atopic

Volume 11, Number 2 · Fall 2013 Wound Care Canada – Supplement 9 individuals may also develop greasy scale. As infants become in 6%, psoriasis in dermatitis in the flexural areas older, it gradually improves. This 3%, contact eczema in 26%, and due to a combination of fac- condition is rare in older chil- no diagnosis (presumed contact tors.4, 21 Contact dermatitis is dren or adults except in associ- eczema) in 20%. Some patients more commonly irritant than ation with immunosuppression had more than one diagnosis. allergic and may be confused or . with intertrigo. Incontinence- Incontinence-associated associated dermatitis in skin Contact dermatitis of the dermatitis folds exposed to urine or flexural regions Incontinence of feces or urine can also be confused with inter- Eighty per cent of contact can result in incontinence-asso- trigo. Infections due to fungi, dermatitis is due to irritants ciated dermatitis.4 This derma- yeasts and bacteria, such as and 20% is allergic in nature. titis may occur in the , erythrasma, can exist with and Irritant contact dermatitis is labial folds, groin, buttocks, without intertrigo, which is often diffuse, whereas many scrotum and perianal and inter- characterized by increased local contact produce bright gluteal cleft. This condition is perspiration and moisture. Some red erythema with discrete mar- also commonly associated with rare flexural disorders are sum- gins. Irritant contact dermatitis candidal infection. In the pres- marized in Table 1. is common, due to irritants in ence of and local tender- soaps, detergents, fabric softener ness, secondary should Psoriasis residue in clothes, , be suspected. Staphylococcal Psoriasis can occur in many antiperspirants and antimicrob- or streptococcal infection may forms, including plaque, pustular, ial preparations. need to be treated with systemic erythrodermic and intertriginous Common contact in antimicrobial therapy. Perianal psoriasis. The intertriginous form the flexural areas include per- cellulitis is more common than of psoriasis is symmetrically fumes; preservatives such as cellulitis of the anterior groin distributed and bright red in col- and formaldehyde area. All anterior groin eruptions our with a sharp margin.21 It is releasers, including quater- may extend around the peri- distinguished from other forms nium-15; topical antimicrobials, neum into the perianal area and of psoriasis by the absence of a such as neomycin, bacitracin, onto the buttocks. Perianal erup- silvery scale even in untreated polymyxin and others; and tions are more common with cases. Intertriginous psoriasis occasionally topical steroids. hemorrhoids or loose, watery is most common in the groin, The allergic reaction can be stools. under the breasts, in the axillae reproduced by the repeat open and in the perianal area, but application test. Products can Atopic dermatitis of the it can occur in other locations. be screened by applying them flexural areas There is usually an absence of twice a day for two or three Atopic individuals often have satellite papules or pustules. days to a coin-shaped circle on a decreased ability to sweat, Involvement of other areas may normal skin. Allergic altered immunity and suscept- help to establish the diagnosis. reactions to irritants or sensitiz- ibility to eczema in the body ing agents can be confirmed by folds. Atopic flexural eczema Seborrheic dermatitis of the patch testing.21 is most common in the ante­ flexural areas Kranke et al. performed a pro- cubital and popliteal fossae, Seborrhea of the flexural areas spective study of 126 patients starting once individuals can is common in otherwise healthy, with a presumptive diagnosis of walk with an upright posture, young infants. Seborrhea pre- anal eczema.22 The clinical diag- and is less common as they sents as yellow-pink erythema, nosis was intertrigo/candidiasis reach adulthood.21 Itch often sometimes with a peripheral in 43%, atopic dermatitis in 6%, leads to scratching and rubbing

10 Wound Care Canada – Supplement Volume 11, Number 2 · Fall 2013 the involved areas, which can Table 1. Rare Forms of Flexural Disorders produce increased skin surface Disease Process Comments markings (lichen simplex chron- Lichen planus Violaceous papules or plaques that leave icus). behind post-inflammatory pigmentation Fox Fordyce disease Rare disorder with extremely itchy peri- Complications of follicular papules in the axilla, groin and around the nipples Intertrigo Hailey-Hailey disease Intertriginous fragile that are often Secondary skin infection can (Benign familial worse in the hot months or when secondar- occur in the presence of inter- ) ily infected trigo or may occur independ- Unusual drug reactions Chemotherapy drug reactions ently of any evidence of MASD. Toxic epidermal necrolysis: most common with anticonvulsants, antibiotics, and non- Secondary skin infection steroidal anti-inflammatory drugs Overhydration of the stratum corneum, due to an inability to evaporate or translocate mois- Table 2. Organisms Cultured from 15 Sites from 9 Patients with Intertrigo ture from a skin fold, can disrupt Organism Times Cultured the moisture barrier, allowing irritants to pass into the skin and Staphylococcus species coagulase negative 12 produce dermatitis.5 Saturated Proteus mirabilis 8 skin is also more susceptible to Diptheroids 5 friction damage, resulting in fur- Enterococcus faecalis 5 ther inflammation, which then allows the penetration of organ- 4 isms to cause secondary bacter- Vancomycin-resistant Enterococcus faecium 3 ial or fungal infection, the most Escherichia coli 2 common of inter- Streptococcus viridans group 1 trigo. The warm, damp environ- Group D Enterococcus 1 ment in skin folds with associ- ated skin damage provides an Acinetobacter baumanni/haemolyticus 1 ideal environment for organisms to proliferate. Infections due to Candida albicans and dermato- intertrigo from nine hospitalized Limitations of this study include 23 phytes, such as Tricophyton patients (Table 2). the small size, the single site, and rubrum, are common, and many In this sample, there was no the lack of a control group. relation between the type or bacterial species can also be quantity of microorganism cul- seen, including staphylococci, Specific types of infection tured and the severity of ery- Although Kugelman21 and others streptococci, Gram-negative thema. At four sites with satellite classify pyodermas, candidiasis, species, and -resistant lesions, the satellites did not all dermatophytosis and erythrasma strains. contain the same organism. In as differential diagnoses for Organisms in intertrigo addition, only two contained intertrigo, this document consid- Edwards et al. conducted a small Candida albicans, suggesting ers them to be secondary infec- single-hospital study to identify that should not be tions, or complications of inter- common microorganisms in prescribed based on the pres- trigo, when chronic exposure to intertrigo by culturing 15 sites of ence of satellite lesions alone. moisture in skin folds is present.

Volume 11, Number 2 · Fall 2013 Wound Care Canada – Supplement 11 Because infections require a por- seen in adult males.21 Itchy, red, ism, but culture can take up to tal of entry and develop on skin scaling plaques on the upper a month. About 20% of fungal that has already been comprom- medial thighs characterize tinea infections are negative on a ised, it is more rational to con- cruris. Lesions tend to grow hydroxide test and on sider them as secondary rather with a circular border, and cen- culture. With a high index of sus- than primary conditions. tral clearing may be seen. The picion clinically, it is important macerated keratin compromises to obtain three negative cultures Candidiasis the cutaneous barrier and acts before considering another diag- Candidal infection is intensely as a portal of entry for second- nosis. Dermatophyte infection itchy, with plaques with sharp ary bacterial infection leading to generally responds well to topic- margins and frequent satellite lymphangitis and cellulitis. al creams.9 lesions beyond the area of fric- Tinea of the interdigital spaces Gloor et al. performed a study tion. Whitish exudate may be of the toewebs is usually accom- of the healthy skin of 27 patients present.21 As candidal organisms panied by tinea pedis, charac- with and 27 healthy are frequently present, positive terized by a dry, white powdery patients to assess biochemical culture alone is insufficient for a scale. This scale accentuates 24 diagnosis; the invasive mycelial and physiological parameters. the skin surface markings and phase of the organism must be The study found that significant- extends around the side of present on microscopic exam- ly more amino acids could be the feet in a distribution that ination of lesion scrapings. extracted from the skin surface would be covered by a mocca- Candidal intertrigo may often of patients with tinea cruris than sin (moccasin tinea pedis). respond to a topical antican- from the healthy controls. The The moccasin changes of tinea didal preparation.9 Resistant or authors hypothesized that the pedis need to be distinguished extensive cutaneous infections increase in amino acids may be from the dry skin that occurs as may require systemic antifungal related to excessive perspiration, a result of the autonomic com- agents, with difluconazole the and this finding may indicate a ponent of the neuropathy asso- most commonly used agent. factor predisposing to dermato- ciated with diabetes and other A study by Gloor et al. of the phyte infection. etiologies. The nails may also be biochemical and physiological involved with a distal streaking Bacterial infections: Pyodermas parameters of areas of healthy and eventual whole plate Most pyodermas are caused by skin in 20 patients with candida involvement. Involvement often coagulase-positive staphylococci intertrigo found a significant starts asymmetrically and then and β-hemolytic streptococci, decrease in the amount of spreads to the other foot and, and systemic antibiotics are the squalene and an increase in wax in susceptible individuals, to usual therapy.21 Staphylococci and cholesterol esters in the skin the . A secondary bac- may cause (superficial surface lipids in these patients terial infection, often from infection) or furun- compared with 39 healthy con- the toewebs in a person with culosis (deep hair follicle infec- trols.24 These alterations may diabetes, can be life or limb tion) in the axilla or groin, which point to a predisposing factor threatening. must also be differentiated from for candidal infection. The diagnosis can be con- , an Dermatophytosis firmed by examining fungal inflammatory condition of the Intertriginous infection with scrapings of the skin surface apocrine . Staphylococci dermatophytes (fungi that cause keratin for the presence of and streptococci may also cause skin disease), which may be septate hyphae in potassium cellulitis. Superficial, honey-col- caused by T. rubrum, T. menta- hydroxide preparations. A posi- oured intertriginous lesions may grophytes, or Epidermophyton tive culture on Sabouraud’s agar be the presenting sign of impe- floccosum, is most frequently can identify the specific organ- tigo.

12 Wound Care Canada – Supplement Volume 11, Number 2 · Fall 2013 Streptococcal intertrigo be infected with bacteria or portals of entry of the infec- Streptococcal intertrigo is molds. Lin et al. reported on a tion as intergluteal intertrigo in caused by group A β-hemolytic case series of interdigital foot three patients, tinea pedis in one streptococci and presents as intertrigo with a poor response patient, a psoriatic plaque in one a fiery red or beefy-red, shiny, to antifungal therapy that patient and a of the exudative lesion with well-de- included 32 episodes in 17 buttock in one patient. No portal fined borders without satellite patients.30 Clinically, the toewebs of entry was found for the sev- lesions and with a foul smell.25 were macerated. Most bacterial Microscopic examination and cultures (93%) grew a mixture of enth patient. culture provide the diagnosis. pathogens, with the most com- This complication of intertrigo mon being Pseudomonas aeru- Consensus statement #6: most commonly occurs in ginosa, Enterococcus faecalis and infants, where it affects mainly Staphylococcus aureus. Complications of the neck, but axillary, inguin- intertrigo al and anal folds may also be Deeper infection Secondary bacterial infection 26-28 involved. Infants have a Secondary infection of the skin is a common complication of predisposition to cervical infec- is a clinically relevant complica- intertrigo that must be treat- tion due to their relatively short tion of intertriginous dermatitis ed effectively to prevent deep , deep skin folds in chubby that can develop into deeper, and surrounding invasive infants and saliva from drooling, clinically important infections.2 infection. which collects in the neck folds. Dupuy et al. performed a case-control study to assess risk Erythrasma factors for of the leg, Assessment of Erythrasma is caused by or cellulitis.31 The analysis includ- Corynebacterium minutissimum, Intertrigo ed 167 patients with erysipelas producing dull red scaling A full history and examination and 294 controls. Multivariate plaques with a sharp margin on of the entire body surface can analysis found an odds ratio (OR) the medial thighs, the axillae, help to differentiate intertrigo for lymphedema of 71.2 (95% toewebs and perianal area. The from conditions that may appear confidence interval [CI] 5.6 to diagnosis is made by finding 908) and an OR for site of entry similar. coral-red fluorescence, which is of 23.8 (95% CI 10.7 to 52.5). The due to an excreted porphyrin, site of entry was defined as dis- History under a Wood’s light. Erythrasma ruption of the cutaneous barrier Clues to the diagnosis of inter- responds to topical imidazole and included leg ulcer, wound, trigo may often be found in antifungal agents (such as fissurated toe-web intertrigo, the patient’s medical hist- and miconazole), pressure ulcer and leg dermato- 9 erythromycin or clindamycin.9 ory. Patients with diabetes or sis. Other risk factors were leg Treatment with oral erythro- immunosuppression may have edema (OR 2.5, 95% CI 1.2 to mycin or clarithromycin may a greater incidence of intertrigo. 5.1), venous insufficiency (OR be necessary.29 In patients with In addition, patients who are 2.9, 95% CI 1.0 to 8.7) and over- interdigital erythrasma, a com- obese, bedridden or incontinent weight (OR 2, 95% CI 1.1 to 3.7). bination of oral and topical ther- are prone to intertrigo. It is also Studer-Sachsenberg et al. apy may be necessary. reported on seven cases of but- important to identify previous Interdigital intertrigo tock cellulitis at varying times therapies, such as topical or sys- Interdigital foot intertrigo after hip replacement surgery.32 temic , as they is commonly infected with In assessing these cases, the may affect the appearance of dermatophytes, but it can also authors identified the presumed the lesion.

Volume 11, Number 2 · Fall 2013 Wound Care Canada – Supplement 13 Physical examination inflammatory signs, such as local infections or pseudohyphae in To assess a patient with pos- increased temperature, cellulitis, candidiasis. sible intertrigo, it is important exudate and smell, often alter to inspect the entire body, the appearance of the primary Consensus statement #7: including all skin folds, right disease process.9 to their base. It may be useful Diagnosis of to measure the depth of skin intertrigo folds, as the deeper the fold, the Diagnosis The diagnosis of intertrigo is more likely is the development The diagnosis is often clear-cut based on the history and char- of intertrigo. Full body exam- and is generally based on the acteristic physical findings ination is best accomplished clinical presentation of charac- supplemented with laboratory with the patient lying flat. With teristic intertriginous dermatitis: testing to rule out secondary some obese patients, assistance mirror-image erythema, inflam- infection. may be necessary to lift large mation or erosion within skin skin folds without exacerbating folds.8 The presence of other Management of existing skin damage. Intertrigo types of lesions, such as pus- Intertrigo appears as mirror-image ery- tules, deep papules, nodules or Evidence Mistiaen et al. performed two systematic literature reviews of “Every effort must be made to restore a normal prevention and treatment of environment that will encourage the natural intertrigo in large skin folds of regenerative capacity of the skin.”21 adults, published in 2004 and — TP. Kugelman 2010.7,33 Only the more recent review is discussed here. The review used a search of 13 data- thema, inflammation or erosion vesicles may offer a clue to the bases followed by reference within skin folds. Other signs diagnosis. If secondary infection tracking and forward citation 7 and symptoms include itch, is likely, it is appropriate to per- searches. Of 316 articles includ- burning, pain and odour. Itch form a culture and sensitivity. ed for full-text assessment, only 68 studies met the inclusion often requires sedating H1 anti- Biopsy may be uninformative in , such as diphenhyd- uncomplicated intertrigo, but in criteria, and only four of these were randomized controlled ramine or , which atypical clinical presentations trials. Most of the studies lacked are taken at night and have a or lesions without a positive carryover effect the following scientific rigour for a variety of bacterial or fungal laboratory day. Pain with intertrigo may be serious methodological reasons. test that are nonresponsive to severe and sometimes requires No study addressed prevention treatment, biopsy may serve a pain medication. The burning of intertrigo. In the studies of useful function. Examination associated with intertrigo may treatment, secondarily infected approximate severe under a Wood’s light may iden- intertrigo was generally the con- symptoms and may respond tify secondary infections, such dition treated, and a large var- to a combination of pain and as erythrasma (coral-red fluores- iety of therapies was evaluated, medication. Pain cence) or pseudomonas (green primarily topical therapies, such may also indicate secondary fluorescence). Potassium hydrox- as antifungal and antibacterial infection. In this situation, super- ide examination may demon- creams. In addition, 15 studies imposed infection-associated strate hyphae in dermatophyte addressed reduction mammo-

14 Wound Care Canada – Supplement Volume 11, Number 2 · Fall 2013 plasty. The review was also ham- “. . . intertrigo deserves more serious attention from pered by differing descriptions the field on all aspects from defining to of intertrigo, diagnostic criteria and measurements of treatment diagnosing, pathophysiology, prevention, treatment 7 success. Overall, no rigorous and evaluation.” randomized controlled trial evi- — P. Mistiaen dence exists for the prevention or treatment of intertrigo of the large skin folds. ure to moisture was anticipated. rinseless cleanser is recom- Furthermore, measures to reduce mended. Irritated skin folds Consensus statement #8: or eliminate skin-on-skin contact should be patted dry, rather and friction are important. than wiped or rubbed.4 Loose- Evidence for fitting, lightweight clothing of intertrigo treatment Consensus statement #9: natural fabrics or athletic cloth- No well-designed clinical trials ing that wicks moisture away are available to support ther- Principles of from the skin are good choices. apies commonly used to treat management of Open-toed shoes may be bene- or prevent intertrigo. intertrigo Prevention and treatment of Notes on Skin Management principles intertrigo should maximize Care for Obese A previous expert panel agreed the intrinsic moisture barrier that a preventive or treatment function of the skin by focus- Individuals Obese patients have a large approach for MASD should be ing on at least one of the fol- skin surface and more and based on at least one of the fol- lowing goals: 2 deeper skin folds compared lowing goals: 1. Minimize skin-on-skin con- with lean individuals.34 “1. an interventional tact and friction. Meticulous skin care is program that removes irri- 2. Remove irritants from the necessary but difficult to tants from the skin, maximiz- skin and protect the skin es its intrinsic moisture bar- achieve in obese individ- from additional exposure to uals. Skin folds in obese rier function, and protects the irritants. skin from further exposure to individuals are often moist 3. Wick moisture away from and predisposed to devel- irritants affected and at-risk skin. 2. use of devices or products oping intertrigo and to 4. Control or divert the mois- that wick moisture away from secondary infection. Due to ture source. affected or at-risk skin the potential itch or pain 5. Prevent secondary infection. 3. prevention of secondary associated with intertrigo, cutaneous infection it is helpful to use rinseless Prevention cleansers when cleansing 4. control or diversion of the No randomized controlled skin folds in obese individ- moisture source” trial, evidence-based literature uals. It is also important to The panel also agreed that a supports strategies to prevent dry skin folds by patting preventive or treatment regi- intertrigo, but common-sense rather than wiping to pre- men should be consistent and approaches are effective.8 It is vent causing more pain, include gentle cleansing, mois- important that skin folds be much as you would for a turization if indicated and appli- kept as clean and dry as pos- patient with sunburn—pat cation of a protective device or sible to minimize friction. Gentle gently, do not wipe. product when additional expos- cleansing with a pH-balanced,

Volume 11, Number 2 · Fall 2013 Wound Care Canada – Supplement 15 Moisture-wicking Textile with Silver This polyurethane-coated polyester textile is impregnated with a silver compound. The coating is specifically designed to assist in the absorption and wicking away, or translocation, of moisture. The moisture-wicking textile with silver translocates excess moisture from the skin fold to keep skin dry, the silver-impregnated formulation provides effective antimicrobial action for five days, and the soft knitted textile provides a friction-reducing surface that reduces the risk of skin tears. The textile is effective for of intertriginous dermatitis, such as maceration, denudement, inflammation, pruritus, erythema and satellite lesions. Overall, the moisture-wick- ing textile with silver treats intertriginous dermatitis by managing moisture, friction, bacteria and odour. In addition to intertriginous dermatitis, other uses of the moisture-wicking textile with silver in MASD include placement under • blood pressure cuffs in intensive care unit patients • immobilizers and medical devices • compression bandages in patients with limb edema ficial in preventing toe-web Consensus statement #10: Treatment 8 intertrigo. However, closed-toe Prevention of A follow-up survey by McMahon shoes would be recommended et al. of nurses’ knowledge about intertrigo for patients with diabetes, and the management of inframam- The following strategies may a moisture-wicking textile with mary intertrigo found they had help to prevent intertrigo silver could be woven between a broad variety of recommen- from developing or recurring: dations, many of which were the toes to help translocate 1. Cleanse skin folds gently, contradictory. An example of a moisture. (See Moisture-wicking dry gently but thoroughly contradictory recommendation Textile with Silver, above.) Proper (pat, do not rub) and edu- included the use of talcum pow- supportive garments, such as cate patients about proper der (16.5%), and its avoidance brassieres, can reduce appos- skin fold hygiene. (15.7%).3 Talcum ( oxide ition of skin surfaces. In addition, 2. Counsel patients to wear powder) can be useful, but this placing moisture-wicking textile open-toed shoes and product may be confused or with silver within large skin folds loose-fitting, lightweight substituted with corn starch, to translocate excessive mois- clothing of natural fabrics which can support the growth ture may be helpful.4 Ensuring or athletic clothing that wicks moisture away from of bacterial organisms. Another that 4 cm of the fabric hangs out the skin. alternative is short-chain fatty of the fold allows translocation 3. Advise patients to wear acid powders, such as undecyclic of moisture. Patient education proper supportive gar- acid, which can decrease organ- should include the importance ments, such as brassieres, to ism growth and facilitate local of showering after reduce skin-on-skin contact. drying. and carefully drying skin folds; 4. Consider using a mois- The consensus recommenda- awareness of the risk of inter- ture-wicking textile with tions included: trigo associated with sweating, silver within large skin folds • hygiene-related suggestions: such as in hot and humid weath- to translocate excessive washing thoroughly and dry- er, should be stressed. moisture. ing well

16 Wound Care Canada – Supplement Volume 11, Number 2 · Fall 2013 • clothing-related approaches: aluminum chloride hexahydrate, to determine the efficacy of the natural fibres and wearing a systemic β-blockers, or anti- moisture-wicking textile with sil- brassiere drugs. ver instead of standard therapy • occlusive dressings and vari- A has been in patients with refractory inter- ous powders, especially short- evaluated in a multicentre trial trigo.36 Study participants were chain fatty acid powders in 145 patients with axillary 21 patients with intertriginous • protective barriers: hyperhidrosis.35 Botulinum toxin dermatitis from two long-term- or petrolatum, film-forming A blocks the release of acetyl- care centres. Mean patient age acrylates and silicone- or , the sympathetic neuro- was 53.8 years and mean body dimethicone-based creams transmitter in the sweat glands, mass index was 54.75. The inter- trigo had been present for a The survey identified a lack of to stop excessive sweating. In varying number of weeks and in coherence in the management each patient, botulinum toxin most cases other products had of inframammary intertrigo. A 200 U was injected into one axilla and placebo into the other. been tried without a response. Ineffective therapies Two weeks later, botulinum Skin assessment was performed A previous expert panel iden- toxin A 100 U was injected into on Day 1, Day 3 and Day 5 for tified several therapies that the axilla that had previously itching/burning, maceration, were ineffective or harmful to received placebo. Patients were denudement, satellite lesions, prevent or treat intertriginous followed for 26 weeks, and the erythema and odour (Table 3). dermatitis.4 Powders, such as rate of sweat production meas- In this study, moisture-wicking cornstarch, have no proven ured. At two weeks, average textile with silver relieved the benefit and may encourage fun- sweat production had decreased patients’ symptoms and signs gal growth, as cornstarch is a by 87.5%. At 26 weeks, sweat of intertrigo within a five-day substrate for growth of yeasts.9 production, which was similar period. The moisture-wicking Textiles, such as gauze, various in both axillae, was still 65.6% textile with silver is also cost-ef- fabrics or paper towels, placed lower than at baseline. Virtually fective, as it reduces nursing time between skin folds, are usually all (98%) patients reported they substantially. (See Cost-effective ineffective as they absorb mois- would recommend the therapy Treatment of Intertrigo, page 18.) ture but do not allow it to evap- to others. Common-sense approaches orate, promoting skin damage.4 Intertrigo treatment relies on Home remedies, such as diluted Intertrigo and moisture-wicking textile with silver common-sense approaches vinegar and wet tea bags, have Various standard treatments because little evidence sup- never been evaluated in clinical for intertrigo, research. such as drying Table 3. Signs and Symptoms in Study Patients Hyperhidrosis agents, barrier Sign or Symptom Day 1 Day 3 Day 5 Intertrigo due to hyperhidrosis, creams, topical or increased perspiration, can be antifungals Itching/burning 15 1 0 treated using several modalities. and absorp- Maceration 10 1* 1* The first-line treatment is alum- tive materi- Denudement 7 3 1 inum chloride hexahydrate 20% als, may be Satellite lesions 5 1 1 in anhydrous ethanol. Second- ineffective in line therapies include oral and some patients. Erythema 21 ↓† ↓† topical and Kennedy- Odour 12 ↓† 2* Evans et al. botulinum toxin A. Intertrigo * One patient had maceration and odour due to urine prevention in this population is performed a soiling of textile that was not removed immediately most commonly addressed with clinical study † Statistically significant decrease

Volume 11, Number 2 · Fall 2013 Wound Care Canada – Supplement 17 Cost-effective Treatment of Intertrigo A comparison of potential retail costs for each treatment and potential nursing time are listed below. In general this type of treatment may be offered in chronic care institutions, but it is unlike- ly that twice daily nursing visits would be authorized through home care.

Table 4. Cost Comparison for Intertrigo Treatment

Agent Associated Costs Clotrimazole antifungal , 30g, twice daily for 2 weeks, 7.5 applications per tube Cost per tube $12.99 Cost per day $3.46

Cost for 2 weeks’ treatment with clotrimazole $48.44 Nursing time 28 applications over 14 days

Nystatin antifungal cream, 30g, twice daily for 2 weeks, 7.5 applications per tube Cost per tube $4.99 Cost per day $1.33

Cost for 2 weeks’ treatment with $18.63 Nursing time 28 applications over 14 days

Moisture-wicking textile with silver, 10” x 12”, applied every 5 days Cost per roll (10” x 12’)* $107.64 Cost per day $1.78

Resolution in 5 days with the moisture-wicking textile with silver $8.97 Nursing time 5 visits

Resolution in 10 days with the moisture-wicking textile with silver $17.94 Nursing time 10 visits

* Retail cost; institutional cost lower Source: Retail pharmacy costs

ports various commonly used ture-wicking textile with silver ous dermatitis has resolved.1 It therapies. Most importantly, it has been shown to be effective is also important to recognize is necessary to establish or con- in treating intertrigo. Treatment that eroded intertrigo skin is not tinue a skin-care regimen that of secondary infection may completely healed until the nor- focuses on keeping the skin require topical and possibly mal skin thickness is re-estab- folds dry and prevents or treats oral therapy. Treatment should lished and the barrier function secondary infection.4 The mois- continue until the intertrigin- restored. The diagnosis should

18 Wound Care Canada – Supplement Volume 11, Number 2 · Fall 2013 be revisited in cases of inter- A Case of Axillary Intertrigo triginous dermatitis that do not A 60-year-old woman with a history of right-sided mastectomy respond to usual therapy. presented with denuded and erythematous skin at the right axil- Weight loss is always an lary fold (Figure 1). The lesion was very painful, and a foul odour appropriate preventive and and drainage were present. The condition had been present for treatment strategy, but it is two weeks. Nystatin powder had been ineffective in improving the notoriously difficult to achieve. problem. At presentation, the lesion was cleaned gently and patted Although intertrigo is not an dry. A piece of moisture-wicking textile with silver was placed with- indication for reduction mam- in the axillary fold and secured at the , leaving adequate moplasty, a meta-analysis of textile exposed for translocation. The textile was replaced after five reduction mammoplasty out- days. At seven days, there was significantly less drainage and red- comes in 4,173 patients found ness and the denuded skin was almost healed (Figure 2). intertrigo decreased from 50.3% to 4.4% after surgery.37

Consensus statement #11: Treatment of intertrigo The following approaches may help treat intertrigo: 1. Follow recommended pre- ventive strategies to keep Figures 1 and 2. Axillary intertrigo before and after seven days with skin folds dry and prevent moisture-wicking textile with silver or treat secondary infection. 2. Consider using a mois- ture-wicking textile with Conclusion silver between affected skin Intertrigo is a common condition folds. associated with MASD. Intertrigo 3. Continue treatment until may be found in a variety of intertriginous dermatitis clinical settings, including acute, has been controlled. chronic, long-term and home 4. Treat secondary infection care. Overall, the limited informa- with appropriate systemic tion about intertrigo currently and topical agents. available is a cause for concern. The incidence and prevalence 5. Revisit the diagnosis in of intertrigo are unknown, and cases that do not respond little evidence supports the use to usual therapy. of commonly used therapies. The 6. Initiate a prevention pro- information in this consensus gram that can include document has been synthesized weight loss, a skin-fold for educational purposes for hygiene program and early clinicians and as a for detection and treatment of more research into this common recurrence. condition.

Volume 11, Number 2 · Fall 2013 Wound Care Canada – Supplement 19 A Case of Inframammary Intertrigo 8. Janniger CK, Schwartz RA, Szepietowski JC, Reich A. Intertrigo A 92-year-old female presenting for care of venous stasis ulcer- and common secondary skin ation complained of a persistent, painful underneath her infections. Am Fam Physician. 2005;72(5):833–8. breasts that had been unresponsive to treatment with a variety 9. Guitart J, Woodley GT. Intertrigo: of oral and topical therapies. Candida intertrigo was present with a practical approach. Compr Ther. erythematous papules, satellite lesions, denudement, weeping 1994;20(7):402–9. and a musty odour. Initial treatment was with an oral prescription 10. Brown J, Wimpenny P, Maughan H. antifungal for five days. When this was ineffective, a topical anti- Skin problems in people with obesity. fungal powder was prescribed twice daily for two weeks. The rash Nursing Stand. 2004;18(35):38–42. persisted and was then treated with an antifungal cream twice 11. Mathur AN, Goebel L. Skin findings daily for two weeks associated with obesity. Adolesc Med State Art Rev. 2011;22(1):146–56. At the next visit, the intertrigo was gently cleaned and pat- 12. Al-Mutairi N. Associated cutaneous ted dry. A piece of moisture-wicking textile with silver was then diseases in obese adult patients: placed beneath each breast, leaving 4 cm exposed for transloca- a prospective study from a skin tion and secured in place using a sports bra. Substantial improve- referral care center. Med Princ Pract. ment was noted by 14 days with complete resolution by 21 days. 2011;20(3):248–52. 13. Boza JC, Trindade EN, Peruzzo J, Sachett L, Rech L, Cestari TF. Skin man- ifestations of obesity: a comparative study. J Eur Acad Dermatol Venereol. 2012;26(10):1220–3. 14. García Hidalgo L. Dermatological complications of obesity. Am J Clin Dermatol. 2002;3(7):497–506. 15. McMahon R. The prevalence of skin problems beneath the breasts of in-patients. Nurs Times. 1991;87(39):48–51. Figures 3 and 4. Inframammary intertrigo before and after mois- 16. Yosipovitch G, Tur E, Cohen O, Rusecki ture-wicking textile with silver Y. Skin surface pH in intertriginous areas in NIDDM patients: possible correlation to candidal intertrigo. Diabetes Care. 1993;16(4):560–3. References 4. Black JM, Gray M, Bliss DZ, Kennedy- 17. Lekan-Rutledge D. Management of Evans KL, Logan S, Baharestani M, 1. Gray M, Bohacek L, Weir D, Zdanuk : skin care, con- Colwell JC, Goldberg M, Ratcliff CR. J. Moisture vs pressure: making tainment devices, catheters, absorp- MASD part 2: incontinence-associated sense out of perineal wounds. J tive products. In: Doughty DB, ed. dermatitis and intertriginous derma- Wound Ostomy Continence Nurse. Urinary & : current titis: a consensus. J Wound Ostomy management concepts. 3rd ed. St. 2007;34(2):134–42. Continence Nurs. 2011;38(4):359–70. Louis, MO: Mosby; 2006. p. 309–40. 2. Gray M, Black JM, Baharestani MM, 5. Voegeli D. Moisture-associated skin 18. Dougherty KA, Chow M, Kenney Bliss DZ, Colwell JC, Goldberg M, damage: an overview for communi- WL. Clinical environmental limits Kennedy-Evans KL, Logan S, Ratcliff ty nurses. Br J Community Nursing. for exercising heat-acclimated lean CR. Moisture-associated skin dam- 2013;18(1):6,8,10–12. and obese boys. Eur J Appl Physiol. age: overview and pathophysiology. 6. Muller N. Intertrigo in the obese 2010;108(4):779–89. J Wound Ostomy Continence Nurse. patient: finding the silver lin- 19. Nino M, Franzese A, Ruggiero Perrino 2011;38(3):233–41. ing. Ostomy Wound Manage. NR, Balato N. The effect of obesity on 3. McMahon R, Buckeldee J. Skin 2011;57(8):16. skin disease and epidermal permea- problems beneath the breasts of 7. Mistiaen P, van Halm-Walters M. bility barrier status in children. Pediatr in-patients: the knowledge, opinions Prevention and treatment of intertrigo Dermatol. 2012;29(5):567–70. and practice of nurses. J Adv Nurs. in large skin folds of adults: a system- 20. O’Regan GM, Sandilands A, McLean 1992t;17(10):1243–50. atic review. BMC Nurs. 2010;9:12. WH, Irvine AD. Filaggrin in atopic

20 Wound Care Canada – Supplement Volume 11, Number 2 · Fall 2013 dermatitis. J Clin Immunol. vical folds in a five-month old . adults: a literature overview. Dermatol 2008;122(4):689–93. Pediatr Infect Dis J. 2012;31(8):872–3. Nurs. 2004;16(1):43-46,49–57. 21. Kugelman TP. Intertrigo—diag- 27. Neri I, Savoia F, Giacomini F, Patrizi 34. Kennedy-Evans KL, Henn T, Levine N. nosis and treatment. Conn Med. A. Streptococcal intertrigo. Pediatr Skin and wound care for the bariatric 1969;33(1):29–36. Dermatol. 2007;24(5):577–8. patient. In: Krasner DL, Rodeheaver GT, Sibbald RG, eds. Chronic wound care: 22. Kränke B, Trummer M, Brabek E, 28. Honig PJ, Frieden IJ, Kim HJ, Yan AC. a clinical source book for healthcare Komericki P, Turek TD, Aberer W. Streptococcal intertrigo: an under- recognized condition in children. professionals. 4th ed. Malvern, PA: HMP Etiologic and causative factors in per- Communications; 2007. p. 695–699. ianal dermatitis: results of a prospec- Pediatrics. 2003;112(6):1427–9. 35. Heckmann M, Ceballos-Baumann AO, tive study in 126 patients. Wien Klin 29. Holdiness MR. Management of Plewig G, for the Hyperhidrosis Study Wochenschr. 2006;118(3-4):90–4. cutaneous erythrasma. Drugs. 2002;62(8):1131–41. Group. Botulinum toxin A for axillary 23. Edwards C, Cuddigan J, Black J. hyperhidrosis (excessive sweating). Identification of organisms colonized 30. Lin JY, Shih YL, Ho HC. Foot bacterial New Engl J Med. 2001;344(7):488–93. intertrigo mimicking interdigital at site of intertriginous dermatitis 36. Kennedy-Evans KL, Viggiano B, Henn in hospitalized patients. Toronto, tinea pedis. Chang Gung Med J. 2011;34(1):44–9. T, Smith D. Multisite feasibility study ON: World Union of using a new textile with silver for Societies: 2008. 31. Dupuy A, Benchikhi H, Roujeau J-C, management of skin conditions Bernard P, Vaillant L, Chosidow O, 24. Gloor M, Geilhof A, Ronneberger located in skin folds. Presented at: The Sassolas B, Guillaume JC, Grob JJ, G, Friederich HC. Biochemical and Clinical Symposium Advances in Skin Bastuji-Garin S. Risk factors for erysip- physiological parameters on the & Wound Care at the Wound Ostomy elas of the leg (cellulitis): case-control and Continence Nurses Society 39th healthy skin surface of persons with study. Br Med J. 1999;318(7198):1591– candidal intertrigo and of persons annual meeting; 2007 Jun 9–13; Salt 4. Lake City, Utah. with tinea cruris. Arch Dermatol Res. 32. Studer-Sachsenberg EM, Ruffieux P, 1976;257(2):203–11. 37. Chadbourne EB, Zhang S, Gordon MJ, Saurat J-H. Cellulitis after hip surgery: Ro EY, Ross BD, Schnur PL, Schneider- 25. Wolf R, Oumeish OY, Parish LC. long-term follow-up of seven cases. Br Redden PR. Clinical outcomes in Intertriginous eruption. Clin Dermatol. J Dermatol. 1997;137(1):133–6. reduction mammaplasty: a system- 2011;29(2):173–9. 33. Mistiaen P, Poot E, Hickox S, Jochems atic review and meta-analysis of 26. Silverman RA, Schwartz RH. C, Wagner C. Preventing and treating published studies. Mayo Clin Proc. Streptococcal intertrigo of the cer- intertrigo in the large skin folds of 2001;76(5):503–10.

Volume 11, Number 2 · Fall 2013 Wound Care Canada – Supplement 21 InterDry® For Skin Fold Management

• Keeps the skin dry by Results using InterDry wicking moisture away from the skin

• Helps eliminate itching, odour and inflammation

• Effective antimicrobial Before: Painful, persistant After 5 days: Complete rash under breasts resolution of symptoms and rash. action for up to 5 days

• Reduces skin to skin friction

Join us at the CAWC Symposium - November 7, 2013 - Vancouver, BC

Coloplast Canada Coloplast develops products and services that make life easier for people with very personal and private medical conditions. Working closely with the people 3300 Ridgeway Drive Unit 12 who use our products, we create that are sensitive to their special needs. We call this intimate healthcare. Our business includes ostomy care, Mississauga, ON L5L 5Z9 urology and continence care and wound and skin care. We operate globally and employ more than 7,000 people. 1-877-820-7008 The Coloplast logo is a registered trademark of Coloplast A/S. © 2012-10 www.coloplast.ca All rights reserved Coloplast Canada,Mississauga, Canada.