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Home , Dermatitis, Intertrigo, Itch

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

This article provides an at-a-glance overview of a more in-depth article available on the Wound Care Canada website. To view the full article, please go to www.woundcarecanada.ca/supplements.

Consensus panel Introduction R. Gary Sibbald MD Professor, Medicine and Moisture-associated skin damage (MASD) and intertrigo Public University of Toronto Moisture is an important risk factor contributing to the Toronto, ON 1 Judith Kelley RN, BSN, CWON development of chronic wounds. Excessive moisture on Henry Ford Hospital – Main Campus the skin for a prolonged period of time may result in a Detroit, MI Karen Lou Kennedy-Evans spectrum of reversible and preventable skin damage that RN, FNP, APRN-BC KL Kennedy LLC ranges from to maceration (increased stratum Tucson, AZ

Chantal Labrecque RN, BSN, corneum moisture content) and erosion (loss of surface MSN CliniConseil Inc. with an epidermal base). MASD is distinct Montreal, QC from damage due to pressure, vascular insufficiency, Nicola Waters RN, MSc, PhD(c) Assistant Professor, Nursing Mount Royal University neuropathy or other factors. This document focuses on Calgary, AB intertriginous , which is due to perspiration

trapped in skin folds plus the effect of friction.

36 Wound Care Canada Volume 11, Number 2 · Fall 2013 Consensus Statements

Moisture-associated skin effectively to prevent deep and do not rub), and educate damage: Moisture is a risk surrounding invasive infection. patients about proper skin- factor for the development of fold hygiene. chronic wounds that is distinct Diagnosis of intertrigo: The • Counsel patients to wear from other risk factors, includ- diagnosis of intertrigo is based open-toed shoes and ing pressure, arterial insufficien- on the history and character- loose-fitting, lightweight cy, venous stasis and neurop- istic physical findings supple- clothing of natural fabrics or athy. mented with laboratory testing athletic clothing that wicks to rule out secondary infection. moisture away from the skin. Definition of intertrigo: • Advise patients to wear prop- Intertrigo, or intertriginous Evidence for intertrigo treat- er supportive garments, such dermatitis, may be defined as ment: No well-designed clinical as brassieres, to reduce skin- resulting from trials are available to support on-skin contact. moisture trapped in skin folds therapies commonly used to • Consider using a mois- subjected to friction. treat or prevent intertrigo. ture-wicking textile with sil- ver within large skin folds to Disease classification of inter- Principles of management translocate excessive moisture. trigo: A disease code for inter- of intertrigo: Prevention and Treatment of intertrigo: The trigo could improve diagnosis treatment of intertrigo should following approaches may help of the condition and support maximize the intrinsic moisture treat intertrigo: research efforts. barrier function of the skin by • Follow recommended pre- focusing on at least one of the ventive strategies to keep skin Epidemiology of intertrigo: following goals: folds dry and prevent or treat The true incidence and preva- • Minimize skin-on-skin contact secondary infection. lence of intertrigo is currently and friction. • Consider using a mois- unknown. • Remove irritants from the ture-wicking textile with silver skin and protect the skin from between affected skin folds. Risk factors for intertrigo: The additional exposure to irri- • Continue treatment until major documented risk factors tants. intertriginous dermatitis has for intertrigo include hyperhid- • Wick moisture away from been controlled. rosis; , especially with affected and at-risk skin. • Treat secondary infection with pendulous breasts; deep skin • Control or divert the moisture appropriate systemic and top- folds; immobility and source. ical agents. mellitus; all risk factors are • Prevent secondary infection. • Revisit the diagnosis in cases aggravated by hot and humid that do not respond to usual conditions. Prevention of intertrigo: The therapy. following strategies may help • Initiate a prevention program Complications of intertrigo: prevent intertrigo from devel- that can include , Secondary bacterial infection oping or recurring: a skin-fold hygiene program is a common of • Cleanse skin folds gently, dry and early detection and treat- intertrigo that must be treated gently but thoroughly (pat, ment of recurrences.

Volume 11, Number 2 · Fall 2013 Wound Care Canada 37 Epidemiology although this has not been stud- titis in the flexural areas due Intertrigo may be found in ied in detail. to a combination of factors.4,7 patients in care, rehabili- is more com- monly irritant than allergic and tation, extended-care facilities, Pathophysiology of hospices and in home care.2 may be confused with intertrigo. European studies have found the Intertrigo Incontinence-associated derma- prevalence of intertrigo to be Although much remains to be titis in skin folds exposed to 17% in a group of nursing home elucidated about the patho- urine or can also be con- patients and 20% in home care physiology of intertrigo, expos- fused with intertrigo. Infections patients.3 Overall, little evidence ure to moisture alone is insuffi- due to fungi, yeasts and can exist with and without inter- quantifies the incidence and cient to produce skin damage.6 prevalence of intertrigo. trigo, which is characterized by Both moisture and friction in increased local perspiration and skin folds are required. The clin- moisture. Risk Factors for ical course of intertrigo6 usually Intertrigo starts with erythema and inflam- No formal risk assessment tool Complications of mation, with the occurrence exists for intertriginous derma- Intertrigo: Secondary of erosions in the presence of titis.4 Risk factors for intertrigo moisture due to macerated kera- Overhydration of the stratum are numerous, with the most tin and wet . Some or all corneum, due to an inability to important including hyperhid- of these features may present evaporate or translocate mois- rosis, obesity and diabetes mel- concurrently or individually. ture from a skin fold, can disrupt

“Every effort must be made to restore a normal environment that will encourage the natural regenerative capacity of the skin.” 7 — TP Kugelman

litus.5 Immunocompromise and Common Differential the moisture barrier, allowing increased skin surface bacterial Diagnoses of Intertrigo irritants to pass into the skin and 8 burden may also be risk factors, Common differential diagnoses produce dermatitis. Saturated as may poor hygiene, malnutri- of intertrigo include inflamma- skin is also more susceptible to tion, tight and closed shoes and tory conditions, such as , friction damage, resulting in fur- large, prominent skin folds. A hot and, less com- ther inflammation, which then and humid climate promotes monly, lichen planus. Atopic indi- allows the penetration of organ- the development of intertrigo, viduals may also develop derma- isms to cause secondary bac-

38 Wound Care Canada Volume 11, Number 2 · Fall 2013 terial, fungal, or yeast infection, symptoms and may barrier function and pro- the most common complication respond to a combination of tects the skin from further of intertrigo. The warm, damp and medica- exposure to irritants environment in skin folds with tion. 2. use of devices or products associated skin damage provides that wick moisture away an ideal environment for organ- Diagnosis from affected or at-risk skin isms to proliferate. The diagnosis is often clear-cut 3. prevention of secondary and is generally based on the cutaneous infection Assessment of Intertrigo clinical presentation of charac- 4. control or diversion of the moisture source” A full history and examination teristic intertriginous dermatitis: of the entire body surface can mirror-image erythema, inflam- The panel also agreed that a help to differentiate intertrigo mation or erosion within skin preventive or treatment regi- from conditions that may appear folds.5 If secondary infection is men should be consistent and similar. likely, it is appropriate to per- include gentle cleansing, mois- form a culture and sensitivity. turization if indicated and appli- History Biopsy may be uninformative in cation of a protective device or Clues to the diagnosis of inter- uncomplicated intertrigo, but in product when additional expos- trigo may often be found in atypical clinical presentations ure to moisture was anticipated. the patient’s medical hist- or lesions without a positive Furthermore, measures to reduce ory.9 Patients with diabetes or bacterial or fungal laboratory or eliminate skin-on-skin contact immunosuppression may have test that are nonresponsive to and friction are important. a greater incidence of intertrigo. treatment, biopsy may serve a In addition, patients who are useful function. Examination Prevention obese, bedridden, or incontinent under a Wood’s light may iden- No randomized controlled are prone to intertrigo. It is also tify secondary infections, such trial evidence-based literature important to identify previous as (coral-red fluores- supports strategies to prevent therapies, such as topical or sys- cence) or pseudomonas (green intertrigo, but common- temic , as they fluorescence). Potassium hydrox- approaches are effective.5 It is may affect the appearance of ide examination may demon- important that skin folds be kept the lesion. strate hyphae in dermatophyte as clean and dry as possible to infections or pseudohyphae in minimize friction. Gentle cleans- . ing with a pH-balanced, rinse- To assess a patient with pos- less cleanser is recommended. sible intertrigo, it is important Management of Irritated skin folds should be to inspect the entire body, Intertrigo patted dry, rather than wiped including all skin folds, right to or rubbed.4 Loose-fitting, light- their base. Intertrigo appears as Management Principles weight clothing of natural fabrics mirror-image erythema, inflam- A previous expert panel agreed or athletic clothing that wicks mation or erosion within skin that a preventive or treatment moisture away from the skin are folds. Other signs and symp- approach for MASD should be good choices. Open-toed shoes toms include , burning, pain based on at least one of the fol- may be beneficial in preventing and odour. Pain with intertrigo lowing goals:6 -web intertrigo.5 However, may be severe and sometimes “1. an interventional closed-toe shoes would be rec- requires pain medication. The program that removes irri- ommended for patients with burning associated with inter- tants from the skin, maxi- diabetes, and a moisture-wick- trigo may approximate severe mizes its intrinsic moisture ing textile with silver could be

40 Wound Care Canada Volume 11, Number 2 · Fall 2013 woven between the to help A Case of Axillary Intertrigo translocate moisture. Proper sup- portive garments, such as bras- A 60-year-old woman with a history of right-sided mastectomy sieres, can reduce apposition of presented with denuded and erythematous skin at the right axil- skin surfaces. In addition, placing lary fold (Figure 1). The lesion was very painful, and a foul odour moisture-wicking textile with and drainage were present. The condition had been present for silver within large skin folds to two weeks. powder had been ineffective in improving the translocate excessive moisture problem. At presentation, the lesion was cleaned gently and patted may be helpful.4 Ensuring that dry. A piece of moisture-wicking textile with silver was placed with- 4 cm of the fabric hangs out of in the axillary fold and secured at the , leaving adequate the fold allows translocation textile exposed for translocation. The textile was replaced after five of moisture. Patient education days. At seven days, there was significantly less drainage and red- should include the importance ness and the denuded skin was almost healed (Figure 2). of showering after exercise and carefully drying skin folds; aware- ness of the risk of intertrigo asso- ciated with sweating, such as in hot and humid weather, should be stressed.

Treatment Ineffective therapies A previous expert panel iden- tified several therapies that Figures 1 and 2. Axillary intertrigo before and after seven days with were ineffective or harmful to moisture-wicking textile with silver prevent or treat intertriginous dermatitis.4 Powders, such as cornstarch, have no proven benefit and may encourage fun- materials, may be ineffective in itching/burning, maceration, gal growth, as cornstarch is a some patients. Kennedy-Evans denudement, satellite lesions, substrate for growth of yeasts.9 et al. performed a clinical study erythema and odour (Table 3). Textiles, such as gauze, various to determine the efficacy of the In this study, moisture-wicking fabrics, or paper towels, placed moisture-wicking textile with sil- textile with silver relieved the between skin folds are usually ver instead of standard therapy patients’ symptoms and signs of ineffective as they absorb mois- in patients with refractory inter- intertrigo within a five-day per- 10 ture but do not allow it to evap- trigo. Study participants were iod. The moisture-wicking textile orate, promoting skin damage.4 21 patients with intertriginous with silver is also cost-effective, Home remedies, such as diluted dermatitis from two long-term- as it reduces nursing time sub- vinegar and wet tea bags, have care centres. Mean patient age stantially. never been evaluated in clinical was 53.8 years and mean body Common-sense approaches research. mass index was 54.75 kg/m2. The Intertrigo treatment relies on intertrigo had been present for a common-sense approaches Intertrigo and moisture-wicking textile with silver varying number of weeks and in because little evidence sup- Various standard treatments most cases other products had ports various commonly used for intertrigo, such as drying been tried without a response. therapies. Most importantly, it agents, barrier creams, topic- Skin assessment was performed is necessary to establish or con- al and absorptive on Day 1, Day 3 and Day 5 for tinue a skin-care regimen that

Volume 11, Number 2 · Fall 2013 Wound Care Canada 41 focuses on keeping the skin A Case of Inframammary Intertrigo folds dry and prevents or treats A 92-year-old female presenting for care of venous stasis ulcer- 4 secondary infection. The mois- ation complained of a persistent, painful underneath her ture-wicking textile with silver breasts that had been unresponsive to treatment with a variety has been shown to be effective in of oral and topical therapies. Candida intertrigo was present with treating intertrigo. Treatment of erythematous , satellite lesions, denudement, weeping secondary infection may require and a musty odour. Initial treatment was with an oral prescription for five days. When this was ineffective, a topical anti- topical and possibly oral therapy. fungal powder was prescribed twice daily for two weeks. The rash Treatment should continue until persisted and was then treated with an antifungal twice the intertriginous dermatitis has daily for two weeks resolved.1 It is also important to At the next visit, the intertrigo was gently cleaned and pat- recognize that eroded intertrigo ted dry. A piece of moisture-wicking textile with silver was then skin is not completely healed placed beneath each breast, leaving 4 cm exposed for transloca- tion, and secured in place using a sports bra. Substantial improve- until the normal skin thickness ment was noted by 14 days with complete resolution by 21 days. is re-established and the barrier function restored. Weight loss is always an appropriate preventive and treatment strategy in obese patients, but it is notoriously diffi- cult to achieve.

Conclusion Intertrigo is a common condition associated with MASD, which Figures 3 and 4. Inframammary intertrigo before and after mois- ture-wicking textile with silver may be found in a variety of clinical settings, including acute,

chronic, long-term and home care. Overall the limited informa- tion about intertrigo currently Table 3. in Study Patients available is a cause for concern. Sign or Symptom Day 1 Day 3 Day 5 The incidence and prevalence Itching/burning 15 1 0 of intertrigo are unknown and Maceration 10 1* 1* little evidence supports the use Denudement 7 3 1 of commonly used therapies. The Satellite lesions 5 1 1 information in this consensus Erythema 21 ↓† ↓† document has been synthesized Odour 12 ↓† 2* for educational purposes for clinicians and as a for * One patient had maceration and odour due to urine soiling of textile that was not removed immediately more research into this common † Statistically significant decrease condition.

42 Wound Care Canada Volume 11, Number 2 · Fall 2013 The development of this consen- in large skin folds of adults: a system- 7. Kugelman TP. Intertrigo—diag- sus document has been supported atic review. BMC Nurs. 2010;9:12. nosis and treatment. Conn Med. by Coloplast. 4. Black JM, Gray M, Bliss DZ, Kennedy- 1969;33(1):29–36. Evans KL, Logan S, Baharestani M, 8. Voegeli D. Moisture-associated skin Editorial support was provided Colwell JC, Goldberg M, Ratcliff CR. damage: an overview for communi- MASD part 2: incontinence-associated by Joanna Gorski of Prescriptum ty nurses. Br J Community Nursing. dermatitis and intertriginous derma- 2013;18(1):6,8,10–12. Health Care Communications Inc. titis: a consensus. J Wound Ostomy Continence Nurs. 2011;38(4):359–70. 9. Guitart J, Woodley GT. Intertrigo: a practical approach. Compr Ther. 5. Janniger CK, Schwartz RA, References 1994;20(7):402–9. Szepietowski JC, Reich A. Intertrigo 1. Gray M, Bohacek L, Weir D, Zdanuk 10. Kennedy-Evans KL, Viggiano B, Henn J. Moisture vs pressure: making and common secondary skin T, Smith D. Multisite feasibility study sense out of perineal wounds. J infections. Am Fam Physician. Wound Ostomy Continence Nurse. 2005;72(5):833–8. using a new textile with silver for 2007;34(2):134–42. 6. Gray M, Black JM, Baharestani MM, management of skin conditions 2. Muller N. Intertrigo in the obese Bliss DZ, Colwell JC, Goldberg M, located in skin folds. Presented at: The patient: finding the silver lin- Kennedy-Evans KL, Logan S, Ratcliff Clinical Symposium Advances in Skin ing. Ostomy Wound Manage. CR. Moisture-associated skin dam- & Wound Care at the Wound Ostomy 2011;57(8):16. age: overview and pathophysiology. and Continence Nurses Society 39th 3. Mistiaen P, van Halm-Walters M. J Wound Ostomy Continence Nurse. annual meeting; 2007 Jun 9–13; Salt Prevention and treatment of intertrigo 2011;38(3):233–41. Lake City, Utah.

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