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 R. Gary Sibbald MD Professor, Medicine and Public Health 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 Waters 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 skin infection ...................................11 and intertrigo ................................................................. 4 Organisms in intertrigo ..............................11 Consensus Statements ................................................ 5 Specific types of infection .................................11 Methodology: Literature Search ............................... 6 Candidiasis .....................................................12 Epidemiology ................................................................. 6 Dermatophytosis ..........................................12 Risk Factors for Intertrigo ........................................... 6 Bacterial infections: Pyodermas ...............12 Skin folds .................................................................. 6 Streptococcal intertrigo ......................13 Perspiration .............................................................7 Erythrasma ..............................................13 Obesity ...................................................................... 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 Physical examination ..........................................14 Increased pH ........................................................... 8 Diagnosis .......................................................................14 Aging ......................................................................... 8 Management of Intertrigo .......................................14 Obesity ...................................................................... 8 Evidence .................................................................14 Atopy ......................................................................... 9 Management principles .....................................15 Location-specific Intertrigo: Clinical Features ...... 9 Prevention..............................................................15 Inframammary and pannus intertrigo ............. 9 Treatment ...............................................................16 Groin and perianal intertrigo ............................. 9 Ineffective therapies ....................................17 Toeweb and fingerweb intertrigo ..................... 9 Hyperhidrosis .................................................17 Common Differential Diagnoses of Intertrigo ...... 9 Intertrigo and moisture-wicking Psoriasis ..................................................................10 textile with silver ..........................................17 Seborrheic dermatitis of the flexural areas ....10 Common-sense approaches ......................18 Contact dermatitis of the flexural areas ........10 Conclusion ....................................................................19 Incontinence-associated dermatitis ...............10 References .....................................................................20 Atopic dermatitis 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 erythema to maceration (increased stratum Karen Lou Kennedy-Evans RN, FNP, APRN-BC corneum moisture content) and erosion (loss of surface KL Kennedy LLC epidermis 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 inflammation 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 diabetes 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- weight loss, 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