Intertrigo and Secondary Skin Infections MONICA G. KALRA, DO, Methodist Health System of Dallas, Dallas, Texas KIM E. HIGGINS, DO, Physician Senior Services, Dallas, Texas BRUCE S. KINNEY, DO, Methodist Health System of Dallas, Dallas, Texas Intertrigo is a superficial inflammatory dermatitis occurring on two closely opposed skin surfaces as a result of mois- ture, friction, and lack of ventilation. Bodily secretions, including perspiration, urine, and feces, often exacerbate skin inflammation. Physical examination of skin folds reveals regions of erythema with peripheral scaling. Excessive friction and inflammation can cause skin breakdown and create an entry point for secondary fungal and bacterial infections, such as Candida, group A beta-hemolytic streptococcus, and Corynebacterium minutissimum. Candidal intertrigo is commonly diagnosed clinically, based on the characteristic appearance of satellite lesions. Diagnosis may be confirmed using a potassium hydroxide preparation. Resistant cases require oral fluconazole therapy. Bacte- rial superinfections may be identified with bacterial culture or Wood lamp examination. Fungal lesions are treated with topical nystatin, clotrimazole, ketoconazole, oxiconazole, or econazole. Secondary streptococcal infections are treated with topical mupirocin or oral penicillin. Corynebacterium infections are treated with oral erythromycin. (Am Fam Physician. 2014;89(7):569-573. Copyright © 2014 American Academy of Family Physicians.) CME This clinical content ntertrigo is caused by cutaneous inflam- progress to severe inflammation and skin conforms to AAFP criteria for continuing medical mation of opposing skin surfaces. It breakdown. This erosion of the epidermal education (CME). See is more common in hot and humid barrier may create an entry point for micro- CME Quiz Questions on environments and during the sum- organisms that cause secondary infections.7 page 515. Imer. Skin folds, including inframammary Author disclosure: No rel- (Figure 1), intergluteal, axillary, and inter- Clinical Manifestations evant financial affiliations. digital (Figure 2) areas, may be involved.1 Intertrigo is often a chronic disorder that ▲ Patient informa- Intertrigo is more common in young and begins insidiously with the onset of pruritus, tion: A handout on older persons secondary to a weakened stinging, and a burning sensation in skin folds. this topic is available at immune system, incontinence, and immo- Physical examination of the skin folds usually http://familydoctor.org/ 2-4 familydoctor/en/diseases- bility, although it can occur at any age. reveals regions of erythema with peripheral conditions/intertrigo.html. scaling. Intertrigo associated with a fungal Etiology and Predisposing Factors superinfection may produce satellite papules Intertrigo most often occurs in patients with and pustules. Candidal intertrigo (Figure 3) obesity (body mass index more than 30 kg is often associated with a foul-smelling odor. per m2), diabetes mellitus, or human immu- In the presence of a bacterial superinfection, nodeficiency virus infection, and in those plaques and abscesses may form.8 who are bedridden. It also occurs in patients with large skin folds and those who wear diapers or other items that trap moisture against the skin. There is a linear increase in the severity of obesity and the presence of intertrigo.5 Patients who are obese sweat more profusely because of their thick layers of subcutaneous brown fat, generating more heat than persons with normal body mass.6 This increases thermal, frictional, and mois- ture components of the skin.5 As the stratum corneum becomes macer- Figure 1. Inframammary intertrigo appearing ated because of hyperhydration, the friction as skin discoloration with no evidence of fun- intensifies and further weakens and dam- gal or bacterial superinfection. ages the epidermal tissue. The condition can Copyright © Logical Images, Inc. AprilDownloaded 1, 2014 from ◆ Volume the American 89, Number Family Physician 7 website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2014 American Academy of FamilyAmerican Physicians. Family For the Physician private, noncom 569- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Intertrigo ulceration, fever, and chills.9 Foot care SORT: KEY RECOMMENDATIONS FOR PRACTICE and patient education are key in prevent- Evidence ing interdigital infections in patients with 10 Clinical recommendation rating References diabetes. Intertrigo associated with Candida should be C 14 Diagnosis managed with topical antifungals applied twice daily until the rash resolves. Intertrigo may be difficult to distinguish Fluconazole (Diflucan), 100 to 200 mg daily for C 14 from other skin disorders, but the patient his- seven days, is used for intertrigo complicated tory will help in the diagnosis (Table 1).8 The by a resistant fungal infection. Patients who history should include previous treatments, are obese may require an increased dosage. especially topical steroids and antibacterial Skin barrier protectants, such as zinc oxide C 20, 21 ointment and petrolatum, as part of a soaps or ointments. Some steroids may cause structured skin care routine that also includes atrophy and maceration, and some soaps and gentle cleansing and moisturizing may reduce ointments may exacerbate skin inflamma- recurrent intertrigo infections. tion. A visual inspection of the skin will help 8 A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited- identify lesions in other areas. quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual The diagnosis of secondary fungal infec- practice, expert opinion, or case series. For information about the SORT evidence tions is commonly made clinically, based rating system, go to http://www.aafp.org/afpsort. on the characteristic appearance and distribution of satellite papules and pus- Interdigital intertrigo (Figure 2) may be mild and tules.11 The diagnosis may, however, be confirmed asymptomatic, but also may lead to intense erythema with a potassium hydroxide preparation positive for and desquamation. The affected skin may have a foul pseudohyphae and spores. Additionally, a potassium odor and may be macerated and ulcerated with copi- hydroxide preparation, Wood lamp examination, ous or purulent discharge. Patients with interdigital or culture of skin scrapings can diagnose conditions intertrigo and comorbidities such as obesity or diabetes such as Candida or dermatophyte infections. The are at greater risk of cellulitis.3 Interdigital intertrigo presence of hyphae on potassium hydroxide exami- can progress to a severe bacterial infection with pain, nation confirms dermatophytic lesions, including mobility problems, erysipelas, cellulitis, abscess forma- tinea versicolor and tinea corporis, and the pres- tion, fasciitis, and osteomyelitis causing pain so severe ence of pseudohyphae confirmsCandida infection. that the patient is unable to ambulate.3 Web space A video showing a potassium hydroxide examina- infections are typically caused by gram-positive cocci tion of a fungal infection is available at http://www. such as Staphylococcus and Streptococcus and may cause youtube.com/watch?v=ugeMsyEDJaw. The Wood Figure 2. Severe interdigital intertrigo with erythema suggestive of cellulitis. Figure 3. Candidal intertrigo in the inguinal fold. 570 American Family Physician www.aafp.org/afp Volume 89, Number 7 ◆ April 1, 2014 Intertrigo Table 1. Differential Diagnosis of Cutaneous Diseases Resembling Intertrigo Disease Characteristics lamp examination fluoresces green with Pseudomonas infection and coral-red Infectious diseases Candidiasis Superficial erythematous infection, commonly affecting with erythrasma (Figure 4), a bacterial (moniliasis) moist, cutaneous areas of the skin; satellite pustules infection caused by Corynebacterium Dermatophytosis Pruritic infections of nonviable keratinized tissues, such as minutissimum.3 (tinea nails and hair; contains a leading scale corporis, tinea Treatment versicolor) Table 2 summarizes treatment options for Erythrasma Small, red-brown macules that may coalesce into larger patches with sharp borders; may be asymptomatic or 3,11-18 intertrigo. pruritic; fluoresces coral-red on Wood lamp examination Pyoderma Aggressive infection with boggy, blue-red bullae that BARRIER AGENTS progress to deep ulcers with hemorrhagic bases In uncomplicated intertrigo, numerous Scabies Infection with intense pruritus and minimal cutaneous agents and mechanisms can be used to keep manifestations, including intertriginous burrows and papules; the head is spared in all age groups except the skin folds dry, clean, and cool. Applying infants barrier protectants reduces skin breakdown Seborrheic Yellow, greasy, scaly plaques with overlying erythema; and alleviates pruritus and pain. Skin pro- dermatitis most often affects the face, postauricular region, and tectants include zinc oxide ointment and chest petrolatum.12 Separating skin surfaces with Noninfectious inflammatory diseases absorbent products, such as gauze, cotton, Atopic dermatitis Red or brownish patches with intense pruritus; personal and/or family history of seasonal allergies and asthma is and products with water vapor–permeable common sheets, may also help reduce friction. Pemphigus Serious, often fatal, autoimmune disease; flaccid bullae, vulgaris Nikolsky sign (i.e., disruption of the epidermal layer with DRYING