Intertrigo


Article Author:
Timothy Nobles


Article Editor:
Richard Miller


Editors In Chief:
Amanda Oakley
Jules Lipoff
Shyam Verma


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
10/27/2018 12:31:40 PM

Introduction

Intertrigo is a superficial inflammatory skin condition of the skin's flexural surfaces, prompted or irritated by warm temperatures, friction, moisture, maceration, and poor ventilation. Intertrigo's Latin translation, inter (between) and terere (to rub) helps explain the physiology of the condition.[1] Intertrigo commonly becomes secondarily infected, notably with Candida; however, other viral or bacterial etiologies may play a factor in its pathogenesis. Intertrigo can be seen in all ages and is primarily a clinical diagnosis with the frequently affected areas being the axilla, inframammary creases, abdominal folds, and perineum. Characteristically, the lesions are erythematous patches of various intensity with secondary lesions appearing as the condition progresses or is manipulated.[2]

Etiology

Mechanical factors and secondary infections are the landscape causes of intertrigo. Heat with maceration plays a central role in facilitating this process. The skin folds battle constant frictional forces producing irritation and at times, erosions to the inflamed skin. Further, moisture builds up in the affected intertriginous areas and develops a feeding ground for secondary infection to flourish. Candida species thrive in heated, high-moisture environments and is a common offender of secondary infection in cases of intertrigo. Moreover, patients with diabetes have increased pH levels in intertriginous areas contributing to their demographic prevalence.[3] However, it is not uncommon to see gram-positive and gram-negative bacteria, as well as other fungi and viruses accounting for some of the cases.[4][5][6]

Epidemiology

People of all ages, from infancy through advanced age, can be affected by intertrigo. The inflammatory condition manifests itself in the infantile age group as a variation of diaper dermatitis. Furthermore, the increased likelihood of a naive or reduced immune system, lack of mobility, and urinary/bowel incontinence contribute to the skin manifestations and its complications.[2] Obesity and diabetes are 2 conditions that increase the frequency of developing intertrigo.[5] The condition is most prevalent in geographic areas that have hot and humid climates. Lastly, there is no race or gender predilection observed with the condition.

Pathophysiology

Environmental factors and genetic causes play a leading role in the development of intertrigo. One of these factors is the friction caused by adjacent skin surfaces causing inflammation of the epidermis. Moreover, flexural surfaces have a higher surface temperature comparable to other body parts. The moisture and sweat build up that gets trapped in these areas add to the maceration of the stratum corneum and epidermis. Nonetheless, the integumentary system houses bacteria and yeast that flourish in this environment and overgrow in these conditions, making infection a common finding.[4][5][6]

Histopathology

There is no characteristic histologic change seen in intertrigo. Some cases can present with mild spongiosis visualized in the epidermis.

History and Physical

The presentation of intertrigo is generally a chronic subtle onset of pruritus, burning, tingling, and pain in the skin folds and flexural surfaces. If there is an acute change in the quality of the symptoms, consider a secondary infection with Candida albicans, bacteria, or other pathologic organisms. Likely, the patient will be involved in an activity that involves rubbing of their skin surfaces together. Hot and humid environmental conditions are also aggravating conditions that contribute to the pathology. Therefore, intertrigo tends to see a higher rate of seasonal incidence. Hyperhidrosis, seen with strenuous exercise, is a prominent contributing factor in the inflammatory condition. Predisposing factors such as obesity and diabetes, as well as signs of incontinence, urethral discharge and draining wounds on exam all contribute to the warm, moist occluded environment responsible for the development of intertrigo.[7]

On physical examination, prevalence is highest among obese patients, yet all body mass index (BMI) subclasses are implicated dependent on other factors. The increased surface area in obese patients accentuates the folds and creases of the body suitable for higher body temperatures. The initial presentation on the skin exam is a mildly erythematous patch on both sides of the skin fold. The degree of inflammation is dependent upon factors such as location and duration, as well as if there is a secondary co-infection. Over time, the erythematous patch can develop erosions, macerations, fissures, crust, and weeping from the site. If a pustule, crust, or vesicle is visible, secondary infection should be considered. If Candida species are suspected, satellite papules and pustules are pathognomic. Bluish-green tint will indicate infection with Pseudomonas.[8] Bacterial intertrigo tends to weep and is an intensely erythematous and potentially tender lesion.[4] In interdigital intertrigo, Trichophyton rubrum, Trichophyton mentagrophytes, and Epidermophyton floccosum are the implicated organisms in this body region.[9]

Evaluation

Further evaluation beyond the clinical diagnosis may be required to determine the exact cause and most effective treatment modality. The lesion can be cultured if a bacterial origin is suspected. Fungus, another common invader, can be elicited by a skin scraping of the lesion. If the presentation is unusual or therapy has failed, consider performing a biopsy.

Treatment / Management

To properly treat intertrigo, it is imperative to recognize the underlying factor that is causing the condition. Therefore, one should reduce or remove the offending causative factor or agent discussed above. If there is an infectious component to the rash, then the proper antimicrobial should be administered. In simple intertrigo, drying agents such as antiperspirants can be used to minimize the sweating. A bath with proper drying using a soft towel should follow excessive physical activity that causes excessive perspiration. Aluminum acetate solution, zinc oxide, and petrolatum, the ingredients that comprise triple paste, is an effective antiperspirant that also reduces frictional exposure and improves skin irritation. Staying cool by wearing loose clothing, and working in air-conditioned environments will help in the prevention of the rash. Absorbent powders compress with an aqueous solution of aluminium triacetate 1:40, and wet tea bags are other preventative measures that have been proven to be effective. Absorbent diapers are more effective at decreasing the moisture; however, if treatment is required, petrolatum ointment cream is effective and safe for diaper dermatitis. If the lesion is infected with a bacteria, then use a topical treatment such as mupirocin. If oral medication is required, an effective option against gram-positive bacteria, notably Staphylococcus or Streptococcus, like flucloxacillin or erythromycin should be prescribed. Topical clotrimazole is an effective treatment for yeast or fungal infected intertrigo. Low-dose steroids may be initiated for anti-inflammatory properties, for example, hydrocortisone cream, yet it is not always needed. A lower strength steroid should be preferred if chosen to prevent atrophy in the already thinner epidermis of the flexural surfaces.[10][11]

Differential Diagnosis

The differential is quite extensive for intertrigo. Many other conditions present in the flexural surfaces. However, infection is most important to rule out, and the proper infectious agent should be sought out to provide the correct antimicrobial therapy necessary to eliminate the offending agent. Bacteria, viruses, dermatophytes, and candidal organisms can all cause intertrigo or provoke a secondary infection.[12] Once infection is ruled out, other similar presenting conditions commonly found in the flexural surfaces can be further investigated. More common conditions such as seborrheic dermatitis, irritant or allergic contact dermatitis, atopic dermatitis, inverse psoriasis, pemphigus, scabies, metabolic derangements, and malignancies frequently present in the skin fold mimicking intertrigo.[13] Nonetheless, intertrigo remains a clinical diagnosis with the findings and clinical picture described above.

Prognosis

The prognosis is positive for the majority of patients. The underlying risk factors should be addressed to diminish the intertrigo outbreaks. However, if the risks such as diabetes and obesity are not properly managed, the condition tends to relapse quite frequently.

Complications

The complications that can arise with intertrigo are predominantly secondary infections that have been discussed at length above. To optimize prevention of infection, the rash should be directed to a physician, primarily a dermatologist to properly manage the condition. If left untreated, the rash can develop into cellulitis.[14] Furthermore, sepsis can result from hidden ulcers that develop in patients without supervision or obese individuals. Contact dermatitis can occur secondary to topical agents used to treat the rash. Also, prolonged steroid use can cause atrophy and striae to the thinned epidermis of the flexural surfaces.

Consultations

Whether it is the pediatrician or adult primary care physician, if there is a doubt of suspicion or a rash that has failed treatment, a dermatologist should be consulted to manage the condition further.

Deterrence and Patient Education

Topics that should be discussed with the patient and their family is weight loss and weight control, proper hygiene, glycemic control in patients who have diabetes, and measures to reduce the frictional component of skin to skin contact.

Pearls and Other Issues

Often, there is a combination of an infectious and inflammatory component. To delineate the 2, infections are often unilateral and asymmetrical. Inflammatory disorders tend to be symmetrical a majority of the time.

Enhancing Healthcare Team Outcomes

Physicians, nurses, and pharmacists all play an optimal role in achieving successful clearance of the rash. Physicians and nurses need to emphasize and educate the preventative risk factors and management of the rash to clear the current and prevent further intertrigo occurrences. The physician can consult the pharmacist when necessary to help with varying formulations of topical therapy as well as oral for certain infectious etiologies.


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Intertrigo - Questions

Take a quiz of the questions on this article.

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A 45-year-old Hispanic female comes to your office with a complaint of a rash underneath her breasts. She tells you the rash has been there for a couple of months. She reports associated discomfort, pruritus, and a tingling sensation that came on all of a sudden. She also admits to increased sweating episodes over the same period. On physical examination, skin findings include an erythematous, confluent patch beneath her breasts with no satellite lesions observed. Her past medical history includes insulin-dependent diabetes mellitus and hyperlipidemia. Her body mass index is 30. What is the most likely diagnosis?



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Which of the following is not a likely causative factor in the pathogenesis of intertrigo?



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A 3-month-old male comes to your office accompanied by his mother. He does not have a significant birth history. All vaccinations are up to date. His mother reports that he soaks his diapers in urine, and at times she is not able to change them as quickly as she would like. She noticed a rash that appeared earlier in the month, and it has gotten worse. On physical examination, there is an extending, erythematous rash when you remove the diaper with scattered papules on the periphery as far as the abdomen and thigh. What is the most likely diagnosis?



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A man who is homeless is admitted to the hospital for acute abdominal pain. During his stay, a rash is noted in his axilla. The rash is described as lightly erythematous with an obscure border. He has no pain in the affected area, denies fever, and is receiving IV fluids. Which of the following treatment modalities will be the most effective in preventing a recurrence of the rash?



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A 75-year-old Caucasian male with a past medical history significant for diabetes mellitus type two, hypercholesterolemia, urinary incontinence, and peripheral artery disease presents to your office with a rash in his groin area. Which of the following is the best next step in management?



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Intertrigo - References

References

Wolf R,Oumeish OY,Parish LC, Intertriginous eruption. Clinics in dermatology. 2011 Mar-Apr     [PubMed]
Kalra MG,Higgins KE,Kinney BS, Intertrigo and secondary skin infections. American family physician. 2014 Apr 1     [PubMed]
Chiriac A,Murgu A,Coroș MF,Naznean A,Podoleanu C,Stolnicu S, Intertrigo Caused by Streptococcus pyogenes. The Journal of pediatrics. 2017 May     [PubMed]
Metin A,Dilek N,Bilgili SG, Recurrent candidal intertrigo: challenges and solutions. Clinical, cosmetic and investigational dermatology. 2018     [PubMed]
Adışen E,Önder M, Viral infections of the folds (intertriginous areas). Clinics in dermatology. 2015 Jul-Aug     [PubMed]
Yosipovitch G,Tur E,Cohen O,Rusecki Y, Skin surface pH in intertriginous areas in NIDDM patients. Possible correlation to candidal intertrigo. Diabetes care. 1993 Apr     [PubMed]
Ndiaye M,Taleb M,Diatta BA,Diop A,Diallo M,Diadie S,Seck NB,Diallo S,Ndiaye MT,Niang SO,Ly F,Kane A,Dieng MT, [Etiology of intertrigo in adults: A prospective study of 103 cases]. Journal de mycologie medicale. 2017 Mar     [PubMed]
Kalkan G,Duygu F,Bas Y, Greenish-blue staining of underclothing due to Pseudomonas aeruginosa infection of intertriginous dermatitis. JPMA. The Journal of the Pakistan Medical Association. 2013 Sep     [PubMed]
Grosshans E,Schwaab E,Samsoen M,Grange D,Koenig H,Kremer M, [Clinical aspects, epidemiology and economic impact of foot epidermomycosis in an industrial milieu]. Annales de dermatologie et de venereologie. 1986     [PubMed]
Honig PJ,Frieden IJ,Kim HJ,Yan AC, Streptococcal intertrigo: an underrecognized condition in children. Pediatrics. 2003 Dec     [PubMed]
Wilmer EN,Hatch RL, Resistant     [PubMed]
Del Rosso JQ, Adult seborrheic dermatitis: a status report on practical topical management. The Journal of clinical and aesthetic dermatology. 2011 May     [PubMed]
Hoeger PH,Stark S,Jost G, Efficacy and safety of two different antifungal pastes in infants with diaper dermatitis: a randomized, controlled study. Journal of the European Academy of Dermatology and Venereology : JEADV. 2010 Sep     [PubMed]
Vanhooteghem O,Szepetiuk G,Paurobally D,Heureux F, Chronic interdigital dermatophytic infection: a common lesion associated with potentially severe consequences. Diabetes research and clinical practice. 2011 Jan     [PubMed]

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